EDITOR. EDITORES ASSOCIADOS Luiz Roberto Aguiar Curitiba / PR Paulo Henrique Pires de Aguiar São Paulo / SP

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3 3 ISSN Órgão Oficial da Academia Brasileira de Neurocirurgia Volume 19 Número 3 Julho - Agosto - Setembro 2008 CONSELHO EDITORIAL Benedito Oscar Colli (Ribeirão Preto / SP) Carlos Umberto Pereira (Aracaju / SE) Carolina Martins (Recife / PE) Evandro Pinto da Luz de Oliveira (São Paulo / SP) Hildo Cirne de Azevedo Filho (Recife / PE) Jorge Wladimir Junqueira Bizzi (Porto Alegre / RS) Luis Alencar Borba (Curitiba / PR) Luiz Renato Mello (Blumenau / SC) Manoel Jacobsen Teixeira (São Paulo / SP) Osvaldo Vilela Filho (Goiânia / GO) Oswaldo Inácio Tella Junior (São Paulo / SP) Paulo Niemeyer Soares Filho (Rio de Janeiro / RJ) Ricardo Ramina (Curitiba / PR) Sebastião Gusmão (Belo Horizonte / MG) EDITOR Ápio Cláudio Martins Antunes Porto Alegre / RS EDITORES ASSOCIADOS Luiz Roberto Aguiar Curitiba / PR Paulo Henrique Pires de Aguiar São Paulo / SP CONSELHO EDITORIAL INTERNACIONAL Alejandra Rabadán (Buenos Aires, Argentina) Antonio Daher (Valencia, Venezuela) Danielle Rigamonti (Baltimore, EUA) Daniel Maitrot (Estrasburgo, França) Graziela Zuccaro (Buenos Aires, Argentina) Howard Eisenberg (Baltimore, EUA) Jacques Morcos (Miami, Florida, EUA) Julio Antico (Buenos Aires, Argentina) Leonidas Quintana (Viña Del Mar, Chile) Marco Gonzales Portillo (Lima, Peru) Marcos Tatagiba (Tubingen, Alemanha) Pradeep Narothan (Nebraska, EUA) René Chapot (Limoges, França) Sugit Prabul (Houston, EUA) Yasunori Fujimoto (Osaka, Japão) Yoko Kato (Nagoya, Japão)

4 4 Expediente Academia Brasileira de Neurocirurgia Filiada à World Federation of Neurosurgical Societies DIRETORIA Biênio 2007/2008 Presidente: Luiz Roberto Aguiar Curitiba Vice-presidente: José Luciano Gonçalves de Araújo Natal Presidente Eleito: Albedy Moreira Bastos Belém Secretário: Adriano Keijiro Maeda Curitiba Tesoureiro: Sérgio Alberto Wolf Joinville Editor do jornal: Ápio Cláudio Martins Antunes Porto Alegre CONSELHO DELIBERATIVO Anselmo Saturnino Teixeira Rio de Janeiro Antonio César Azevedo Neves Belém Ápio Cláudio Martins Antunes Porto Alegre Carlos Tadeu Parisi de Oliveira São Paulo Durval Peixoto de Deus Goiânia Edson Mendes Nunes Rio de Janeiro Evandro Pinto da Luz Oliveira São Paulo Flávio Belmino Barbosa Evangelista Fortaleza Gervásio de Britto Mello Filho Belém Hélio Ferreira Lopes Rio de Janeiro Hildo Rocha Cirne Azevedo Filho Recife José Arnaldo Motta de Arruda Fortaleza Marcos Masini Brasília Paulo Henrique Pires de Aguiar São Paulo Sebastião Natanael Silva Gusmão Belo Horizonte SECRETARIA PERMANENTE Secretário geral: Edson Mendes Nunes Rio de Janeiro Secretário auxiliar: Hélio Ferreira Lopes Rio de Janeiro Marco Antonio Herculano Jundiaí SEDE PRÓPRIA Rua da Quitanda, 159, 10º andar, Centro Rio de Janeiro, RJ Brasil Telefax: (21) PROJETO GRÁFICO E EDITORAÇÃO Midia Arte PARA ANUNCIAR - PUBLICIDADE NS&A Av. Cândido de Abreu, 140. cj Curitiba. PR nsapr@nsaonline.com.br Telefones: RS: (51) MG: (31) PR: (41) DF: (61) SC : (48) SP: (11) J Bras Neurocirurg 19 (3): 4, 2008

5 5 Índice Contents / Índice Original Articles / Artigos Originais Vascular complications in transsphenoidal surgery Complicações vasculares na cirurgia transesfenoidal Edward R Laws, Paulo Henrique Aguiar Cognitive function in neurosurgical clipping of patients with unruptured intracranial aneurysms: a systematic literature review Função cognitiva no tratamento cirúrgico de pacientes com aneurismas intracranianos não-rotos: revisão sistemática da literatura Arthur A. Pereira Filho, Matthew M. Kang, Tibor Becske, Peter K. Nelson, Jafar J. Jafar Spot-the-Word Test como instrumento neuropsicológico para avaliação de inteligência pré-mórbida em idosos: revisão da literatura Spot-the-Word Test as a neuropsychological instrument to assess premorbid intelligence in elderly people: a review of the literature Eliane Correa Miotto, Glaucia Rosana Guerra Benute, Catarina Andréa Santana Teixeira, Mara Cristina Souza de Lucia, Paulo Henrique Pires de Aguiar, Milberto Scaff Biópsia vertebral percutânea pelo método de preensão direta do tumor vertebral Percutaneous vertebral biopsy by direct apprehension of tumor Fabrizio Borges Scardino, Alécio Cristino Evangelista Santos Barcelos, José Marcus Rotta, Ricardo Vieira Botelho Hemorragia subaracnóidea traumática: aspectos clínicos, radiológicos e complicações Traumatic subarachnoid hemorrhage: clinical and radiological aspects and complications Eduardo Joaquim Lopes Alho, Wellingson Silva Paiva, Robson Luis Oliveira Amorim, Eberval Gadelha Figueiredo, Almir Ferreira de Andrade, Manoel Jacobsen Teixeira Entubulation of sciatic nerve of rats with poly-l lactide-co p-lactide Tunelização do nervo ciático de ratos com poly-l lactide-co p-lactide Santino N. Lacanna, Mirto N. Prandini, João Roberto Pereiro, Rodrigo Fagundes de Moraes, Edílson Toshio Shoji Review Article / Artigos de Revisão Considerações sobre o diagnóstico e tratamento de cistos colóide de III ventrículo Diagnosis ans treatment of III ventricle colloid cyst Wellingson Silva Paiva, Fernando Campos Gomes Pinto, Robson Luís de Oliveira Amorim, Paulo Henrique Pires de Aguiar, Manoel Jacobsen Teixeira Scientific Events / Eventos Científicos Agenda de Eventos Científicos J Bras Neurocirurg 19 (3): 5, 2008

