The healthcare system has been placed under an enormous burden by the SARS-CoV-2 (COVID-19) pandemic. In addition to the challenge of providing sufficient care for COVID-19 patients, there is also a need to ensure adequate care for non-COVID-19 patients. We investigated neurosurgical care in a university hospital during the pandemic. We examined the second wave of the pandemic from 1 October 2020 to 15 March 2021 in this retrospective single-center study and compared it to a pre-pandemic period from 1 October 2019 to 15 March 2020. Any neurosurgical intervention, along with patient- and treatment-dependent factors, were recorded. We also examined perioperative complications and unplanned readmissions. A statistical comparison of the study groups was performed. We treated 535 patients with a total of 602 neurosurgical surgeries during the pandemic. This compares to 602 patients with 717 surgeries during the pre-pandemic period. There were 67 fewer patients (reduction to 88.87%) admitted and 115 fewer surgeries (reduction to 83.96%) performed, which were essentially highly elective procedures, such as cervical spinal stenosis, intracranial neurinomas, and peripheral nerve lesions. Regarding complication rates and unplanned readmissions, there was no significant difference between the COVID-19 pandemic and the non-pandemic patient group. Operative capacities were slightly reduced to 88% due to the pandemic. Nevertheless, comprehensive emergency and elective care was guaranteed in our university hospital. This speaks for the sufficient resources and high-quality processes that existed even before the pandemic.

A monitoração intraventricular da pressão intracraniana (PIC) com drenagem contínua do líquido cefalorraquiano (LCR) já é um procedimento difundido na prática da neurocirurgia e considerado de grande importância diagnóstica, terapêutica e prognóstica por sua precisão. Entretanto, por se tratar de um método invasivo, apresenta riscos potenciais de complicações, sendo a infecção a mais freqüente. O presente estudo teve como objetivo verificar e analisar as taxas de infecções decorrentes deste método de monitoração da PIC, assim como as taxas de seus fatores de risco. As informações obtidas através de prontuários e arquivo dos exames laboratoriais foram registradas em duas fichas de coleta de dados próprias e posteriormente submetidas a testes estatísticos como o de Kruskal-Wallis, de Mann-Whitney, de qui-quadrado, teste exato de Fisher e o coeficiente de correlação de Spearman. Obtidas as freqüências relativas e absolutas, médias e desvio-padrão, sendo de 5% o nível de significância utilizado para os testes. A população deste estudo foi de 79 pacientes dos quais 70.9% eram do sexo masculino com média de 33.7 anos, sendo que os diagnósticos presentes em 82.3% eram referentes ao trauma craniencefálico (TCE) seguido de tumores intracranianos e acidentes vasculares cerebrais (AVCs). Todos fizeram uso de antibioticoprofilaxia. A taxa de ventriculite foi de 26.6%, permanecendo o cateter, em média, 6.7 dias e apresentando taxas diárias desta infecção variáveis. Não encontramos associação estatisticamente significativa entre tempo de monitoramento e infecção, porém houve um aumento no índice diário de ventriculite após os três primeiros dias e picos no 6°, 9° e 12° dia indicando uma provável ligação não acumulativa ou linear. Outras variáveis avaliadas neste estudo que apresentaram associação direta com a ocorrência de ventriculite foram o sexo masculino, hemorragia subdural e infecções em outros sítios, principalmente a sepses. Variáveis como idade, procedimentos invasivos, TCE aberto, fístulas liquóricas, hemorragia intraventricular, múltiplas ventriculostomias, presença de PIC acima de 20mmHg, intercorrências durante a cateterização ou manutenção desta não apresentaram associação com a taxa ventriculite, no entanto muitas destas variáveis estiveram presentes em poucos casos dificultando uma conclusão definitiva. / Intraventricular monitoring of the intracranial pressure (ICP) with continuous drainage of cerebrospinal fluid (CSF) is already a widespread procedure in neurosurgical practice and considered as of great diagnostic, therapeutic and prognostic importance due to its precision. However, as it is an invasive method, it presents a potential risk of complications, the infection being the most frequent. The present study aims at verifying and analyzing the rates of infection originating from this monitoring method of ICP, as well as the rates of its risk factors. The information obtained from case histories and laboratory test