Resumo Antecedentes Em 2012, a Neurocritical Care Society lançou uma compilação de protocolos sobre as questões centrais que devem ser abordadas nas primeiras horas de emergências neurológicas – Emergency neurological life support (ENLS). Objetivo Avaliar a repercussão do ENLS por meio de uma análise bibliométrica. Métodos A base de dados Scopus foi utilizada em outubro de 2022 para a busca por artigos mencionando o ENLS. As seguintes variáveis foram obtidas: número de citações; número de citações por ano; número de publicações por ano; ano de publicação; tipo de pesquisa; país do autor correspondente e sua categoria de renda; revista de publicação e seu fator de impacto de 5 anos (IF); e seção onde o ENLS apareceu. Resultados Os 421 artigos incluídos foram publicados de 2012 a 2022. A média de citações por artigo foi de 17.46 (intervalo de confiança (IC) 95% = 8.20–26.72), enquanto a de citações por ano por artigo foi de 4.05 (IC95% = 2.50–5.61). O IF médio por revista foi de 5.14 (IC95% = 4.19–6.09). A maioria dos artigos era de pesquisa secundária (57.48%; n= 242/421), dos quais a maioria eram revisões narrativas (71.90%; n= 174/242). Os países de alta renda foram os mais prolíficos (80.05%; n= 337/421 artigos). Não houve publicações de países de baixa ou média renda. Conclusão Embora ainda baixo, o número de publicações mencionando o ENLS vem aumentando recentemente. A maioria dos artigos foram publicados em revistas de medicina intensiva, neurologia, neurocirurgia e medicina de emergência. Artigos de pesquisa secundária foram os mais comuns, com revisões narrativas sendo o subtipo mais frequente. . (ENLS) bibliométrica 202 obtidas (IF) apareceu 42 201 1746 17 46 17.4 intervalo IC (IC 95 8.20–26.72, 8202672 8.20–26.72 , 8 20 26 72 8.20–26.72) 405 4 05 4.0 IC95% IC95 (IC95 2.50–5.61. 250561 2.50–5.61 2 50 61 2.50–5.61) 514 14 5.1 4.19–6.09. 419609 4.19–6.09 19 6 09 4.19–6.09) 57.48% 5748 57 48 (57.48% n 242/421, 242421 242/421 242 242/421) 71.90% 7190 71 90 (71.90% 174/242. 174242 174/242 174 174/242) 80.05% 8005 80 (80.05% 337421 337 337/42 artigos. artigos) baixo recentemente intensiva neurologia emergência comuns frequente (ENLS (IF 1 17. 9 820267 8.20–26.7 7 40 0 4. IC9 (IC9 25056 2.50–5.6 51 5. 41960 4.19–6.0 57.48 574 (57.48 24242 242/42 24 71.90 719 (71.90 17424 174/24 80.05 800 (80.05 33742 33 337/4 82026 8.20–26. 2505 2.50–5. 4196 4.19–6. 57.4 (57.4 2424 242/4 71.9 (71.9 1742 174/2 80.0 (80.0 3374 3 337/ 8202 8.20–26 250 2.50–5 419 4.19–6 57. (57. 242/ 71. (71. 174/ 80. (80. 820 8.20–2 25 2.50– 41 4.19– (57 (71 (80 82 8.20– 2.50 4.19 (5 (7 (8 8.20 2.5 4.1 ( 8.2 2. 8.

Abstract Background In 2012, the Neurocritical Care Society launched a compilation of protocols regarding the core issues that should be addressed within the first hours of neurological emergencies – the Emergency neurological life support (ENLS). Objective We aim to evaluate this repercussion through a bibliometric analysis. Methods We searched Scopus on October 2022 for articles mentioning ENLS. The following variables were obtained: number of citations; number of citations per year; number of publications per year; year of publication; research type; research subtype; country of corresponding author and its income category and world region; journal of publication and its 5-year impact factor (IF); and section where ENLS appeared. Results After applying eligibility criteria, we retrieved 421 articles, published from 2012 to 2022. The mean number of citations per article was 17.46 (95% Confidence Interval (CI) = 8.20–26.72), while the mean number of citations per year per article was 4.05 (95% CI = 2.50–5.61). The mean destiny journal 5-year IF was 5.141 (95% CI = 4.189–6.093). The majority of articles were secondary research (57.48%; n= 242/421) of which most were narrative reviews (71.90%; n= 174/242). High-Income countries were the most prominent (80.05%; n= 337/421 articles). There were no papers from low-income countries. There were no trials or systematic reviews from middle-income countries. Conclusion Although still low, the number of publications mentioning ENLS is increasing. Articles were mainly published in journals of intensive care medicine, neurology, neurosurgery, and emergency medicine. Most articles were published by authors from high-income countries. The majority of papers were secondary research, with narrative review as the most frequent subtype. . (ENLS) analysis 202 obtained type subtype region 5year 5 (IF) appeared criteria 42 201 1746 17 46 17.4 95% 95 (95 (CI 8.20–26.72, 8202672 8.20–26.72 , 8 20 26 72 8.20–26.72) 405 4 05 4.0 2.50–5.61. 250561 2.50–5.61 2 50 61 2.50–5.61) 5141 141 5.14 4.189–6.093. 41896093 4.189–6.093 189 6 093 4.189–6.093) 57.48% 5748 57 48 (57.48% n 242/421 242421 242 71.90% 7190 71 90 (71.90% 174/242. 174242 174/242 174 174/242) HighIncome High Income 80.05% 8005 80 (80.05% 337421 337 337/42 articles. articles) lowincome low middleincome middle increasing medicine neurology neurosurgery highincome high (ENLS (IF 1 17. 9 (9 820267 8.20–26.7 7 40 0 4. 25056 2.50–5.6 514 14 5.1 4189609 4.189–6.09 18 09 57.48 574 (57.48 242/42 24242 24 71.90 719 (71.90 17424 174/24 80.05 800 (80.05 33742 33 337/4 ( 82026 8.20–26. 2505 2.50–5. 51 5. 418960 4.189–6.0 57.4 (57.4 242/4 2424 71.9 (71.9 1742 174/2 80.0 (80.0 3374 3 337/ 8202 8.20–26 250 2.50–5 41896 4.189–6. 57. (57. 242/ 71. (71. 174/ 80. (80. 820 8.20–2 25 2.50– 4189 4.189–6 (57 (71 (80 82 8.20– 2.50 418 4.189– (5 (7 (8 8.20 2.5 41 4.189 8.2 2. 4.18 8. 4.1