6 6 Normas para publicação indexado na base de dados LILACS Jornal Brasileiro de Neurocirurgia O Jornal Brasileiro de Neurocirurgia é o órgão oficial da Academia Brasileira de Neurocirurgia e propõe-se a publicar artigos sobre Neurocirurgia e todas as ciências afins. Assim, trabalhos inéditos, sob a forma de artigos originais, resumo de teses, apresentação de casos ou notas técnicas poderão ser aceitos, desde que não tenham sido enviados para publicação em outro periódico. Os trabalhos podem ser redigidos em Português ou Espanhol, com resumo em Inglês, mas preferentemente redigidos em Inglês, com resumo em Português. Todo e qualquer trabalho poderá receber modificações, para que se adapte à estrutura geral do Jornal. Os artigos que não se enquadrarem nas normas ou que não forem adequados às necessidades editoriais do Jornal serão devolvidos ao(s) autor(es), para que proceda(m) às adaptações necessárias. Os artigos devendo ser enviada de preferência por , mas serão aceitos em CD ou DVD e poderão ser utilizados os editores de texto Word, devendo ser enviadas também uma via de texto original. A estruturação do artigo deverá obedecer à seguinte orientação: a) página-título, na qual constem o título do artigo, nome completo do(s) autor(es) e da instituição onde o trabalho foi realizado; b) página constando a sinopse estruturada do trabalho (objetivo, métodos, resultados e conclusão), com, no máximo, 200 palavras, transmitindo a idéia geral da publicação, seguida por um Abstract, que deve incluir: objective, methods, results, and conclusion; c) corpo do artigo; d) referências bibliográficas, dispostas em ordem alfabética pelo sobrenome do primeiro autor, numeradas arábica e consecutivamente para efeito de citação no texto, de acordo com as normas Vancouver. Comunicações pessoais e trabalhos em preparação poderão ser citados no texto, mas não constarão das referências. Artigos de periódicos Schramm VL, Myers EN, Maroon JC. Anterior skull base surgery for benign and malignant disease. Laryngoscope. 1979; 89(2): Netterville JL, Jackson CG, Schramm VL, Myers EN, Maroon JC, Petersen R et al. Anterior skull base surgery for benign and malignant disease. Laryngoscope. 1980; 90(2): Livros Donald PJ, editor. Surgery of the skull base. Philadelphia: Lippincott- Raven; Capítulos de livros Netterville JL, Jackson CG. Reconstruction of the skull base with regional s and grafts. In: Donald PJ, editor. Surgery of the skull base. Philadelphia: Lippincott-Raven; p Dissertações e teses Marutinho AF. Alterações neurológicas em portadores de meningiomas. [dissertação]. São Paulo: Universidade Federal de São Paulo Trabalhos apresentados em congressos, simpósios, encontros, seminários e outros Petersen R, Grundman M, Thomas R, Thal L. Use of titanium mesh for reconstruction of large anterior cranial base defects; 2004 July; United States, Philadelphia; Artigos em periódicos eletrônicos Boog MCF. Construção de uma proposta de ensino de cirurgia de retalho. Rev Bras Neuro [periódico eletrônico] 2002 [citado em 2002 Jun 10];15(1). Disponível em: Textos em formato eletrônico Instituto Brasileiro de Geografia e Estatística. Estatísticas da saúde: assistência médico-sanitária. Disponível em: Acessado em: 5/2/2004. Os artigos serão classificados em quatro tipos: artigos originais, relatos de casos, artigos de revisão e notas breves. Sugestão para elaboração do corpo de cada artigo: Artigos Originais - introdução - material e métodos - resultados - discussão Relato de Casos - introdução - apresentação do caso - discussão Artigos de Revisão - introdução - apresentação do assunto As ilustrações, para o caso de fotos ou exames por imagem, devem ser enviadas em arquivo com extensão JPEG, nomeadas com a indicação de sua entrada no texto (exemplo, Meningioma Fig1.jpeg), com resolução 300 dpi, evitando enviar imagens inseridas no arquivo de Word ou Power Point, pois perdem a qualidade. Tabelas, algoritmos e gráficos podem ser inseridos no arquivo do texto ou em arquivo Power Point. Os artigos deverão ser enviados ao Editor-chefe, Dr. Ápio Antunes, Rua Luciana de Abreu, 471, cj , Porto Alegre, RS Telefax: (51) End. eletrônico: apioantunes@gmail.com apioantunes@hotmail.com J Bras Neurocirurg 19 (3): 6, 2008

7 7 Vascular complications in transsphenoidal surgery Complicações vasculares na cirurgia transesfenoidal Edward R Laws 1 Paulo Henrique Aguiar 2 ABSTRACT Objectives: Vascular complications can and do arise from transsphenoidal surgery and, when occur, they have a high incidence of mortality and serious morbidity. The anatomic substrate for such complications is discussed, along with technical aspects of surgery and other methods for the avoidance of vascular complications. The aim of this paper is discuss the main vascular complications of transsphenoidal approach. Methods: The authors retrospectively analyzed the data regarding 4175 pituitary transsphenoidal operations from 1974 to Results: Thirty-four (34) patients (0.8%) developed direct vascular complications from transsphenoidal surgery. Nine (0.2 %) of these were fatal. Conclusions: Intra-operative injury of the carotid artery is predominately associated with microadenomas, basilar perforator injury may be associated with invasive macroadenomas and anterior cerebral artery injury may be associated with supra- sellar tumors. Regarding outcomes, injury of anterior circulation vessels shows relatively low morbidity and mortality, and injury to posterior circulation vessels shows relatively high morbidity and mortality. Key-words: Pituitary tumors, transsphenoidal approach, basilar artery, vascular complications, pseudoaneurysm, carotid-cavernous fistula. SUMÁRIO Objetivos: Os autores discutem os fatores que interferem nas complicações vasculares do acesso transesfenoidal para tumores hipofisários. Procuram entender as causas e as relações entre os tipos de tumor, tamanho e as lesões arteriais por região. Casuística e Método: 4175 cirurgias transesfenoidais realizadas pelo autor principal no período de 1974 à 2004 foram analisadas quanto a incidência, tipo e causa de lesão vascular. Resultados: Trinta e quatro pacientes desta casuística, apresentaram lesão vascular relacionada ao procedimento cirúrgico, sendo fatal em 9 casos. Microadenomas apresentaram relação com lesão da artéria carótida e macroadenomas com lesão da artéria basilar, bem como adenomas com extensão supraselar com lesões da artéria comunicante anterior. Conclusão: Dados como cirurgia prévia, localização e extensão tumoral são importantes para se predizer uma complicação vascular. O seu tratamento depende da rapidez com que há o tamponamento arterial, mas também da viabilidade de termos procedimentos endovasculares de emergência. Doppler intraopeartório, neuronavegação e ressonância intraoperatória podem ser úteis para se evitar a lesão arterial. As vias minimamente invasivas, como acesso endoscópico endonasal, parecem ter um papel importante para se minimizar as complicações. Palavras-chaves: Tumor hipofisário, acesso transesfenoidal, pesudoaneurisma de artéria carótida, complicação vascular. 