files were recorded on two own separate data collection cards and later submitted to statistical tests like the Kruskal-Wallis, Mann-Whitney, Chi-Square, Fisher’s exact test, and Spearman correlation coefficients. Relative and absolute, average and standard deviation frequency were verified, 5% was the significance level utilized for the tests. The population of this study was of 79 patients, 70.9% of which were male averaging 37.7 years of age, this being so that the diagnostics present in 82.3% are related to traumatic head injury followed by intracranial tumors and stroke. All of them made use of antibioticprophylaxis. The ventriculitis rate was of 26.6 %, the catheter remaining, on average, 6.7 days and showing variable daily rates of this infection. We have not found a statistically meaningful association between monitoring time and infection, however there was an increase in the daily ventriculitis rate after the first three days and peaks on the 6th, 9th and 12th days showing a probable non-cumulative or linear link. Other variables evaluated in this study which presented a direct association with the occurrence of ventriculitis were the male sex, subdural hemorrhage and infections at other sites, mainly sepsis. Variables such as age, invasive procedures, open traumatic head injury, CSF leaks, intraventricular hemorrhage, multiple ventriculostomies, presence of ICP above 20mmHg, intercurrences during catheterization or its maintenance did not show association with the ventriculitis rate, nevertheless many of these variables were present in few cases making a definite conclusion difficult.

Introdução. As hemisferectomias são cirurgias utilizadas há décadas para se tratar epilepsias refratárias à medicação anticonvulsivante. Embora o controle das crises seja satisfatório, a morbidade, per e pós-operatória, ainda é considerada um importante fator limitante à sua utilização. Dessa maneira, compreender as complicações mais comuns do procedimento, e os fatores que as influenciam, é essencial para se estabelecer o melhor uso para a técnica. Métodos. Foram coletados dados de 30 pacientes, operados por seis cirurgiões no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo no período entre 1980 e 2003. Foram realizadas 11 hemisferectomias com a abordagem de Rasmussen, três hemisferectomias anatômicas, nove hemisferectomias funcionais extraventriculares e sete hemisferotomias. Foram estudados cinco grupo de pacientes de acordo com a fisiopatologia da doença de base: Dezesseis pacientes eram portadores de Síndrome de Rasmussen, dois da Síndrome de Sturge-Weber, quatro de malformações corticais, dois de lesões sequelares e seis de cistos porencefálicos. Os fatores de morbidade foram avaliados dentro de rês perspectivas: 1- da doença de base; 2- da técnica utilizada; e 3- do fator humano. Resultados. Nossos dados mostraram ausência de diferença estatisticamente significativa entre as técnicas cirúrgicas empregadas nos itens: tempo cirúrgico; tempo de internação na unidade de terapia intensiva; queda da hemoglobina; volume de hemoderivados transfundidos e febre no pós-operatório. Presença de leucograma acima de 15.000 leucócitos/mm3 no pós-operatório imediato foi associada a estadias mais longas na unidade de terapia intensiva A média diária de temperatura dos pacientes, mostrou temperaturas acima de 38º C entre o terceiro e sexto dia pós-operatório. Pacientes com hemimegalencefalia apresentaram temperaturas mais elevadas quando comparados com os portadores de cistos porencefálicos. Doenças com maior manto cortical contribuíram para aumentar o tempo cirúrgico, embora o fator humano tenha sido decisivo nesse item. Ao comparar nossos achados com os da literatura, vimos que os pacientes submetidos à hemisferectomia anatômica apresentaram no pós-operatório temperaturas mais elevadas e reação inflamatória liquórica mais intensa que os submetidos a técnicas de desconexão hemisférica, no entanto, a importância desse dado necessita ser estabelecida. Conclusões: O principal fator de morbidade nas hemisferectomias é a doença de base, assim, os dados presentes na literatura, incluindo nossa casuística, não nos permite concluir que uma técnica seja superior à outra ou que as técnicas desconectivas sejam melhores que as ressectivas / Hemispherectomy has been the treatment of choice in some sorts of refractory epilepsies for decades. Although surgery results in satisfactory control of seizures, its morbidity remains a major concern. Thus, understanding most common complications, as well as the factors that contribute to it, becomes an essential