RESUMO Antecedentes Existem poucos dados sobre a influência da homocisteína na formação e rotura de aneurismas intracranianos (AI). Objetivo Comparar os níveis de homocisteína entre pacientes com AI rotos e não rotos e influências no vasoespasmo e resultados funcionais. Métodos Estudo caso-controle, que avaliou as diferenças de homocisteinemia entre pacientes com aneurismas rotos e não rotos, além da associação entre níveis de homocisteína, vasoespasmo e estado funcional. Regressões logísticas foram realizadas. Resultados Um total de 348 participantes foram incluídos: 114 (32,8%) com aneurismas rotos e 234 (67,2%) não rotos. A homocisteína mediana foi de 10,75μmol/L (IQR = 4,59) nos rotos e 11,5μmol/L (IQR = 5,84) nos não rotos. Não houve associação significativa entre os níveis de homocisteína e o status de ruptura (OR = 0,99, 95% CI = 0,96-1,04). Nem a hiperhomocisteinemia leve (>15μmol/L; OR = 1,25, 95% CI = 0,32-4,12) nem a moderada (>30μmol/L; OR = 1,0, 95% CI = 0,54-1,81) mostraram correlações significativas com aneurismas rotos. Modelos univariados (OR = 0,86; 95% CI = 0,71-1,0) e multivariados ajustados por idade (OR = 0,91; 95% CI = 0,75-1,05) não evidenciaram associação entre homocisteína e vasoespasmo. A homocisteinemia não influenciou resultados funcionais excelentes em seis meses (mRS ≤ 1) (OR = 1,04; 95% CI = 0,94-1,16). Conclusão Não houve diferenças em relação à homocisteinemia entre pacientes com aneurismas intracranianos rotos e não rotos. Em pacientes com aneurismas rotos, a homocisteinemia não foi associada ao vasoespasmo ou resultados funcionais. AI. . (AI) casocontrole, casocontrole caso controle, controle caso-controle funcional realizadas 34 incluídos 11 32,8% 328 32 8 (32,8% 23 67,2% 672 67 2 (67,2% 1075μmolL μmolL 10 75μmol L μmol IQR 4,59 459 4 59 115μmolL 5μmol 5,84 584 5 84 099 0 99 0,99 95 0,961,04. 096104 0,96 1,04 96 1 04 0,96-1,04) >15μmol/L 15μmolL 15μmol (>15μmol/L 125 25 1,25 0,324,12 032412 0,32 4,12 12 0,32-4,12 >30μmol/L 30μmolL 30μmol (>30μmol/L 1,0 0,541,81 054181 0,54 1,81 54 81 0,54-1,81 0,86 086 86 0,711,0 07110 0,71 71 0,71-1,0 0,91 091 91 0,751,05 075105 0,75 1,05 75 05 0,75-1,05 mRS 104 0,941,16. 094116 0,94 1,16 94 16 0,94-1,16) (AI 3 32,8 (32,8 67,2 6 (67,2 4,5 45 5,8 58 09 9 0,9 961 0,961,04 09610 096 0,96-1,04 1,2 324 0,324,1 03241 032 0,3 412 4,1 0,32-4,1 1, 541 0,541,8 05418 054 0,5 181 1,8 0,54-1,8 0,8 08 711 0,711, 0711 071 0,7 7 0,71-1, 751 0,751,0 07510 075 105 0,75-1,0 941 0,941,16 09411 094 116 1,1 0,94-1,16 32, (32, 67, (67, 4, 5, 0, 0,961,0 0961 0,96-1,0 0,324, 0324 03 41 0,32-4, 0,541, 0541 18 0,54-1, 0,711 07 0,71-1 0,751, 0751 0,75-1, 0,941,1 0941 0,94-1,1 (32 (67 0,961, 0,96-1, 0,324 0,32-4 0,541 0,54-1 0,71- 0,751 0,75-1 0,941, 0,94-1, (3 (6 0,961 0,96-1 0,32- 0,54- 0,75- 0,941 0,94-1 ( 0,96- 0,94-