1 Stanford Pituitary Center - Stanford University, California, USA 2 Department of Neurology, São Paulo Medical School, University of São Paulo, Brazil Recebido em janeiro de Aceito em março de LAWS ER, AGUIAR PH - Vascular complications in transsphenoidal surgery J Bras Neurocirurg 19 (3): 7-14, 2008

8 8 INTRODUCTION Vascular complications during or after transsphenoidal surgery are rare, but when they occur can produce a high incidence of mortality and morbidity. Significant advances in the recognition and management of pituitary adenomas has taken place over recent decades 14. Highly sensitive hormonal assays and magnetic resonance imaging with gadolinium enhancement have led to earlier and more frequent diagnosis of pituitary adenomas 14. The microscopic transsphenoidal approach for pituitary tumors has demonstrated excellent results with minimal morbidity and almost no mortality; and has become the therapy of choice for the majority of pituitary adenomas 14,22,38,57,59,60. Continued attempts to improve surgical outcomes, reduce the incidence of complications, and hasten post-operative recovery have led to the development of a minimally invasive fully endoscopic transsphenoidal approach to remove pituitary adenomas. Hirch`s original endonasal rhinoseptal route 6,7,8,33,42,43 was later modified. It avoids an anterior nasal or sublabial incision, requires no anterior dissection through nasal or sublabial incision, no anterior dissection of the nasal septum is necessary, and it requires only minimal dissection of the posterior nasal mucosa. This approach per si is better tolerated, with less postoperative pain, than the more traditional sublabial or rinoseptal routes. The most common vascular complications described in literature are carotid occlusion, carotid stenosis, carotid pseudoaneurysm, sphenopalatine false aneurysm, middle cerebral artery occlusion, anterior cerebral artery occlusion and rupture, basilar artery compression and rupture, carotid cavernous fistula 7,13,40,46. The aim of this study is to evaluate the incidence of intraopaerative vascular injury during transsphenoidal surgery. ANATOMIC AND TECHNICAL ASPECTS OF THE TRANSSHENOIDAL APPROACH The sella has its limits which are well known. From above the limits are the optic nerves and chiasm, as well as the circle of Willis. Laterally they consist of the cavernous sinuses, and internal carotid arteries. Posteriorly, they are the clivus, basilar artery and brainstem 47. The initial aspects of the traditional approach are through the mucous membranes of the nose and the undersurface of the lip. These membranes can often be quite vascular, with numerous small interconnecting vascular channels, and bleeding can be considerable if no attempt is made to produce decongestion and hemostasis. Rhinologic surgeons have used a number of techniques to avoid this type of bleeding. The paired sphenopalatine arteries, branches of the internal maxillary artery, supply the nasal structures, which should be avoided. Ordinarily, the midline approach will not disturb the main trunks of the sphenopalatine arteries and every attempt during the approach should be made to avoid injury to these vessels. The carotid arteries and their bony canals lie on either side of the sphenoid sinus. Theses canals need to be idenfied carefully and injury or entrance into them obviously should be avoided as the sella is exposed 40. The cavernous portion of the carotid artery is vulnerable to damage during the exposure of the sella. The cavernous carotid may be quite tortuous and the carotids, in some cases can actually come in contact centrally within the sella. These arterial segments can also be quite atherosclerotic, particularly in patients with acromegaly, and they may lie just behind the dura where they are vulnerable to injury during the opening of the sellar dura and exposure of the pituitary lesion. The cavernous sinuses on either side of the sella are vascular structures filled with venous blood under venous pressure. The two cavernous sinus frequently connect through dural channels, most commonly the superior and inferior intercavernous sinuses. These connecting channels can be injured during the opening of the dura. The dura itself consists of two layers and between these layers vascular channels commonly proliferate, particularly in the normal sella or one that harbors a microadenoma. The removal of the lesion may also lead the surgeon directly into the cavernous sinus. It is important to remember that in addition to the carotid artery the third, fourth, fifth and sixth cranial nerves are intimately associated with the cavernous sinus, and are therefore are subject to surgical injury. As with other venous channels, if the head of the patient is raised above the level of the heart, there is a potential for air embolus into the interconnecting veins or directly into cavernous sinus. Venous air embolism can be detected when careful anesthetic monitoring is done, but we have not experienced clinical consequences of air embolism in our patients. A number of specific vessels have been described that commonly supply lesions occurring in and around the sella turcica. The most important of these is the meningohypophyseal trunk whichs gives rise to important arterial vessels supplying the pituitary gland and the pituitary stalk. This vessel can also proliferate to provide vascular supply to pituitary lesions. Above the diaphragm, there is a circuminfundibular plexus that likewise can elaborate to feed pituitary lesions. There are several so called capsular arteries that rise from the cavernous carotid and LAWS ER, AGUIAR PH - Vascular complications in transsphenoidal surgery J Bras Neurocirurg 19 (3): 7-14, 2008