step to learn the limits on technique applications. Methods. Hospital charts from 30 patients operated on by six different surgeons at the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo from 1980 to 2003 were reviewed. Eleven functional hemispherectomies using Rasmussen approach, three anatomical hemispherectomies, nine extraventricular functional hemispherectomies, and seven hemispherotomies were included in this study. Sixteen patients presented with Rasmussen Syndrome, two Sturge-Weber Syndrome, four cortical malformations, two hemispheric lesions, and six porencephalic cysts. Morbidity was evaluated from three different perspectives 1- background disease, 2- employed technique, and 3- human factor. Results: our data presented no statistical difference among the employed techniques regarding 1- surgical time, 2- intensive care unit time, 3- per and postoperative fall of hemoglobin, 4- blood transfusion volume, and 5- postoperative axilar temperature variation. Patients that presented over 15,000 leucocytes per mm3 stayed longer at the intensive care unit, regardless of the surgical technique employed. Daily average temperatures varied around 38 degrees Celsius from the third to the sixth postoperative day. Patients with hemimegalencephaly had higher postoperative axilar temperatures when compared to those with porencephaly. Thicker cortical mantle contributed to increase surgical time, though human factor also showed to be important in this item. Comparing data from this study and the literature disclosed that patients undergoing anatomical hemispherectomies presented an inflammatory response in the cerebrospinal fluid more evident than those submitted to cerebral disconnection, although the importance of this finding is still elusive. Conclusions: The main factors of morbidity in the hemispherectomy are the background disease and patient\'s peculiarities, therefore, it is not reasonable to infer that there is a superior technique or that hemisphere disconnection is better than removal

There is limited knowledge of cognitive outcome extending beyond 5 years after childhood traumatic brain injury, CTBI. The main objectives of this thesis were to investigate cognitive outcome at 6-14 years after CTBI, and to evaluate if advancements in the neurosurgical care, starting 1992, did influence long-term outcome and early epidemiology. An additional aim was to study the relationship between early brain injury parameters and early functional outcome. Study 1 evaluated cognitive progress during 14 years after CTBI, over three neuropsychological assessments in 8 patients with serious CTBI. Study 2 used patient records to investigate early epidemiology, received rehabilitation and medical follow up in two clinical cohorts, n=82 and n=46, treated neurosurgically for CTBI before and after 1992. An exploratory cluster analysis was applied to analyse the relation between early brain injury severity parameters and early functional outcome. In Study 3, participants in the two cohorts, n=18 and n=23, treated neurosurgically for CTBI before and after 1992, were subject to an extensive neuropsychological assessment, 13 and 6 years after injury, respectively. Assessment results of the two cohorts were compared with each other and with controls. Data were analysed with multivariate analyses of variance. Results and discussion. There were significant long-term cognitive deficits of similar magnitude and character in the two cohorts with CTBI, treated before and after the advancements in neurosurgical care. At 6-14 years after injury, long-term deficits in verbal intellectual and executive functions were found, and were discussed in terms of their late maturation and a decreased executive control over verbal memory-functions after CTBI. Visuospatial functions had a slightly better long-term recovery. The amount of rehabilitation received was equally low in both cohorts. The length of time spent in intensive care and the duration of care in the respirator may have a stronger relationship to early outcome than does a single measure of level of consciousness at admission. Main conclusions are that cognitive deficits are apparent at long-term follow up, 6-13 years after neurosurgically treated CTBI, even after advancements in the neurosurgical care in Sweden. Measures of verbal IQ, verbal memory and executive functions were especially low while visuospatial intellectual functions appear to have a better long-term recovery. / At the time of the doctoral defense, the following paper was unpublished and had a status as follows: Paper 3: Manuscript.