Abstract Background There is very few data regarding homocysteine's influence on the formation and rupture of intracranial aneurysms. Objective To compare homocysteine levels between patients with ruptured and unruptured intracranial aneurysms, and to evaluate possible influences of this molecule on vasospasm and functional outcomes. Methods This is a retrospective, case-control study. We evaluated homocysteinemia differences between patients with ruptured and unruptured aneurysms; and the association of homocysteine levels with vasospasm and functional outcomes. Logistic regressions were performed. Results A total of 348 participants were included: 114 (32.8%) with previous aneurysm rupture and 234 (67.2%) with unruptured aneurysms. Median homocysteine was 10.75μmol/L (IQR = 4.59) in patients with ruptured aneurysms and 11.5μmol/L (IQR = 5.84) in patients with unruptured aneurysms. No significant association was detected between homocysteine levels and rupture status (OR = 0.99, 95% CI = 0.96-1.04). Neither mild (>15μmol/L; OR = 1.25, 95% CI 0.32-4.12) nor moderate (>30μmol/L; OR = 1.0, 95% CI = 0.54-1.81) hyperhomocysteinemia demonstrated significant correlations with ruptured aneurysms. Neither univariate (OR = 0.86; 95% CI 0.71-1.0) nor multivariable age-adjusted (OR = 0.91; 95% CI = 0.75-1.05) models evidenced an association between homocysteine levels and vasospasm. Homocysteinemia did not influence excellent functional outcomes at 6 months (mRS≤1) (OR = 1.04; 95% CI = 0.94-1.16). Conclusion There were no differences regarding homocysteinemia between patients with ruptured and unruptured intracranial aneurysms. In patients with ruptured aneurysms, homocysteinemia was not associated with vasospasm or functional outcomes. homocysteines s retrospective casecontrol case control study performed 34 included 11 32.8% 328 32 8 (32.8% 23 67.2% 672 67 2 (67.2% 1075μmolL μmolL 10 75μmol L μmol IQR 4.59 459 4 59 115μmolL 5μmol 5.84 584 5 84 099 0 99 0.99 95 0.961.04. 096104 0.96 1.04 . 96 1 04 0.96-1.04) >15μmol/L 15μmolL 15μmol (>15μmol/L 125 25 1.25 0.324.12 032412 0.32 4.12 12 0.32-4.12 >30μmol/L 30μmolL 30μmol (>30μmol/L 1.0 0.541.81 054181 0.54 1.81 54 81 0.54-1.81 0.86 086 86 0.711.0 07110 0.71 71 0.71-1.0 ageadjusted age adjusted 0.91 091 91 0.751.05 075105 0.75 1.05 75 05 0.75-1.05 mRS≤1 mRS1 mRS (mRS≤1 104 0.941.16. 094116 0.94 1.16 94 16 0.94-1.16) 3 32.8 (32.8 67.2 (67.2 4.5 45 5.8 58 09 9 0.9 961 0.961.04 09610 096 0.96-1.04 1.2 324 0.324.1 03241 032 0.3 412 4.1 0.32-4.1 1. 541 0.541.8 05418 054 0.5 181 1.8 0.54-1.8 0.8 08 711 0.711. 0711 071 0.7 7 0.71-1. 751 0.751.0 07510 075 105 0.75-1.0 mRS≤ (mRS≤ 941 0.941.16 09411 094 116 1.1 0.94-1.16 32. (32. 67. (67. 4. 5. 0. 0.961.0 0961 0.96-1.0 0.324. 0324 03 41 0.32-4. 0.541. 0541 18 0.54-1. 0.711 07 0.71-1 0.751. 0751 0.75-1. (mRS 0.941.1 0941 0.94-1.1 (32 (67 0.961. 0.96-1. 0.324 0.32-4 0.541 0.54-1 0.71- 0.751 0.75-1 0.941. 0.94-1. (3 (6 0.961 0.96-1 0.32- 0.54- 0.75- 0.941 0.94-1 ( 0.96- 0.94-

Resumo Antecedentes O prognóstico da hemorragia subaracnoidea (HSA) permanece ruim. Vasoespasmo pode estar associado à inflamação. Razões neutrófilo-linfócito (NLR) e plaqueta-linfócito (PLR) têm sido estudadas como marcadores de inflamação e prognóstico. Objetivo Investigar NLR e PLR na admissão como preditores de vasoespasmo angiográfico e desfecho aos 6 meses. Métodos Este estudo de coorte incluiu pacientes consecutivos com HSA aneurismática de um centro terciário. Contagem de leucócitos, neutrófilos, linfócitos e plaquetas, proporção de neutrófilos para linfócitos e de plaquetas para linfócitos foram coletados como variáveis independentes. Ocorrência de vasoespasmo, escala de Rankin modificada, escala de desfecho de Glasgow e o escore de Hunt-Hess na admissão e 6 meses após a mesma foram registradas como variáveis dependentes. Modelos de regressão logística multivariável foram usados para ajustar potenciais fatores de confusão e avaliar valor prognóstico independente de NLR e PLR. Resultados Um total de 74,1% pacientes eram do sexo feminino, com idade média de 55,6 ± 12,4 anos. Na admissão, a pontuação média de Hunt-Hess foi de 2 (IQR 1) e a mediana de mFisher foi de 3 (IQR 1). Clipagem microcirúrgica foi o tratamento escolhido para 66,2% dos pacientes. A incidência de vasoespasmo angiográfico foi de 16,5%. Aos 6 meses, a escala de desfecho de Glasgow mediana era 4 (IQR 0,75) e a escala de Rankin modificada mediana era 3 (IQR 1,5). Vinte e um pacientes (15,1%) morreram. Os níveis de NLR e PLR não diferiram entre resultados funcionais favoráveis e desfavoráveis (mRS > 2 ou GOS < 4). Nenhuma variável foi significativamente associada ao vasoespasmo angiográfico. Conclusão Razão neutrófilo-linfócito e a PLR não apresentaram valor preditivo de desfecho funcional ou risco de vasoespasmo angiográfico. Mais pesquisas são necessárias neste campo. (HSA ruim neutrófilolinfócito neutrófilo linfócito (NLR plaquetalinfócito plaqueta (PLR terciário leucócitos independentes HuntHess Hunt Hess dependentes 741 74 1 74,1 feminino 556 55 55, 124 12 12, anos IQR 1. . 662 66 66,2 165 16 5 16,5% 0,75 075 0 75 1,5. 15 1,5 1,5) 15,1% 151 (15,1% morreram mRS 4. 4) campo 7 74, 66, 16,5 0,7 07 1, 15,1 (15,1 16, 0, 15, (15, (15 (1 (