9 9 ordinarily supply the sellar dura and can also proliferate to feed pituitary lesions. All of these vessels have the potential of causing technical difficulty when dealing with lesion directly. Just above the diaphragm of the sella is the circle of Willis, and its relationship to the dorsal aspect of variety of pituitary lesions can place it at risk for significant damage. The surgeon should carefully consider the anatomy of the Circle and its integrity with regard to collateral flow. Hypothalamic damage may occur from vascular injury or direct trauma. Immediately behind the clivus lies the basilar artery with its branches. Some lesions that destroy the clivus can make this vessel vulnerable to injury and a misdirected approach through the clivus rather than through the floor of the sella can also injure the basilar vessels. INTERNAL CAROTID INJURY Injury of the internal carotid artery were associated with microadenomas in 18 patients in a total of 22 cases (81%). Figure 1 shows the CT scan of a patient with intracranial bleeding after a carotid injury, and Figure 2 shows an angiogram of a patient harboring an ACTH microadenoma surgically treated by transsphenoidal surgery, which resulted in pseudoaneurysm of the right carotid artery. Fourteen of these patients had previous surgery (64%). Invasion of the cavernous sinus by the tumor was found in 12 (55%). METHODS Retrospectively the personal series of the senior author was reviewed consisted of 4175 consecutive transsphenoidal operations between 1972 and 2004 to determine incidence, causes, and management of vascular complications. Figure 1: CT scan A(left) - hematoma in interpeduncular fossa. B(Right) intraventricular hematoma. RESULTS A Thirty four (34) patients (0.8%) developed direct vascular complications from transsphenoidal surgery. Nine (0.2) of these were fatal. The data are summarized in the table I. Carotid artery injury 22 patients Table I - Vascular complications Fatal Non-Fatal pseudoaneurysm 0 4 carotid artery thrombosis during treatment wall laceration Anterior Cerebral Artery 4 patients Basilar artery and perforations 8 patients (8=direct repair & 4=PBO) Total (34) 9 25 Figure 2 Digital subtraction angiogram shows a pseudoaneurysm of the right carotid artery after transsphenoidal approach for a 33 years-old patient with Cushing`s syndrome. LAWS ER, AGUIAR PH - Vascular complications in transsphenoidal surgery J Bras Neurocirurg 19 (3): 7-14, 2008

10 10 BASILAR ARTERY PERFORATOR INJURY Lesions of basilar artery were associated with invasive macroadenomas which were adjacent and adherent to basilar perforators in 8 patients. There were 7 tumors with suprasellar extension (88%). Previous surgery had been done in 4 of 8 (50%). ANTERIOR CEREBRAL ARTERY INJURY Injuries to the anterior cerebral artery were associated with macroadenomas evolving adjacent to suprasellar structures, 4/4 (100%). Suprasellar extension of tumour had occurred in 4/4 (100%). An extended transsphenoidal approach was done in 3/4 of patients (75%). DISCUSSION Victor Horsley in 1889, using a transcranial approach is credited with performing the first operation for a pituitary tumor 23,58. In 1906 Schloffer reported the first removal of a pituitary tumor through an extracranial transsphenoidal approach 22,50,58. Hirsch later modified this approach in ,58. In 1912, Cushing 9 described the transseptal transsphenoidal approach to the sella turcica. Guiot and Hardy 15,16,17,18,19,20 refined the technique and added intraoperative fluoroscopic guidance and the use of the surgical microscope. Since then, the approach has become the standard for lesions of the sella and those extending in the midline in a suprasellar direction. The complications of the approach are well described and include septal perforation, septal deviation, tearing of the nares, persistent nasal discharge, recurrent nosebleeds, tooth analgesia, asymmetry of mucosal contour, sinusitis, and mucocele among others 5,34,35. It wasn t until the late 1950 s that Guiot who learned Cushing s transseptal-transsphenoidal method from Norman Dott, reintroduced this approach 20,22,58. Guiot improved the transsphenoidal approach with the addition of intra-operative fluoroscopy to guide the insertion of instruments into the sella, allowing for safer and more complete tumor removal 15,16,22,58. It is Hardy, however, who deserves much of credit for reestablishing the validity of the transsphenoidal approach, when in the 1960 s he combined fluoroscopy and microsurgical techniques to further augment transsphenoidal pituitary tumor resection 19,20,22,58. These new technologies provided the transsphenoidal approach with significant advantages over the transcranial procedure. The improved visualization, allowed for more complete tumor removal, and reduced the incidence of complications. In the ensuing 40 years several large series have established the transsphenoidal approach as the procedure of choice for all but the most massive pituitary adenomas, demonstrating outcomes equivalent or better than those reported for the transcranial procedure with fewer complications 10,14,21,22,39,48,59,60,61. The use of rigid endoscopes for sinus surgery provided the inspiration for their application to pituitary surgery 14,53,54. Currently,endoscopic surgery is a safe and accepted method of sinus surgery. Stankiewicz 53,54 has described