RESUMO A clipagem microcirúrgica é, atualmente, o principal método de tratamento dos aneurismas cerebrais, mesmo com o aprimoramento das técnicas de terapia endovascular nos últimos anos. O tratamento visa à oclusão completa da lesão, o que nem sempre é factível. Apesar de parecer superior ao tratamento endovascular, a clipagem microcirúrgica pode apresentar porcentagens variadas de oclusão incompleta. Tal incidência pode ser reduzida com utilização de estudo vascular intraoperatório. Algumas classificações foram elaboradas na tentativa de padronizar as características das lesões residuais, mas os critérios de classificação e a terminologia utilizados nos trabalhos mantêm-se vagos e pobremente documentados, não havendo consenso para uma classificação uniforme. Dessa forma, não há também concordância sobre quais aneurismas residuais devam ser submetidos a tratamento. O objetivo do presente estudo é realizar uma revisão da literatura a respeito das lesões residuais após microcirurgia para tratamento dos aneurismas cerebrais e como proceder diante dessas.

SUMMARY Microsurgical clipping is currently the main method of treating cerebral aneurysms, even with the improvement of endovascular therapy techniques in recent years. Treatment aims at complete occlusion of the lesion, which is not always feasible. Although appearing superior to endovascular treatment, microsurgical clipping may present varying percentages of incomplete occlusion. Such incidence may be reduced with the use of intraoperative vascular study. Some classifications were elaborated in an attempt to standardize the characteristics of residual lesions, but the classification criteria and terminology used in the studies remain vague and poorly documented, and there is no consensus for a uniform classification. Thus, there is also no agrément on which residual aneurysms should be treated. The aim of this study is to review the literature on residual lesions after microsurgery to treat cerebral aneurysms and how to proceed with them.

OBJECTIVES: This study aimed to analyze the incidence and epidemiological, angiographic, and surgical aspects associated with incomplete clipping of brain aneurysms in a cohort of patients undergoing microsurgical treatment. METHODS: The medical record data of patients who underwent microsurgery for cerebral aneurysm treatment and postoperative digital subtraction angiography, treated at the same teaching hospital between 2014 and 2019, were retrospectively analyzed. The studied variables involved epidemiological and clinical data, as well as neurological status and findings on neuroimaging. The time elapsed between hemorrhage and microsurgical treatment, data on the neurosurgical procedure employed for aneurysm occlusion, and factors associated with the treated aneurysm, specifically location and size, were also evaluated. RESULTS: One hundred and seventeen patients were submitted to 139 neurosurgical procedures, in which 167 aneurysms were clipped. The overall rate of residual injury was 23%. Smoking (odds ratio [OR]: 3.38, 95% confidence interval [CI95%]: 1.372-8.300, p=0.008), lesion size >10 mm (OR: 5.136, CI95%: 2.240-11.779, p<0.001) and surgery duration >6 h (OR: 8.667, CI95%: 2.713-27.681, p<0.001) were found to significantly impact incomplete aneurysm occlusion in the univariate analyses. CONCLUSION: Incomplete microsurgical aneurysm occlusion is associated with aneurysm size, complexity, and current smoking status. Currently, there is no consensus on postoperative assessment of clipped aneurysms, hindering the correct assessment of treatment outcomes.

RESUMO Objetivo: avaliar o tratamento endovascular de lesões vasculares da artéria carótida interna (ACI), segmento cavernoso, realizado na Santa Casa de São Paulo. Métodos: estudo descritivo, retrospectivo e prospectivo, de pacientes com aneurisma da porção cavernosa da ACI ou com fístulas carótido-cavernosas diretas (FCCd) submetidos a tratamento endovascular. Resultados: foram incluídos 26 pacientes com aneurismas intracavernosos e dez com FCCd. Todos os aneurismas foram tratados com oclusão da ACI. Os com FCCd foram tratados com oclusão, em sete casos, e com oclusão seletiva da fístula nos outros três. Houve melhora da dor e proptose ocular em todos os pacientes com FCCd. Nos pacientes com aneurisma intracavernoso, a incidência de dor retro-orbitária caiu de 84,6% para 30,8% após o tratamento. Após o tratamento endovascular houve uma melhora importante da disfunção de nervos cranianos afetados em ambos os grupos, sobretudo no nervo oculomotor. Conclusão: o tratamento endovascular trouxe melhora para os pacientes deste estudo, especialmente nos critérios dor e acometimento do nervo oculomotor.