A monitoração intraventricular da pressão intracraniana (PIC) com drenagem contínua do líquido cefalorraquiano (LCR) já é um procedimento difundido na prática da neurocirurgia e considerado de grande importância diagnóstica, terapêutica e prognóstica por sua precisão. Entretanto, por se tratar de um método invasivo, apresenta riscos potenciais de complicações, sendo a infecção a mais freqüente. O presente estudo teve como objetivo verificar e analisar as taxas de infecções decorrentes deste método de monitoração da PIC, assim como as taxas de seus fatores de risco. As informações obtidas através de prontuários e arquivo dos exames laboratoriais foram registradas em duas fichas de coleta de dados próprias e posteriormente submetidas a testes estatísticos como o de Kruskal-Wallis, de Mann-Whitney, de qui-quadrado, teste exato de Fisher e o coeficiente de correlação de Spearman. Obtidas as freqüências relativas e absolutas, médias e desvio-padrão, sendo de 5% o nível de significância utilizado para os testes. A população deste estudo foi de 79 pacientes dos quais 70.9% eram do sexo masculino com média de 33.7 anos, sendo que os diagnósticos presentes em 82.3% eram referentes ao trauma craniencefálico (TCE) seguido de tumores intracranianos e acidentes vasculares cerebrais (AVCs). Todos fizeram uso de antibioticoprofilaxia. A taxa de ventriculite foi de 26.6%, permanecendo o cateter, em média, 6.7 dias e apresentando taxas diárias desta infecção variáveis. Não encontramos associação estatisticamente significativa entre tempo de monitoramento e infecção, porém houve um aumento no índice diário de ventriculite após os três primeiros dias e picos no 6°, 9° e 12° dia indicando uma provável ligação não acumulativa ou linear. Outras variáveis avaliadas neste estudo que apresentaram associação direta com a ocorrência de ventriculite foram o sexo masculino, hemorragia subdural e infecções em outros sítios, principalmente a sepses. Variáveis como idade, procedimentos invasivos, TCE aberto, fístulas liquóricas, hemorragia intraventricular, múltiplas ventriculostomias, presença de PIC acima de 20mmHg, intercorrências durante a cateterização ou manutenção desta não apresentaram associação com a taxa ventriculite, no entanto muitas destas variáveis estiveram presentes em poucos casos dificultando uma conclusão definitiva. / Intraventricular monitoring of the intracranial pressure (ICP) with continuous drainage of cerebrospinal fluid (CSF) is already a widespread procedure in neurosurgical practice and considered as of great diagnostic, therapeutic and prognostic importance due to its precision. However, as it is an invasive method, it presents a potential risk of complications, the infection being the most frequent. The present study aims at verifying and analyzing the rates of infection originating from this monitoring method of ICP, as well as the rates of its risk factors. The information obtained from case histories and laboratory test files were recorded on two own separate data collection cards and later submitted to statistical tests like the Kruskal-Wallis, Mann-Whitney, Chi-Square, Fisher’s exact test, and Spearman correlation coefficients. Relative and absolute, average and standard deviation frequency were verified, 5% was the significance level utilized for the tests. The population of this study was of 79 patients, 70.9% of which were male averaging 37.7 years of age, this being so that the diagnostics present in 82.3% are related to traumatic head injury followed by intracranial tumors and stroke. All of them made use of antibioticprophylaxis. The ventriculitis rate was of 26.6 %, the catheter remaining, on average, 6.7 days and showing variable daily rates of this infection. We have not found a statistically meaningful association between monitoring time and infection, however there was an increase in the daily ventriculitis rate after the first three days and peaks on the 6th, 9th and 12th days showing a probable non-cumulative or linear link. Other variables evaluated in this study which presented a direct association with the occurrence of ventriculitis were the male sex, subdural hemorrhage and infections at other sites, mainly sepsis. Variables such as age, invasive procedures, open traumatic head injury, CSF leaks, intraventricular hemorrhage, multiple ventriculostomies, presence of ICP above 20mmHg, intercurrences during catheterization or its maintenance did not show association with the ventriculitis rate, nevertheless many of these variables were present in few cases making a definite conclusion difficult.