an endoscopic approach to the sphenoidal sinus. Building on this experience, otolaryngologists have reported pituitary tumor resection aided by endoscopic techniques 49. Complications in transsphenoidal pituitary surgery are typically related to blind dissection, inability to determine normal gland from tumor, injury of the optic tracts and chiasm, or aggressive tumor dissection near the lateral and posterior aspects of the sella turcica 5,27,28,31,34,35,36,37,38,39,40,41,45,52. Improved visualization allows the surgeon to identify and avoid injury to the normal pituitary gland, carotid prominences, hypothalamus, and optic chiasm or bulbs. Recognizing these structures during pituitary tumor removal is critical to avoid catastrophic complications, which have been reported in several microscopic series. The incidence of vascular complications in the largest series based on literature ranged from 0.2% to 1.5% 13,25,27,37,40,46,59. The mortality of the patients who presented vascular complication after transsphenoidal surgery reached 100% in some series 13,46,59. Figure 3 shows a huge hematoma in a patient treated surgically for a macroadenoma with suprassellar extension (autopsy specimen). Figure 3 Autopsy specimen (sagital view) Department of Neurology, São Paulo Medical School). Forty-five years-old male patient harboring a macroadenoma with suprasellar extension treated by a transphenoidal approach: after recovering from anesthesia, the patient developed a sudden coma and died in a few hours. LAWS ER, AGUIAR PH - Vascular complications in transsphenoidal surgery J Bras Neurocirurg 19 (3): 7-14, 2008

11 11 As the number of the cases increased in the past 30 years, we observed an increment of the rate of vascular complications, however in a velocity lower than the increase of the number of the surgically treated patients. In 1982, we published 810 cases with a rate of vascular complications of 0.4%, in 1999, 3061 cases with 0.78% and in the present study, 2004, 4175 cases, with 0.9% of complications37,40. Tables II and III show the previous publications and their incidence of vascular complications as well as number of fatal cases. Table IV shows the incidence of rebleeding after transphenoidal surgery which ranges from 0.3% to 1.2% 5,13,17,37,44,59. Table II - Incidence of vascular complications (literature review) Author Number of vascular injuries Total of transsphenoidal procedures Fatal Kautzky & Lüdecke 2(1.5%) 130 NA Wilson & Dempsey (0.4%) 250 1(0.4%) Laws 3(0.4%) 810 NA Fahlbusch 3(0.2%) (0.2%) Raymond& Hardy 21(1.16%) (0.16%) Laws 24(0.78%) (0.2%) Kanter 1(3.03%) 33(pediatric Cushing) Present study 34(0.9%) (0.2%) Table III - An overview of mortality after transsphenoidal surgery Author Year Patients Mortality (%) Guiot & Derome Fahlbusch & Stass Hardy & Mohr 20, Laws Landolt Tindall & Barrow 4, Fahlbusch Injury to the cavernous internal carotid artery is an unusual and serious complication of transsphenoidal surgery. Ahuja et al, described two such patients with injury to the carotid artery, referred for endovascular treatment. The favorable clinical course and successful treatment of these patients were due to endovascular immediate procedure, one for an intracavernous false aneurysm and one for a carotid cavernous fistula. Treatment during the acute phase of bleeding is the operative repair: muscle, fat, gelfoam, Sundt clip and sellar reconstruction, pediatric Foley catheter insertion. It is a dramatic situation, and it is very difficult to manage quickly and safely in order to prevent additional damage. Table IV - Rebleeding after transsphenoidal surgery requiring re-operation Author Year Patients Incidence% Guiot & Derome / Wilson & Dempsey / Mohr & Hardy / Laws / Black / Fahlbusch / Kai et al, 24 report on a case of a patient who suffered a pseudo internal carotid artery (IC) aneurysm following transsphenoidal surgery. He was successfully treated with bypass surgery and IC occlusion involving the pseudoaneurysm using Guglielmi detachable coils (GDCs). Another patient treated by Kobayashi et al, 29 developed a traumatic carotid cavernous fistula (CCF) caused by transnasal-transsphenoidal surgery, and was successfully treated using detachable coils. They suggested that drilling is a safer procedure than using a chisel for dissection of a sphenoid sinus with incomplete pneumatization and that endovascular treatment using detachable coils proved useful to manage the carotid cavernous fistulae, an unusual complication of transsphenoidal surgery. To avoid arterial lesions, perfect understanding of anatomical structures and their relation is very important. Also, the use of an endoscopic approach may provide safe and more minimal invasive surgery. During dissection of large pituitary tumor, a mini doppler is useful before incising the dura 2,61. Yamazaki et al, 61 described an intraoperative use of pulsed Doppler ultrasonography in transsphenoidal surgery to prevent mechanical vascular injury, particularly to the intracavernous portion of the internal carotid artery. This system is integrated by connection to a video processor. They emphasize that the use of Doppler sonography provided real-time measurement of arterial or venous flow velocity and source of flow by both real-time sonograms and sound frequencies. With the use of a microprobe, 1mm in diameter, vessels located within 7mm from the tip of the probe could be easily, rapidly, and noninvasively detected, without disturbing the operative field. Other important advantage of this Doppler is that both the size and the distance of a vessel could be measured by turning the dial of Doppler signal gain from initially waxing to waning Doppler sounds, because the acoustic sounds were adjusted to the axial flow of each vessel in 0.1-mm increments 61. The preoperative imaging studies is helpful to plan the access, and the position between bone and arteries in the sellar proximities. LAWS ER, AGUIAR PH - Vascular complications in transsphenoidal surgery J Bras Neurocirurg 19 (3): 7-14, 2008