Abstract Background Subarachnoid hemorrhage (SAH) prognosis remains poor. Vasospasm mechanism might be associated with inflammation. Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been studied as inflammation markers and prognostic predictors. Objective We aimed to investigate NLR and PLR in admission as predictors of angiographic vasospasm and functional outcome at 6 months. Methods This cohort study included consecutive aneurysmal SAH patients admitted to a tertiary center. Complete blood count was recorded at admission before treatment. White blood cell count, neutrophil count, lymphocyte count, platelet count, NLR, and PLR were collected as independent variables. Vasospasm occurrence-modified Rankin scale (mRS), Glasgow outcome scale (GOS), and Hunt-Hess score at admission and at 6 months were recorded as dependent variables. Multivariable logistic regression models were used to adjust for potential confounding and to assess the independent prognostic value of NLR and PLR at admission. Results A total of 74.1% of the patients were female, with mean age of 55.6 ± 12.4 years. At admission, the median Hunt-Hess score was 2 (interquartile range [IQR] 1), and the median mFisher was 3 (IQR 1). Microsurgical clipping was the treatment for 66.2% of the patients. Angiographic vasospasm incidence was 16.5%. At 6 months, the median GOS was 4 (IQR 0.75), and the median mRS was 3 (IQR 1.5). Twenty-one patients (15.1%) died. Neutrophil-to-lymphocyte ratio and PLR levels did not differ between favorable and unfavorable (mRS > 2 or GOS < 4) functional outcomes. No variables were significantly associated with angiographic vasospasm. Conclusion Admission NLR and PLR presented no value for prediction of functional outcome or angiographic vasospasm risk. Further research is needed in this field. (SAH poor Neutrophiltolymphocyte Neutrophil (NLR platelettolymphocyte (PLR center occurrencemodified occurrence modified mRS, , (mRS) GOS, (GOS) HuntHess Hunt Hess 741 74 1 74.1 female 556 55 55. 124 12 12. years interquartile IQR [IQR 1, 1) 1. . 662 66 66.2 165 16 5 16.5% 0.75, 075 0.75 0 75 0.75) 1.5. 15 1.5 1.5) Twentyone Twenty one 15.1% 151 (15.1% died outcomes risk field (GOS 7 74. 66. 16.5 07 0.7 15.1 (15.1 16. 0. 15. (15. (15 (1 (

ABSTRACT Purpose: Temporary arterial occlusion (TAO) is a widespread practice in the surgical treatment of intracranial aneurysms. This study aimed to investigate TAO’s role during ruptured aneurysm clipping as an independent prognostic factor on short- and long-term outcomes. Methods: This prospective cohort included 180 patients with ruptured intracranial aneurysms and an indication of microsurgical treatment. Patients who died in the first 12 hours after admission were excluded. Results: TAO was associated with intraoperative rupture (IOR) (odds ratio – OR = 10.54; 95% confidence interval – 95%CI 4.72–23.55; p < 0.001) and surgical complications (OR = 2.14; 95%CI 1.11–4.07; p = 0.01). The group with TAO and IOR had no significant difference in clinical (p = 0.06) and surgical (p = 0.94) complications compared to the group that had TAO, but no IOR. Among the 111 patients followed six months after treatment, IOR, number of occlusions, and total time of occlusion were not associated with Glasgow Outcome Scale (GOS) in the follow-up (respectively, p = 0.18, p = 0.30, and p = 0.73). Among patients who underwent TAO, IOR was also not associated with GOS in the follow-up (p = 0.29). Conclusions: TAO was associated with IOR and surgical complications, being the latter independent of IOR occurrence. In long-term analysis, neither TAO nor IOR were associated with poor clinical outcomes. Purpose (TAO TAOs s short longterm long term outcomes Methods 18 1 excluded Results (IOR odds 10.54 1054 10 54 95 95CI CI 4.72–23.55 4722355 4 72 23 55 0.001 0001 0 001 2.14 214 2 14 1.11–4.07 111407 11 07 0.01. 0.01 . 01 0.01) 0.06 006 06 0.94 094 94 occlusions (GOS followup follow up respectively, respectively (respectively 018 0.18 030 30 0.30 0.73. 073 0.73 73 0.73) 0.29. 029 0.29 29 0.29) Conclusions occurrence analysis 10.5 105 5 9 4.72–23.5 472235 7 0.00 000 00 2.1 21 1.11–4.0 11140 0.0 0.9 09 0.1 03 3 0.3 0.7 02 0.2 10. 4.72–23. 47223 2. 1.11–4. 1114 0. 4.72–23 4722 1.11–4 4.72–2 472 1.11– 4.72– 47 1.11 4.72 1.1 4.7 1. 4.

SUMMARY OBJECTIVE: The aim of this study was to carry out a systematic review of the literature with meta-analysis to evaluate the effect of using oral contraceptive and hormone replacement therapy as a protective factor in the formation of intracranial aneurysms and subarachnoid hemorrhage. METHODS: This is a systematic review of the literature with meta-analysis, using PubMed and Embase as databases and the PRISMA method. Case-control and cohort studies published until December 2022 were included in this review. RESULTS: Four studies were included in this review; three of which were eligible for meta-analysis. Regarding the use of oral contraceptive and the development of subarachnoid hemorrhage, there was a lower risk of aneurysm rupture with an odds ratio 0.65 (confidence interval 0.5–0.85). In the analysis of patients using hormone replacement therapy and developing subarachnoid hemorrhage, there was also a lower risk of aneurysm rupture with an OR 0.54 (CI 0.39–0.74). Only one article analyzed the formation of intracranial aneurysm and the use of hormone replacement therapy and oral contraceptive, and there was a protective effect with the use of these medications. oral contraceptive: OR 2.1 (CI 1.2–3.8) and hormone replacement therapy: OR 3.1 (CI 1.5–6.2). CONCLUSION: The use of hormone replacement therapy and oral contraceptive has a protective effect in intracranial aneurysm rupture and formation. OBJECTIVE metaanalysis meta hemorrhage METHODS metaanalysis, analysis, method Casecontrol Case control 202 RESULTS metaanalysis. analysis. 065 0 65 0.6 confidence 0.5–0.85. 05085 0.5–0.85 . 5 85 0.5–0.85) 054 54 0.5 CI 0.39–0.74. 039074 0.39–0.74 39 74 0.39–0.74) medications 21 2 1 2. 1.2–3.8 1238 3 8 31 3. 1.5–6.2. 1562 1.5–6.2 6 1.5–6.2) CONCLUSION 20 06 0. 0508 0.5–0.8 05 03907 0.39–0.7 7 1.2–3. 123 156 1.5–6. 050 0.5–0. 0390 0.39–0. 1.2–3 12 15 1.5–6 0.5–0 039 0.39–0 1.2– 1.5– 0.5– 03 0.39– 1.2 1.5 0.39 1. 0.3