Introdução. As hemisferectomias são cirurgias utilizadas há décadas para se tratar epilepsias refratárias à medicação anticonvulsivante. Embora o controle das crises seja satisfatório, a morbidade, per e pós-operatória, ainda é considerada um importante fator limitante à sua utilização. Dessa maneira, compreender as complicações mais comuns do procedimento, e os fatores que as influenciam, é essencial para se estabelecer o melhor uso para a técnica. Métodos. Foram coletados dados de 30 pacientes, operados por seis cirurgiões no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo no período entre 1980 e 2003. Foram realizadas 11 hemisferectomias com a abordagem de Rasmussen, três hemisferectomias anatômicas, nove hemisferectomias funcionais extraventriculares e sete hemisferotomias. Foram estudados cinco grupo de pacientes de acordo com a fisiopatologia da doença de base: Dezesseis pacientes eram portadores de Síndrome de Rasmussen, dois da Síndrome de Sturge-Weber, quatro de malformações corticais, dois de lesões sequelares e seis de cistos porencefálicos. Os fatores de morbidade foram avaliados dentro de rês perspectivas: 1- da doença de base; 2- da técnica utilizada; e 3- do fator humano. Resultados. Nossos dados mostraram ausência de diferença estatisticamente significativa entre as técnicas cirúrgicas empregadas nos itens: tempo cirúrgico; tempo de internação na unidade de terapia intensiva; queda da hemoglobina; volume de hemoderivados transfundidos e febre no pós-operatório. Presença de leucograma acima de 15.000 leucócitos/mm3 no pós-operatório imediato foi associada a estadias mais longas na unidade de terapia intensiva A média diária de temperatura dos pacientes, mostrou temperaturas acima de 38º C entre o terceiro e sexto dia pós-operatório. Pacientes com hemimegalencefalia apresentaram temperaturas mais elevadas quando comparados com os portadores de cistos porencefálicos. Doenças com maior manto cortical contribuíram para aumentar o tempo cirúrgico, embora o fator humano tenha sido decisivo nesse item. Ao comparar nossos achados com os da literatura, vimos que os pacientes submetidos à hemisferectomia anatômica apresentaram no pós-operatório temperaturas mais elevadas e reação inflamatória liquórica mais intensa que os submetidos a técnicas de desconexão hemisférica, no entanto, a importância desse dado necessita ser estabelecida. Conclusões: O principal fator de morbidade nas hemisferectomias é a doença de base, assim, os dados presentes na literatura, incluindo nossa casuística, não nos permite concluir que uma técnica seja superior à outra ou que as técnicas desconectivas sejam melhores que as ressectivas / Hemispherectomy has been the treatment of choice in some sorts of refractory epilepsies for decades. Although surgery results in satisfactory control of seizures, its morbidity remains a major concern. Thus, understanding most common complications, as well as the factors that contribute to it, becomes an essential step to learn the limits on technique applications. Methods. Hospital charts from 30 patients operated on by six different surgeons at the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo from 1980 to 2003 were reviewed. Eleven functional hemispherectomies using Rasmussen approach, three anatomical hemispherectomies, nine extraventricular functional hemispherectomies, and seven hemispherotomies were included in this study. Sixteen patients presented with Rasmussen Syndrome, two Sturge-Weber Syndrome, four cortical malformations, two hemispheric lesions, and six porencephalic cysts. Morbidity was evaluated from three different perspectives 1- background disease, 2- employed technique, and 3- human factor. Results: our data presented no statistical difference among the employed techniques regarding 1- surgical time, 2- intensive care unit time, 3- per and postoperative fall of hemoglobin, 4- blood transfusion volume, and 5- postoperative axilar temperature variation. Patients that presented over 15,000 leucocytes per mm3 stayed longer at the intensive care unit, regardless of the surgical technique employed. Daily average temperatures varied around 38 degrees Celsius from the third to the sixth postoperative day. Patients with hemimegalencephaly had higher postoperative axilar temperatures when compared to those with porencephaly. Thicker cortical mantle contributed to increase surgical time, though human factor also showed to be important in this item. Comparing data from this study and the literature disclosed that patients undergoing anatomical hemispherectomies presented an inflammatory response in the cerebrospinal fluid more evident than those submitted to cerebral disconnection, although the importance of this finding is still elusive. Conclusions: The main factors of morbidity in the hemispherectomy are the background disease and patient\'s peculiarities, therefore, it is not reasonable to infer that there is a superior technique or that hemisphere disconnection is better than removal