12 12 Previous surgery requires meticulous evaluation of imaging studies, and historical records in order to identify any prior intraoperative bleeding and even minor hemorrhage 45. Prior arterial injury has to be considered, especially in Cushing`s disease patients 25. Raymond et al, concluded that profuse bleeding during and after transsphenoidal surgery should be investigated by angiography. Lesions of the sphenopalatine arteries are effectively treated by embolization. Internal carotid injuries are best treated by carotid occlusion to prevent life-threatening epistaxis. In their retrospective study of the arterial hemorrhagic complications, their management, and the clinical outcomes that occurred in 21 of the more than 1800 patients who had transsphenoidal surgery for pituitary adenomas were assessed. Of the 21 patients who had complications, 17 had internal carotid injuries and four had injuries of the sphenopalatine artery. Angiography was performed in 18 patients. Bleeding occurred and was controlled during surgery in 16 cases. Delayed epistaxis occurred in 10 patients, including five whose surgery was uneventful. After internal carotid injury, the most frequent angiographic findings were carotid occlusion (eight patients), stenosis (five patients), and false aneurysms (three patients). Internal carotid balloon occlusion was performed in five patients. No rebleeding occurred in patients who had complete carotid occlusion either from surgical packing or balloon embolization. Two of the patients who had carotid stenosis after surgical packing had delayed epistaxis necessitating balloon occlusion. Injuries to the sphenopalatine artery were successfully treated by surgery (one patient) or by endovascular treatment (three patients) without complication. Three deaths and five permanent deficits were directly related to the arterial injury or its treatment 46. Our series shows similar incidence. They listed a series of predisposing factors or surgical events before the vascular complication: nonpneumatized sphenoid, multiple sphenoidal septa, oblique sphenoidal septa, tumor adherent to carotid artery, acromegalic changes, cavernous sinus invasion, cavernous aneurysms, sphenopalatine avulsion during the opening and bleeding difficult to control during the opening. Kurschel et al, reported a case of a 61-year-old man, who underwent transsphenoidal surgery for a pituitary macroadenoma. The presence of tough fibrous septa dividing the tumor permitted only a partial resection. Progressive loss of consciousness soon after surgery occurred, an emergency CT scan showed no evidence of hemorrhage. Twenty hours later, MRI revealed compression of both internal carotid arteries with arrest of arterial flow resulting in stroke caused by an enlarging hemorrhagic mass consistent with pituitary apoplexy. On the second postoperative day, the patient died as a result of this extensive stroke. Barker et al, studied the data from 5497 operations performed in the United States during the period from 1996 to 2000, performed by 825 surgeons at 538 hospitals. The records regarding mortality and morbidity were sampled and compared with Hospital and surgeon volume 3. Outcome measured at hospital discharge was death in 0.6%, discharge to long term care (0.9%), to short term rehabilitation (2.1%) or directly home 96.2%. Outcomes were better after surgery in higher volume hospitals (OR 0.74 for 5-fold larger caseload, p=0.007) or by higher volume surgeons (OR 0.62, p=0.02). A total of 5.4 % of patients were not discharged directly home from lowest volume-quartile hospitals, compared with 2.6% at highest volume-quartile hospitals. In-hospital mortality was lower with higher volume hospitals (p=0.03) and surgeons (p=0.09). Mortality rates were 0.9% at lowest-caseload-quartile hospitals and 0.4% at highest volume quartile hospitals. They demonstrated that postoperative complications (26.5% of admissions) were less frequent with higher volume hospitals (p=0.03) or surgeons (p=0,005). Length of stay was shorter with high volume hospitals (p=0.02) and surgeons (p<0.001). Also, the hospital charges were lower for high volume hospitals, but not significantly. Finally, they concluded this analysis suggests that higher volume hospitals and surgeons provide superior short term outcomes after transsphenoidal pituitary tumor surgery with shorter lengths of stay and a trend toward lower charges 3. The closure of sellar floor should be meticulous. Sometimes the best solution is using fat, or considering reconstruction of the sellar dura in transsphenoidal surgery using an expanded polytetrafluoroethylene dural substitute 45,51. Videofluoroscopy has served to provide intraoperative guidance, for many decades, however, frameless stereotaxy with archived computed (CT) or magnetic resonance imaging (MRI) exploits the concept of neuronavigation to its fullest 11. Frameless stereotaxy allows precise planning of the approach with reference to lesion perimeters, anatomic landmarks such as the carotid arteries, and other potential operative hazards 23. Frameless stereotaxy is a safe and effective modality for the treatment of recurrent or invasive sellar masses 23. All three frameless stereotaxy modalities provided accurate information regarding the anatomical midiline and the trajectory to the sella turcica 23. Neuronavigation is particularly helpful in reoperative pituitary surgery where few anatomic landmarks remain. We believe that frameless stereotaxy adds greatly to surgeon comfort and confidence during the procedure. It is extremely important to emphasize that the surgeon using the technique must always remember that the information used is based on navigation points that are prerecorded and are only as accurate as the system allows in a perfectly set-up state. Minor movement in the pin holders results in a disastrous loss of accuracy 55. In our opinion intraoperative MRI takes away this reliance on experience and should be a major advance in resection control. LAWS ER, AGUIAR PH - Vascular complications in transsphenoidal surgery J Bras Neurocirurg 19 (3): 7-14, 2008