Resumo Antecedentes Os neutrófilos para linfócitos (NLR), monócitos para linfócitos (MLR), proporção de plaquetas para linfócitos (PLR) e largura de distribuição de glóbulos vermelhos (RDW) foram previamente estudados como preditores de sobrevivência em diferentes malignidades. Objetivo O objetivo deste estudo foi avaliar o valor preditivo desses biomarcadores inflamatórios hematológicos para pacientes com metástases cerebrais (MB). Métodos Nós revisamos uma coorte consecutiva de pacientes no Instituto do Câncer do Estado de São Paulo (ICESP-FMUSP) de 2011 a 2016 com ≥ 1 MB tratados principalmente por ressecção cirúrgica. O desfecho primário foi a sobrevida em 1 ano. Otimizamos os valores de corte de NLR, MLR, PLR e RDW, preservando a robustez e evitando superestimação do tamanho do efeito. Resultados Um total de 200 pacientes (idade média de 56,1 anos; 55,0% mulheres) preencheram os critérios de inclusão. A ressecção grosseira total foi obtida em 89,0%. A mediana (quartis) dos escores KPS pré-operatório e pós-operatório foram 60 (50–80) e 80 (60–90), respectivamente. O NLR pré-operatório foi significativamente associado à sobrevida (HR 2,66, IC 95%: 1,17–6,01, p = 0,019). Um valor de corte de NLR de 3,83 exibiu a divisão da curva de sobrevivência mais significativa. Conclusões O NLR pré-operatório é um preditor independente de sobrevida em MBs recém-diagnosticados. Propomos que um valor de corte de 3,83 para o teste de NLR pré-operatório pode ser clinicamente útil como preditor de baixa sobrevida nesta população. A ampla acessibilidade do NLR favorece sua inclusão nos processos de tomada de decisão clínica para o gerenciamento de BM. , (NLR) MLR (MLR) (PLR RDW (RDW malignidades MB. . (MB) ICESPFMUSP ICESP FMUSP (ICESP-FMUSP 201 cirúrgica ano efeito 20 idade 561 56 56, anos 550 55 0 55,0 mulheres 890 89 89,0% quartis (quartis préoperatório pré operatório pósoperatório pós 6 50–80 5080 50 (50–80 8 60–90, 6090 60–90 90 (60–90) respectivamente HR 266 2 66 2,66 95% 95 117601 17 01 1,17–6,01 0,019. 0019 0,019 019 0,019) 383 3 83 3,8 significativa recémdiagnosticados. recémdiagnosticados recém diagnosticados. diagnosticados recém-diagnosticados população BM (NLR (MLR (MB 5 55, 89,0 50–8 508 (50–8 609 60–9 9 (60–90 26 2,6 11760 1,17–6,0 001 0,01 38 3, 89, 50– (50– 60– (60–9 2, 1176 1,17–6, 00 0,0 (50 (60– 117 1,17–6 0, (5 (60 11 1,17– ( (6 1,17 1,1 1,

Abstract Background The neutrophil-to-lymphocyte (NLR), monocyte-to-lymphocyte (MLR), platelet-to-lymphocyte ratio (PLR), and red blood cell distribution width (RDW) have been previously studied as predictors of survival in different malignancies. Objective The aim of this study was to evaluate the predictive value of these hematologic inflammatory biomarkers for patients with brain metastases (BM). Methods We reviewed a consecutive cohort of patients at Instituto do Cancer do Estado de São Paulo (ICESP-FMUSP) from 2011 to 2016 with ≥ 1 BM treated primarily by surgical resection. The primary outcome was 1-year survival. We optimized the NLR, MLR, PLR, and RDW cutoff values, preserving robustness and avoiding overestimation of effect size. Results A total of 200 patients (mean age 56.1 years; 55.0% female) met inclusion criteria. Gross-total resection was achieved in 89.0%. The median (quartiles) preoperative and postoperative KPS scores were 60 (50-80) and 80 (60-90), respectively. Preoperative NLR was significantly associated with survival (HR 2.66, 95% CI: 1.17-6.01, p = 0.019). A NLR cutoff value of 3.83 displayed the most significant survival curve split. Conclusions Preoperative NLR is an independent predictor of survival in newly diagnosed BM. We propose a cutoff value of 3.83 for preoperative NLR testing may be clinically useful as predictor of poor survival in this population. The wide accessibility of the NLR favors its inclusion in clinical decision-making processes for BM management. neutrophiltolymphocyte neutrophil lymphocyte , (NLR) monocytetolymphocyte monocyte MLR (MLR) platelettolymphocyte platelet PLR (PLR) (RDW malignancies . (BM) ICESPFMUSP ICESP FMUSP (ICESP-FMUSP 201 1year year values size 20 mean 561 56 56. years 550 55 0 55.0 female criteria Grosstotal Gross 890 89 89.0% quartiles (quartiles 6 5080 50 (50-80 8 6090, 6090 90 (60-90) respectively HR 266 2 66 2.66 95 CI 1.176.01, 117601 1.17 6.01, 17 01 1.17-6.01 0.019. 0019 0.019 019 0.019) 383 3 83 3.8 split population decisionmaking decision making management (NLR (MLR (PLR (BM 5 55. 89.0 508 (50-8 609 9 (60-90 26 2.6 176 1.176.01 11760 117 1.1 601 6.01 1.17-6.0 001 0.01 38 3. 89. (50- (60-9 2. 1.176.0 1176 11 1. 6.0 1.17-6. 00 0.0 (50 (60- 1.176. 6. 1.17-6 0. (5 (60 1.176 1.17- ( (6