Abstract The purpose of the present study was to implement a unique low-field open magnetic resonance scanner for perioperative imaging in neurosurgery. A paradigm was created for joint intraoperative/interventional MRI, including premises, surgical practice and an operational model. The feasibility of the paradigm was tested in clinical work. The joint use of the facilities between the Departments of Neurosurgery and Diagnostic Radiology was found to enhance the economic rationale and provide for perioperative imaging. It was also found to be organizationally viable in the long run. Intraoperative MRI was implemented and studied in connection with neuronavigation and other intraoperative instruments, tools and imaging modalities. The unique shut down possibility of the magnet enabled staged operating-imaging practice, use of non-MRI-compatible instruments and devices, multimodal imaging with navigation, and avoidance of safety risks associated with operating in magnetic fringe fields. Two dynamic contrast enhanced MR imaging sequences, which used undersampled projection reconstruction, were implemented in the low-field scanner. The applicability of these imaging sequences to follow contrast enhancement of meningiomas was studied in laboratory experiments and in two patient cases. The laboratory experiments showed a nearly linear response in signal intensity to the concentration of gadopentetate dimeglumine in purified water up to 1.25 mM. The patient cases showed results consistent with an earlier study performed at high-field strength. The potential of low-field MRI study including dynamic contrast enhanced imaging to predict surgical and histopathologic characteristics of meningiomas was studied in a series of 21 patients. Dynamic contrast enhanced imaging could be used to evaluate microvessel densities of meningiomas. Surgical bleeding, blood loss during operation, progesterone receptor expression and collagen content were statistically best correlated to the relative intensity of meningioma on FLAIR images. Tissue hardness correlated best with relative intensity on T2-weighted images.

With its increasing potential, Virtual Reality (VR) technology has found a growing presence in medical education. In the domain of neurosurgical training, VR has been thoroughly investigated, but gaps still persist, such as in the field of Minimally Invasive Surgery (MIS) and assistive visualizations. Thus, this thesis project aims at combining visualizations of motion captured surgical simulation data with a VR environment for training in the minimally invasive procedure of External Ventricular Drain (EVD) placement. A user study was conducted with the goal of investigating effectiveness (in terms of speed, confidence, and accuracy) when identifying certain features of the trajectory of a catheter simulating an EVD placement. The conditions compared were two visualization techniques, 4D-time density and trail, as well as a VR and desktop environment. The study employed a betweensubjects design when comparing visualizations and a within-subjects design when comparing environments. Results from 20 participants indicate a higher speed for the 4D-time density visualization compared to the trail visualization and no visualization in the VR environment. Participants also found the 4D-time density visualization significantly more helpful in VR compared to desktop, when identifying one of the features. The VR environment also had a significant positive impact on speed as well as confidence for certain combinations of the conditions, compared to the desktop environment. Further, participants tended to prefer the VR environment and found tasks easier in this environment. In conclusion, the 4D-time density visualization and VR environment have the potential to improve efficiency when interpreting and understanding the trajectory of a catheter during EVD placement. / Med ökande potential har Virtuell Verklighet-teknik (VR) funnit en växande närvaro inom medicinsk utbildning. Specifikt inom