ABSTRACT Objective: to evaluate the endovascular treatment of vascular lesions of the cavernous segment of the internal carotidartery (ICA) performed at our institution. Methods: we conducted a descriptive, retrospective and prospective study of patients with aneurysms of the cavernous portion of the ICA or with direct carotid-cavernous fistulas (dCCF) undergoing endovascular treatment. Results: we included 26 patients with intracavernous aneurysms and ten with dCCF. All aneurysms were treated with ICA occlusion. Those with dCCF were treated with occlusion in seven cases and with selective fistula occlusion in the remaining three. There was improvement of pain and ocular proptosis in all patients with dCCF. In patients with intracavernous aneurysms, the incidence of retro-orbital pain fell from 84.6% to 30.8% after treatment. The endovascular treatment decreased the dysfunction of affected cranial nerves in both groups, especially the oculomotor one. Conclusion: the endovascular treatment significantly improved the symptoms in the patients studied, especially those related to pain and oculomotor nerve dysfunction.

RESUMO As fístulas carotidocavernosas (FCC) são comunicações anormais entre a artéria carótida e o seio cavernoso. Elas são consideradas diretas quando há uma comunicação direta entre a artéria carótida interna e o seio cavernoso. Nesses casos, são geralmente traumáticas. As FCC diretas são lesões de alto fluxo, podendo estar relacionadas a sangramento intracraniano, perda visual, exposição corneana ou até mesmo a epistaxe fatal. Seu tratamento é sempre indicado. O tratamento ideal da FCC direta é a exclusão da fístula da circulação, com preservação do fluxo carotídeo. Isso pode ser obtido por meio de técnicas endovasculares diversas. O objetivo do presente artigo é realizar uma revisão sobre as FCC diretas, com especial enfoque nas opções de tratamento endovascular disponíveis na atualidade.

SUMMARY Carotid cavernous fistulas (CCFs) are abnormal connections between the carotid artery and the cavernous sinus. They are considered direct when there is a direct connection between the internal carotid artery and the cavernous sinus. These cases are generally traumatic. Direct CCFs are high-flow lesions, possibly related to intracranial bleeding, visual loss, corneal exposure or even fatal epistaxis. Treatment of such lesions is, thus, always recommended. The ideal treatment for direct CCF is to exclude the fistula from circulation, preserving the carotid flow. This can be attained using diverse endovascular techniques. The objective of the present article is to review the current techniques for treatment of direct CCFs, with special attention to the currently available endovascular treatment options.

RESUMO Introdução: o tratamento da infecção pelo vírus da imunodeficiência humana (HIV) tem diminuído a morbidade e a mortalidade por infecções oportunistas nesses pacientes e, portanto, aumentado a sobrevida. Essa nova realidade tem mudado o espectro de doenças que afetam esses pacientes. Objetivo: discutir a associação entre HIV e ocorrência de aneurismas cerebrais. Método: foi realizada revisão da literatura utilizando bancos de dados médicos. Foram pesquisados os seguintes descritores: "HIV e aneurismas intracranianos", "aneurismas intracranianos e síndrome da imunodeficiência adquirida", aneurismas, cérebro e HIV. Resultados: a relação entre a infecção pelo HIV e a formação de aneurismas parece ser real; porém, ainda faltam dados que confirmem a fisiopatologia dessa condição e seu melhor tratamento. Conclusão: existem novos sinais e sintomas, que devem ser estudados e pesquisados, relacionando o HIV com outras alterações previamente desconhecidas.