ABSTRACT Purpose: To evaluate the risk factors for poor outcomes after surgical and endovascular treatment of aneurysmal subarachnoid hemorrhage (aSAH). Methods: Patients with ≥ 18-years of age and aSAH were included, while patients who died within 12 h of admission or lost follow-up were excluded. All participants underwent standardized clinical and radiological assessment on admission and were reassessed at discharge and at 6-months follow-up using the Glasgow Outcome Scale (GOS). Results: Death at discharge was associated with female gender, anterior communication artery (ACoA) aneurysm location and presence of atherosclerotic plaque in the surgical group, and with age in the endovascular group. Both groups had clinical condition on follow-up associated with mFisher score on admission and hypertension. GOS on follow-up was also associated with presence of atherosclerotic plaque and multiple aneurysms in surgical group, and with age in endovascular group. Conclusions: Subjects treated surgically are prone to unfavorable outcomes if atherosclerotic plaques and multiple aneurysms are present. In patients with endovascular treatment, age was the main predictor of clinical outcome.

ABSTRACT Purpose: To analyze the role of serum creatinine levels as a biomarker of intracranial aneurysm outcomes. Methods: This is a prospective analysis of outcomes of patients with intracranial aneurysm. One hundred forty-seven patients with serum creatinine at admission and 6 months follow up were included. Linear and logistic regressions were used to analyze the data. Modified Rankin scale (mRS) was used to assess outcome. Results: Creatinine level was not directly related to aneurysm outcome nor aneurysm rupture (p > 0.05). However, patients with a glomerular filtration rate (GFR) lower than 72.50 mL·min–1 had an odds ratio (OR) of 3.049 (p = 0.006) for worse outcome. Similarly, aneurysm rupture had an OR of 2.957 (p = 0.014) for worse outcomes. Stepwise selection model selected 4 variables for outcomes prediction: serum creatinine, sex, hypertension and treatment. Hypertensive patients had, on average, an increase in 0.588 in mRS (p = 0.022), while treatment with microsurgery had a decrease in 0.555 (p = 0.038). Conclusions: Patients with higher GFR had better outcomes after 6 months. Patients with higher GFR had better outcomes after 6 months. Creatinine presented an indirect role in GFR values and should be included in models for outcome prediction.

RESUMO Objetivo: Identificar evidências atuais sobre topiramato para o estado de mal epiléptico refratário. Métodos: Foi revisada a literatura para investigar a eficácia do topiramato no tratamento de estado de mal epiléptico refratário. Os termos de busca utilizados foram: “status epilepticus”, “refractory”, “treatment” e “topiramate”. Não se empregaram restrições. Resultados: A busca identificou 487 artigos que descreviam o uso de topiramato para tratamento de estado de mal epiléptico refratário e seus resultados. Relatos de caso, revisões e experimentos em animais foram excluídos. Após exclusão de duplicatas e aplicação dos critérios de inclusão e exclusão, restaram nove estudos. Realizaram-se análises descritivas e qualitativas, com os seguintes resultados: as taxas de resposta, definidas como término de crises até 72 horas após administração de topiramato, variaram entre 27% e 100%. A mortalidade variou de 5,9% a 68%. Desfechos funcionais positivos, definidos como alta hospitalar, volta à funcionalidade basal ou reabilitação, foram documentados por sete estudos, e as taxas variaram entre 4% e 55%. A maioria dos estudos reportou apenas efeitos colaterais leves ou ausentes. Conclusão: Topiramato foi efetivo em abortar estado de mal epiléptico refratário, apresentando baixa mortalidade e boa tolerabilidade. Portanto, topiramato poderia ser uma boa opção como terceira linha para estado de mal epiléptico refratário, porém mais estudos são necessários.

ABSTRACT Objective: To identify current evidence on the use of topiramate for refractory status epilepticus. Methods: We reviewed the literature to investigate the efficacy of topiramate in the treatment of refractory status epilepticus. The search terms used were “status epilepticus”, “refractory”, “treatment” and “topiramate”. No restrictions were used. Results: The search yielded 487 articles that reported using topiramate as a treatment for refractory status epilepticus and its outcomes. Case reports, review articles, and animal experiments were excluded. After excluding duplicates and applying inclusion and exclusion criteria, nine studies were included for analyses. Descriptive and qualitative analyses were performed, and the results were as follows: response rates (defined as termination in-hospital until 72 hours after the administration of topiramate) varied from 27% to 100%. The mortality rate varied from 5.9% to 68%. Positive functional long-term outcomes, defined as discharge, back to baseline or rehabilitation, were documented by seven studies, and the rates ranged between 4% and 55%. Most studies reported no or mild adverse effects. Conclusion: Topiramate was effective in terminating refractory status epilepticus, presented relatively low mortality and was well tolerated. Therefore, topiramate could be a good option as a third-line therapy for refractory status epilepticus, but further studies are necessary.