neurokirurgisk utbildning har VR undersökts grundligt, men hål i forskningen kvarstår, exempelvis inom området för minimalinvasiv kirurgi (MIS) och assisterande visualiseringar. Detta examensarbete syftar därför att kombinera visualiseringar av kirurgisk simuleringsdata, inspelad med hjälp av motion capture-teknik, med en VRmiljö för träning i den minimalinvasiva proceduren placering av Externt Ventrikulär Dränage (EVD). En användarstudie genomfördes med målet att undersöka effektivitet (i termer av hastighet, självförtroende och exakthet) vid identifiering av vissa kännetecken hos en kateters bana som simulerar en EVDplacering. Villkoren som jämfördes var två visualiseringstekniker, 4D-time Density och trail, samt de två miljöerna VR och desktop. I studien användes en testdesign där visualiseringarna jämfördes mellan två testgrupper och miljöerna jämfördes inom testgruppen. Resultat från 20 deltagare indikerar en högre hastighet för 4D-time-density visualiseringen jämfört med trail visualiseringen och ingen visualisering i VR-miljön. Deltagarna uppfattade också 4D-time-density visualiseringen som betydligt mer hjälpsam i VR jämfört med desktop, när de identifierade en av kännetecknen. Ytterligare hade VR-miljön en signifikant positiv inverkan på deltagarnas hastighet samt självförtroende för vissa kombinationer av villkor, jämfört med desktopmiljön. Deltagarna tenderade också att föredra VR-miljön och uppfattade uppgifterna som lättare i denna miljö. Sammanfattningsvis har 4D-time density visualiseringen och VR-miljön potential att förbättra effektiviteten när man tolkar och bildar en uppfattning om en kateters bana under EVDplacering.

INTRODUÇÃO: A autorregulação cerebral representa um dos mecanismos fisiopatológicos incertos na hemorragia intracerebral espontânea, cujo comprometimento pode influenciar no resultado prognóstico e terapêutico. O objetivo deste trabalho é avaliar a autorregulação cerebral dinâmica em modelo suíno de hemorragia intracerebral espontânea através do índice de reatividade pressórica cerebrovascular e determinar a eficácia das intervenções clínicas e cirúrgicas. MÉTODOS: Foram estudados 21 suínos híbridos machos com idade de 3 meses. O modelo experimental simulou o efeito expansivo de uma hemorragia intracerebral espontânea de grande volume quando comparado ao cérebro humano. Foram avaliados volumes de expansão diferentes, distribuídos em três grupos com sete suínos cada. O protocolo anestésico incluiu uma monitoração hemodinâmica invasiva associada a preservação da autorregulação cerebral. Os experimentos foram submetidos a monitoração neurológica multimodal e divididos em 5 fases. O índice de reatividade pressórica cerebrovascular estimou a autorregulacão cerebral durante todas as fases, sendo as três primeiras sem intervenções terapêuticas e as duas últimas para avaliar a eficácia das intervenções salina hipertônica e cirurgia. RESULTADOS: Os grupos avaliados foram homogêneos e sem diferença estatística quanto ao comprometimento da autorregulação cerebral comparando os diferentes volumes e tempos de compressão durante as duas primeiras horas da expansão do volume intracraniano. O comprometimento do índice de reatividade pressórica cerebrovascular ocorreu em alguns experimentos influenciando nas fases de tratamento subsequentes, salina hipertônica e cirurgia. CONCLUSÕES: Volumes expansivos elevados podem comprometer a autorregulação cerebral dinâmica e apresentar desfecho terapêutico desfavorável. A intervenção clínica e cirúrgica tem benefício nos experimentos com preservação do índice de reatividade pressórica cerebrovascular / INTRODUCTION: Cerebral autoregulation represents one of the uncertain pathophysiological mechanisms in spontaneous intracerebral hemorrhage, whose impairment may influence prognostic and therapeutic outcome. The aim of this study was to evaluate the dynamic cerebral autoregulation in the swine model of spontaneous intracerebral hemorrhage through the cerebrovascular reactivity index and to determine the efficacy of clinical and surgical interventions. METHODS: Twenty-one male hybrid pigs aged 3 months were studied. The experimental model simulated the expansive effect of a large intracerebral hemorrhage when compared to the human brain. Different volumes were evaluated, distributed in three groups with seven pigs each. Each experiment was divided in five phases. The anesthetic protocol included invasive hemodynamic monitoring associated with the preservation of cerebral autoregulation. Multimodallity