13 13 Surgery is performed with the patient lying directly on the table of MRI scanner 55. After the endoscopic transophenoidal or a standard transsphenoidal procedure, an intraoperative MRI is performed while the operative exposure and sterile field are both maintained so that if residual tumor is seen, further resection is undertaken. REFERENCES 1. Ahuja A, Guterman LR, Hopkins LN. Carotid cavernous fistula and false aneurysm of the cavernous carotid artery: complications of transsphenoidal surgery. Neurosurgery 1992 ; 31: Atkinson JL, Kasperbauer JL, James EM, Lane JI, Nippoldt TB Transcranial-transdural real-time ultrasonography during transsphenoidal resection of a large pituitary tumor. Case report. J Neurosurg. 2001;94: Barker FG, Klibanski A, Swearingen B. Transsphenoidal surgery for pituitary tumor in the United States, : Mortality, morbidity, and effects of hospital and surgeon volume. J Clin Endocrinol Metab 2003; 88: Barrow DL, Tindall GT. Loss of vision after transsphenoidal surgery. Neurosurgery. 1990; 27: Black PM, Zervas NT, Candia GL. Incidence and management of complications of transsphenoidal operation for pituitary adenomas. Neurosurgery 1987; 20: Ciric I, Mikhael M, Stafford T, Lawson L,Garces R. Transsphenoidal microsurgery of pituitary macroadenomas with long-term follow-up results, J Neurosurg 1983; 59: Ciric I, Ragin A, Baumgartner C, Pierce D. Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery 1997; 40: Ciric I, Rosenblatt S, Zhao JC. Transsphenoidal microsurgery. Neurosurgery. 2002;51: Cushing H: The Pituitary Body and its Disorders. Clinical Status Produced by Disorders of the Hypophysis Cerebri. Philadelphia: JB Lippincott, Ebersold MJ, Quast LM, Laws ER Jr, Scheithauer B, Randall RV. Long-term results in transsphenoidal removal of nonfunctioning pituitary adenomas. J Neurosurg 1986; 64: Elias W, Chadduck J, Alden T, Laws ER Jr. Frameless stereotaxy for transsphenoidal surgery. Neurosurgery 1999; 45: Fahlbusch R, Stass P. Pituitary adenomata. Status of diagnosis and therapy. MMW Munch Med Wochenschr. 1981; 123: Fahlbusch R, Buchfelder M. Surgical complications. In: Landolt AM, Vance ML, Reilly RL, eds. Pituitary adenomas. New York; Churchill Livingstone, 1996, Freda PU, Wardlaw SL, Post KD. Long-term endocrinological follow-up evaluation in 115 patients who underwent transsphenoidal surgery for acromegaly. J Neurosurg 1998; 89: Guiot G (ed). Adenomes Hypophysaires. Paris: Mason, Guiot G, Thibaut B. L` extirpation des adénomes hypohysaires par voie trans sphénoidale. Neurochirurgie 1959; 1: Guiot G, Derome P.Surgical problems of pituitary adenomas. In: Krayenbühl H (ed) Advances and technical standards in Neurosurgery. Springer Verlag, Wien, 1976 ; pp Hardy J. L Exerese des adenomas hyophysaires par voie trans-sphenoidale. Union Med Can 1962: 91: Hardy J. Transphenoidal microsurgery of the normal and pathological pituitary. Clin Neurosurg, 1969; 16: Hardy J, Mohr G. Les prolactinomas. Aspects chirurgicaux. Neurochirurgie 1985; 27(suppl): Hardy J. Trans-sphenoidal approach to the pituitary gland. Neurosurgery. In: Wilkins RH, Rengachary SS (eds), MacGraw-Hill, New York. 1996, pp Horsley V. Disease of the pituitary gland. Brit Med J, 1906; 1: Jagannathan J, Prevedello DM, Ayer VS, Dumont AS, Jane JA, Laws ER. Computer assisted frameless stereotaxy in transsphenoidal surgery at a single institution: review of 176 cases. Neurosurg Focus 2006; 20:E Kai Y, Hamada J, Nishi T, Ushio Y. Successful treatment with bypass and interventional surgery for a ruptured pseudo carotid artery aneurysm after transsphenoidal surgery: a case report. No Shinkei Geka. 2001; 29 : Kanter AS, Diallo AO, Jane JA Jr, Sheehan JP, Asthagiri AR, Oskouian RJ, et al. Single-center experience with pediatric Cushing s disease J Neurosurg. 2005;103: Kassam A, Thomas AJ, Snyderman C, Carrau R, Gardner P, Mintz A, et al. Fully endoscopic expanded endonasal approach treating skull base lesions in pediatric patients. J Neurosurg: Pediatrics 2007;106( 2 ) : Kautzky R, Lüdecke D, Nowakowiski H, Saeger W, Schrader D. Trassphenoidal operations in acromegaly. In: Fahlbusch R, Von Werder K(eds). Treatment of pituitary adenomas. Georg Thieme Verlag, Stuttgart, 1978, pp: Kawamata T, Iseki H, Ishizaki R, Hori T. Minimally invasive endoscope assisted endonasal trans-sphenoidal microsurgery for pituitary tumors :experience with 215 cases comparing with sublabial trans-sphenoidal approach. Neurol Res 2002;24: Kobayashi N, Abe T, Furuya H, Dohi K, Shimazu M, Sasaki K, et al.. Successful treatment using detachable coils for traumatic carotid cavernous fistula as a complication of transsphenoidal surgery for a pituitary adenoma: a case report. No Shinkei Geka ;28: Kurschel S, Leber KA, Scarpatetti M, Roll P. Rare fatal vascular complication of transsphenoidal surgery. Acta Neurochir (Wien) 2005; 147: Landolt AM. Complication and pitfalls of transsphenoidal pituitary surgery. Neurosurgery 1984; 4: Landolt AM. Transsphenoidal surgery.of pituitary tumors:its pit- LAWS ER, AGUIAR PH - Vascular complications in transsphenoidal surgery J Bras Neurocirurg 19 (3): 7-14, 2008