SUMMARY OBJECTIVE: Decompressive craniectomy may be a life-saving measure in ischemic stroke patients, who still have several associated complications. The objective of this study is to evaluate a novel decompressive surgery technique for severe hemispheric ischemic stroke. METHODS: For the hinge decompressive craniectomy (HDC), linear durotomies were performed. Vertical (one or two frontal and two parietal), and two horizontal (temporal), with approximately 5 cm long, linear durotomies were carried out. Duroplasty was performed using an autologous subgaleal tissue graft fixed with separate sutures to avoid CSF leak and direct contact of the cortex with the bone flap. The bone flap was fixed in three parietal locations. We compared 10 patients who underwent our modified HDC with 9 patients submitted to classical decompressive craniectomy (CDC). The primary outcome of this study was mortality. RESULTS: Nineteen patients were included, with a mean age of 52.3 years (±8.2). Four (44%) patients from the HDC group had to be reoperated to remove the bone flap because of brain swelling worsening, but none of them died. The average time of HDC was 90 minutes. Overall 14-days mortality was 21.1% (n=4), and cumulative six-months mortality was 42.1% (n=8). Five (50%) patients submitted to CDC died, while 3 (33.3%) submitted to HDC died (χ2=0.07, p=0.79). The mean length of stay was 46.7 days (±32.1) for HDC and 38.7 (±27.1) for CDC (p=0.60). CONCLUSIONS: We present a modified technique of hinge craniectomy with linear vertical and horizontal durotomies, which seems to have reduced operative time and mortality compared to classical decompressive craniotomy, although the difference was not statistically significant.

RESUMO Epilepsia refratária secundária a tumores cerebrais são geralmente causadas por gliomas de baixo grau. Esse grupo de tumor é frequentemente localizado em áreas eloquentes do cérebro como na insula, córtex rolândico e área motora suplementar; e sua ressecção apresenta alto risco de déficits neurológicos no pós operatório. Objetivo: O objetivo do estudo consiste em apresentar nossa experiência no tratamento cirúrgico de pacientes com epilepsia refratária secundário a gliomas em áreas eloquentes. Métodos: O estudo consiste em investigação retrospectiva de variáveis que interferem no controle de crises, tais como localização do tumor, grau de ressecção, invasão tumoral de artérias lenticulo estriadas, principalmente em gliomas insulares. Dentre 67 pacientes portadores de gliomas em área eloquente operados no período de 2007 a 2016, 14 doentes apresentavam epilepsia refrataria associada. Análise volumétrica do tumor, grau de ressecção, acesso cirúrgico, bem como o uso de mapeamento cortical intraoperatório foram correlacionados com desfecho de controle de crises epilepticas em 12 meses. Resultados: Em análise univariada os fatores relacionados com controle de crises em 12 meses foram volume tumoral pré operatório (p = 0,005), grau de ressecção (p = 0,028) e volume tumoral pós operatório. Conclusão: O grau de ressecção apresentou significância estatística em relação ao controle de crises conforme escala de Engel. Ressecções menores que 70% apresentaram correlação com Engel II, III e IV; enquanto ressecções maiores que 90% apresentaram correção positiva com Engel I. Gliomas em áreas eloquentes podem ser ressecados de forma segura desde que seja realizada por equipe experiente com conhecimento acurado da anatomia microcirúrgica e emprego de mapeamento cortical intraoperatório.

ABSTRACT Drug-resistant epilepsy associated with central nervous system tumors is generally caused by low grade gliomas. This group of tumors is usually found in brain eloquent areas, such as the insular lobe, rolandic cortex and supplementary motor area and, historically, possess a greater risk of postoperative deficits. Objective: The aim of this investigation was to present our surgical experience on patients with drug-resistant epilepsy caused by gliomas in eloquent areas. We retrospectively investigated variables that impact seizure control, such as tumor location, extent of resection, invasion into the lenticulostriate arteries in the patient, especially those with insular gliomas. Methods: Out of 67 patients with eloquent area brain tumors operated on in our service between 2007 and 2016, 14 patients had symptoms of drug-resistant epilepsy. Volumetric analysis, extent of resection (EOR), type of approach and mapping, among other factors were correlated with the 12-month postoperative seizure outcome. Results: Univariate analysis showed that the factors showing statistical relevance with seizure control were preoperative volume (p = 0.005), EOR (p = 0.028) and postoperative volume (p = 0.030). Conclusion: There was a statistically significant association between the EOR and the Engel score for epilepsy control: an EOR < 70 was associated with Engel II, III, IV and an EOR > 90 was associated with Engel I. Eloquent area gliomas can safely be resected when surgeons use not only microsurgical anatomy concepts but also brain mapping.

RESUMO A esclerose mesial temporal é uma síndrome epiléptica focal que requer ablação de estruturas mesiais temporais. Objetivo: Descrever e padronizar a técnica operatória e resultados clínicos. Métodos: Série prospectiva de casos de uma única instituição, realizadas por um único cirurgião, de 2006 a 2012. 120 doentes foram submetidos a amigdalo-hipocampectomia transtemporal por acesso mínimo (keyhole). Resultados: 55% eram do sexo masculino, 85% apresentavam doença do lado direito. As primeiras 70 cirurgias tiveram um tempo cirúrgico médio de 2,51 horas, e as últimas 50 cirurgias tiveram um tempo cirúrgico médio de 1,62 horas. Houve morbidade de 3,3%. 5% dos doentes apresentaram atrofia leve de músculo temporal. O controle das convulsões foi avaliado com a Escala de Engel no segundo ano de pós operatorio, 71% eram Classe I, 21% Classe II, 6% Classe III. Conclusão: Esta nova técnica é viável, reprodutível e com resultados clínicos adequados.

ABSTRACT Mesial temporal sclerosis creates a focal epileptic syndrome that usually requires surgical resection of mesial temporal structures. Objective: To describe a novel operative technique for treatment of temporal lobe epilepsy and its clinical results. Methods: Prospective case-series at a single institution, performed by a single surgeon, from 2006 to 2012. A total of 120 patients were submitted to minimally-invasive keyhole transtemporal amygdalohippocampectomy. Results: Of the patients, 55% were male, and 85% had a right-sided disease. The first 70 surgeries had a mean surgical time of 2.51 hours, and the last 50 surgeries had a mean surgical time of 1.62 hours. There was 3.3% morbidity, and 5% mild temporal muscle atrophy. There was no visual field impairment. On the Engel Outcome Scale at the two-year follow-up, 71% of the patients were Class I, 21% were Class II, and 6% were Class III. Conclusion: This novel technique is feasible and reproducible, with optimal clinical results.