monitoring was realised in all experiments. The cerebrovascular reactivity index estimated the cerebral autoregulation during all phases. The first three phases were without therapeutic interventions, and the last two phases were with therapeutic intervention of hypertonic saline solution and neurosurgery respectively. RESULTS: The evaluated groups were homogeneous and without statistical difference regarding the impairment of the cerebral autoregulation comparing different volumes and compression times during the first two hours of the intracranial volume expansion. CONCLUSIONS: Elevated expansive volumes may compromise dynamic cerebral autoregulation and have unfavorable therapeutic outcome. Clinical and surgical intervention had benefit in the experiments with preservation of cerebrovascular reactivity index

INTRODUÇÃO: A autorregulação cerebral representa um dos mecanismos fisiopatológicos incertos na hemorragia intracerebral espontânea, cujo comprometimento pode influenciar no resultado prognóstico e terapêutico. O objetivo deste trabalho é avaliar a autorregulação cerebral dinâmica em modelo suíno de hemorragia intracerebral espontânea através do índice de reatividade pressórica cerebrovascular e determinar a eficácia das intervenções clínicas e cirúrgicas. MÉTODOS: Foram estudados 21 suínos híbridos machos com idade de 3 meses. O modelo experimental simulou o efeito expansivo de uma hemorragia intracerebral espontânea de grande volume quando comparado ao cérebro humano. Foram avaliados volumes de expansão diferentes, distribuídos em três grupos com sete suínos cada. O protocolo anestésico incluiu uma monitoração hemodinâmica invasiva associada a preservação da autorregulação cerebral. Os experimentos foram submetidos a monitoração neurológica multimodal e divididos em 5 fases. O índice de reatividade pressórica cerebrovascular estimou a autorregulacão cerebral durante todas as fases, sendo as três primeiras sem intervenções terapêuticas e as duas últimas para avaliar a eficácia das intervenções salina hipertônica e cirurgia. RESULTADOS: Os grupos avaliados foram homogêneos e sem diferença estatística quanto ao comprometimento da autorregulação cerebral comparando os diferentes volumes e tempos de compressão durante as duas primeiras horas da expansão do volume intracraniano. O comprometimento do índice de reatividade pressórica cerebrovascular ocorreu em alguns experimentos influenciando nas fases de tratamento subsequentes, salina hipertônica e cirurgia. CONCLUSÕES: Volumes expansivos elevados podem comprometer a autorregulação cerebral dinâmica e apresentar desfecho terapêutico desfavorável. A intervenção clínica e cirúrgica tem benefício nos experimentos com preservação do índice de reatividade pressórica cerebrovascular / INTRODUCTION: Cerebral autoregulation represents one of the uncertain pathophysiological mechanisms in spontaneous intracerebral hemorrhage, whose impairment may influence prognostic and therapeutic outcome. The aim of this study was to evaluate the dynamic cerebral autoregulation in the swine model of spontaneous intracerebral hemorrhage through the cerebrovascular reactivity index and to determine the efficacy of clinical and surgical interventions. METHODS: Twenty-one male hybrid pigs aged 3 months were studied. The experimental model simulated the expansive effect of a large intracerebral hemorrhage when compared to the human brain. Different volumes were evaluated, distributed in three groups with seven pigs each. Each experiment was divided in five phases. The anesthetic protocol included invasive hemodynamic monitoring associated with the preservation of cerebral autoregulation. Multimodallity monitoring was realised in all experiments. The cerebrovascular reactivity index estimated the cerebral autoregulation during all phases. The first three phases were without therapeutic interventions, and the last two phases were with therapeutic intervention of hypertonic saline solution and neurosurgery respectively. RESULTS: The evaluated groups were homogeneous and without statistical difference regarding the impairment of the cerebral autoregulation comparing different volumes and compression times during the first two hours of the intracranial volume expansion. CONCLUSIONS: Elevated expansive volumes may compromise dynamic cerebral autoregulation and have unfavorable therapeutic outcome. Clinical and surgical intervention had benefit in the experiments with preservation of cerebrovascular reactivity index