SUMMARY Introduction: the treatment of human immunodeficiency virus (HIV) infection has been decreasing patient morbidity and mortality by opportunistic infections and, thus, survival has increased. This new reality has been changing the spectrum of diseases affecting such patients. Objective: to discuss the association between HIV and the emergence of aneurysmal brain injuries. Method: it was performed a literature review using medical database. The following descriptors were searched: "Intracranial Aneurysms and HIV", "Intracranial Aneurysms and Acquired Immunodeficiency Syndrome," "aneurysm and brain and HIV". Results: after performed a literature review, it was observed that the relationship between HIV infection and the formation of aneurysms appears to be real, however, it still lacks data to confirm the pathophysiology of this condition and its best treatment. Conclusion: there are new signs and symptoms that should be studied and researched relating HIV with other changes not previously known.

Objetivo Descrever e analisar a técnica empregada para a cateterização bilateral dos seios petrosos inferiores (SPI) em nosso serviço, discutindo as dificuldades e as taxas de sucesso encontradas. Sujeitos e métodos Entre 2009 e 2012, foram submetidos ao cateterismo bilateral dos SPI 14 pacientes com suspeita de síndrome de Cushing, sendo descrita a técnica empregada para o cateterismo e para a análise hormonal. Resultados O procedimento foi bem tolerado por todos os pacientes, sendo alcançada a cateterização adequada dos SPI em 92,85% dos casos. O diagnóstico de doença de Cushing foi firmado em 10 casos, sendo o resultado do cateterismo dos SPI após estímulo com CRH coerente em todos, não havendo falso-negativos. Conclusão O cateterismo dos SPI, apesar de ser uma técnica invasiva, é um procedimento seguro. A sua realização pode ser feita de forma adequada na maioria dos casos e, quando bem indicada, permanece como padrão-ouro na distinção da forma hipofisária da ectópica na síndrome de Cushing.

Objective To describe and analyze technique for bilateral catheterization of inferior petrosal sinus in our service, discussing the difficulties and success rates found. Subjects and methods Fourteen patients with suspected Cushing’s syndrome underwent bilateral inferior petrosal sinuses (IPS) catheterization between 2009 and 2012. The technique for catheterization and for hormone analysis were described. Results The procedure was well tolerated by all patients, and adequate catheterization was achieved in 92.85% of cases. The diagnosis of Cushing’s disease was confirmed in 10 cases. The result of IPS catheterization after CRH infusion was coherent in all cases, without false negatives. Conclusion The catheterization of IPS, despite being an invasive technique, is a safe procedure. The objectives can be done properly in most cases. When well indicated, this procedure remains the gold standard in distinguishing the ectopic form to pituitary source in Cushing’s syndrome.

OBJECTIVES: Evaluate the degree of vascular occlusion, vascular recanalization, and necrosis of the vascular wall caused by polyvinyl alcohol-covered polyvinyl acetate (PVAc) particles compared to trisacryl particles after renal embolization. METHODS: Seventy-nine female albino New Zealand rabbits underwent arterial catheterization of the right kidney. Thirty-three animals were embolized with trisacryl particles, thirty-one with PVAc particles, and fifteen were kept as controls. Four animals were excluded (three trisacryl and one PVAc) due to early death. Five subgroups of six animals were created. The animals in the different groups were sacrificed either 48 hours, 5 days, 10 days, 30 days, or 90 days after embolization. The control group was divided into subgroups of three animals each and kept for the same periods of time. The kidneys were dyed with hematoxylin-eosin and Masson's trichrome and then examined using optical microscopy. RESULTS: There were significant differences in the degree of vascular occlusion caused by the trisacryl and the PVAc particles between the five-day and the ten-day groups. Additional differences were noted between the five-day and 48-hour groups in regard to the amount of necrosis. For both findings, the PVAc group members showed adequate tissue reaction (ischemia and volumetric reduction) and less recanalization than those treated with trisacryl. CONCLUSION: The use of PVAc as an embolization material exhibited an adequate tissue reaction (ischemia and volumetric reduction), more expressive vascular occlusion and necrosis, and less recanalization than the trisacryl material.