RESUMO Avaliamos a reprodutibilidade e segurança do algoritmo Upper Cervical Spine Injuries Treatment Algorithm (UCITA) recém proposto para a escolha do tratamento das lesões traumáticas da junção crânio-cervical. Métodos Trinta casos previamente tratados de acordo com o algoritmo foram apresentados a quatro cirurgiões de coluna, sendo questionada a conduta pessoal dos mesmos e a conduta segundo a aplicação do algoritmo. Após 4 semanas, foram refeitas as mesmas perguntas para avaliar a reprodutibilidade (intra e interobservador) do algoritmo, através do índice estatístico “Kappa”. Resultados A reprodutibilidade da conduta com o uso do algoritmo foi superior a reprodutibilidade da conduta pessoal dos cirurgiões. Com o uso do UCITA, a concordância do tratamento realmente efetivado foi encontrada em mais de 89% dos casos. Conclusão O uso do UCITA foi seguro e reprodutível, podendo ser usado como ferramenta auxiliar na tomada de decisão entre tratamento cirúrgico versus conservador dos traumatismos da junção crâniocervical.

ABSTRACT In the present study, we evaluated the reliability and safety of a new upper cervical spine injury treatment algorithm to help in the selection of the best treatment modality for these injuries. Methods Thirty cases, previously treated according to the new algorithm, were presented to four spine surgeons who were questioned about their personal suggestion for treatment, and the treatment suggested according to the application of the algorithm. After four weeks, the same questions were asked again to evaluate reliability (intra- and inter-observer) using the Kappa index. Results The reliability of the treatment suggested by applying the algorithm was superior to the reliability of the surgeons’ personal suggestion for treatment. When applying the upper cervical spine injury treatment algorithm, an agreement with the treatment actually performed was obtained in more than 89% of the cases. Conclusion The system is safe and reliable for treating traumatic upper cervical spine injuries. The algorithm can be used to help surgeons in the decision between conservative versus surgical treatment of these injuries.

A história da neurocirurgia na Universidade de São Paulo remonta a 1918, quando surge sob o Departamento de Neurologia da cadeira de Clínica Psiquiátrica e Doenças Nervosas. O Professor Enjolras Vampré foi o grande inspirador da especialidade no estado de São Paulo. Em 1929, foram realizadas as primeiras intervenções neurocirúrgicas na então recentemente organizada Seção de Neurocirurgia. A fundação oficial da Divisão de Neurocirurgia Funcional data de junho de 1977 e contou com a participação de diversos cientistas de renome internacional. A Divisão passou por profunda reorganização sob a direção do Professor Raul Marino Jr. entre as décadas de 1990 e 2000, quando foi estruturada com os setores de neurocirurgia geral, neurocirurgia funcional e emergência neurocirúrgica. Desde 2008, o Professor Manoel Jacobsen Teixeira é responsável pela Divisão, que conta com os melhores recursos tecnológicos disponíveis, realizando mais de 3.000 cirurgias por ano e formando profissionais que certamente serão futuros líderes na neurocirurgia brasileira.

The history of neurosurgery at University of São Paulo comes from 1918, since its origins under the Department of Neurology from Chair of Psychiatric Clinic and Nervous Diseases. Professor Enjolras Vampré was the great inspiration for such medical specialty in the State of Sao Paulo. In 1929, the first neurosurgical procedures were performed in the recently (at time) organized Section of Neurosurgery. The official inauguration of the Division of Functional Neurosurgery occurred at June 1977, with the presence of worldwide well-known neuroscientists. The division suffered a deep streamlining under the leadership of Professor Raul Marino Jr., between the decades of 1990 and 2000. At this time, it was structured with the sections of neurological surgery, functional neurosurgery and neurosurgical emergency. Since 2008, Professor Manoel Jacobsen Teixeira is the Chairman of the Division and has provided the Division with the best available technological resources, performing more than 3,000 surgeries a year and training professionals who will, certainly, be some of the future leaders of brazilian neurosurgery.

O aumento da sobrevivência do paciente oncológico decorrente da melhoria e do avanço das modalidades terapêuticas promove progressivo aumento da prevalência das neoplasias metastáticas da coluna vertebral, tornando o seu conhecimento condição sine qua non para os profissionais da área de saúde. As metástases na coluna vertebral são usualmente procedentes de neoplasia maligna da mama, pulmão e próstata, o gênero masculino é o mais acometido e a dor é o sintoma inicial em mais de 90% dos pacientes. Estima-se que 30-90% dos pacientes com câncer em estágio terminal apresentem metástase em algum segmento da coluna vertebral. A alta prevalência das neoplasias malignas e a significativa experiência dos autores no tratamento das metástases na coluna vertebral motivaram uma atualização do tema. Acreditamos que a padronização da conduta e o conhecimento pormenorizado dos principais aspectos da doença, podem promover a melhor opção terapêutica. O presente estudo visa à revisão e descrição didática dos principais aspectos relacionados à fisiopatologia, diagnóstico e tratamento desta entidade.

The increased survival of cancer patients due to the improvement and advancement of therapeutic modalities has promoted progressive increase in the prevalence of metastatic tumors of the spine, making it important for healthcare professionals to acquire knowledge in the field. Spinal column metastases are usually secondary to malignant neoplasm of the breast, lung and prostate, male gender being the most often affected and pain being the initial symptom in 90% of patients. It is estimated that 30-90% of terminally ill patients with cancer have metastases at some spinal column segment. Clinical history, physical and neurological assessments are critical to determine the degree and extent of the lesion, and therefore choose the appropriate imaging method to be requested. This study aims to perform a review and didactic description of the main aspects related to the physiopathology, diagnosis and treatment of this disease.