14 14 falls and complications. In: Villiers JC de(eds). Some pitfalls and problems in Neurosurgery, Basel, Karger, 1990, pp Lanzino G, Laws ER Jr: Key personalities in the development and popularization of the transphnoidal approach to pituitary tumors: an historical overview. Neurosurg Clin N Am 2003; 14: Laws E R Jr, Kern EB. Complications of trans-sphenoidal surgery. Clin Neurosurg, 1976; 23: Laws E R Jr, Kern EB. Complications of transsphenoidal surgery. Clinical Management of Pituitary Disorders in : Tindall GT & Collins WF ( Eds ), Raven Press, New York,1979 pp Laws ER Jr, Kern E B. Complications of transsphenoidal surgery. In : Laws ER, Randel RV, Kern EB( eds ) Management of Pituitary Adenomas and Related Lesions., Appleton-Century-Crofts, New York, 1982, pp Laws E R Jr. Complications of transsphenoidal microsurgery for pituitary adenoma. In : Brock M. Modern Neurosurgery. Springer- Verlag, Berlin, 1982, pp Laws E R Jr. Transsphenoidal approach to lesions in and about the sella turcica. In : Schmidek HH, Sweet WH ( eds).operative Neurosurgical Technique: Indications, Methods, and Results., W.B. Saunders Co., Philadelphia, 1988, pp Laws ER Jr. Clivus chordomas, in Sekhar LN, Janecka IP (eds) Surgery of cranial base tumors. New York:Raven Press, 1993, pp Laws ER Jr. Vascular complications of transshenoidal surgery. Pituitary 1999; 2: Laws ER Jr, Kanter AS, Jane JA Jr, Dumont AS. Extended transphenoidal approach. J Neurosurg 2005; 102: Liu JK, Das K, Weiss MH, Laws ER Jr, Couldwell WT. The history and evolution of transshenoidal surgery. J Neurosurg 2001; 95: Mc Donald TJ, Laws ER Jr. Historical aspects of the management of pituitary disordes with emphasis on transsphenoidal surgery, in Laws ER, Randall RV, Kern EB, et al (eds): Management of Pituitary Adenomas and Related Lesions with Emphasis on Transsphenoidal Microsurgery, Appleton Century- Croft, New York 1982, pp Mohr G, Hardy J, Comtois R, Beauregard H. Surgical management of giant pituitary adenomas. Can J Neurol Sci ; 17: Oskouian R, Kelly D, Laws Jr. ER Vascular Injury and Transsphenoidal Surgery. In: Laws ER Jr, Sheehan JP (eds): Pituitary Surgery - A Modern Approach. Front Horm Res. Basel, Karger, 2006, vol 34, pp Raymond J, Hardy J, Czepko R, Roy D. Arterial injuries in transsphenoidal surgery for pituitary adenoma; the role of angiography and endovascular treatment. AJNR Am J Neuroradiol ; 18: Rhoton AL Jr: The supratentorial cranial space: microsurgical anatomy and surgical approaches. Neurosurgery 2002; 51(suppl1): Ross D A, Wilson, C B. Results of transsphenoidal microsurgery for growth hormone-secreting pituitary adenoma in a series of 214 patients. J Neurosurg 1988; 68: Shikani AH, Kelly JH: Endoscopic debulking of a pituitary tumor. Am J Otolaryngol 1993; 14: Schloffer H. Frage der Operationen an der Hypophyse. Beitr Klin Chir 1906; 50: Sherman JT, Pouratian N, Okonkwo DO, Jane Jr JA,Laws ER Jr. Reconstruction of the sellar dura in transsphenoidal surgery using an expanded polytetrafluoroethylene dural substitute. Surg Neurol 2008; 69: Spencer W R, Das K, Nwagu C, Wenk E, Schaefer, S D, Moscatello A, et al. Approaches to the sellar and parasellar region: anatomic comparison of the microscope versus endoscope. Laryngoscope 1999; 109: Stankiewicz JA: Complications of endoscopic intranasal ethmoidectomy. Laryngoscope 1987; 97: Stankiewicz JA: The endoscopic approach to the sphenoid sinus. Laryngoscope 1989; 99: Thapar K, Laws Jr E. Transphenoidal surgery. In: Powell MP, Lightman SL, Laws Jr ER (eds). Management of Pituitary tumors. The clinician`s pratical guide. 2nd edition. Human Press Totowa, New Jersey, 2003, Chapter 8, pp Tindall GT, Barrow DL. Pituitary surgery. In: Disorders of the pituitary.cv, Mosby Company, St Louis,1986 pp van t Verlaat J W, Nortier J W, Hendriks M J, Bosma N J, Graamans K, Lubsen H, et al. Transsphenoidal microsurgery as primary treatment in 25 acromegalic patients: results and follow-up. Acta Endocrinol (Copenh) 1988; 117: Welbourn R B. The evolution of transsphenoidal pituitary microsurgery. Surgery 1986; 100: Wilson C B, Dempsey L C. Transsphenoidal microsurgical removal of 250 pituitary adenomas. J Neurosurg 1978; 48: Wilson C B. A decade of pituitary microsurgery. The Herbert Olivecrona lecture. J Neurosurg 1984; 61: Yamasaki T, Moritake K, Hatta J, Nagai H. Intraoperative monitoring with pulse Doppler ultrasonography in transsphenoidal surgery: technique application. Neurosurgery 1996; 38: Zervas, N. T. Surgical results in pituitary adenomas: Results in an international survey. In: Black PM, Zervas NT, Ridgway EC, Martin JB), Secretory Tumors of the Pituitary Gland. Raven Press, New York, 1984, pp CORRESPONDING AUTHOR Paulo H. Aguiar, MD. 280 Durand Way 94304, Palo Alto, California, USA or Rua David Bem Gurion 1077, Apto 11, Morumbi, São Paulo, Brazil. phpaneurocir@gmail.com LAWS ER, AGUIAR PH - Vascular complications in transsphenoidal surgery J Bras Neurocirurg 19 (3): 7-14, 2008

15 15 Cognitive function in neurosurgical clipping of patients with unruptured intracranial aneurysms: a systematic literature review Função cognitiva no tratamento cirúrgico de pacientes com aneurismas intracranianos não-rotos: revisão sistemática da literatura Arthur A. Pereira Filho 1 Matthew M. Kang 2 Tibor Becske 3 Peter K. Nelson 3 Jafar J. Jafar 4 ABSTRACT There is a consensus that most unruptured intracranial aneurysms can be treated with acceptably low morbidity and mortality. However, some studies recently reported postoperative cognitive impairment, suggesting that it could be attributable to neurosurgical clipping. The goal of this report is to review and discuss aspects referring to cognitive function and neurosurgical repair in patients with unruptured intracranial aneurysms. Key-words: Cognitive Function; Cerebral Aneurysm; Surgical Clipping. SUMÁRIO Existe um consenso na literatura de que a maioria dos aneurismas intracranianos não-rotos pode ser tratada com índices aceitáveis de morbid-mortalidade. No entanto, alguns estudos recentemente reportaram danos cognitivos no período pós-operatório, sugerindo que estes poderiam ser atribuídos à clipagem neurocirúrgica. Os objetivos deste estudo são revisar e discutir aspectos referentes à função cognitiva e ao tratamento neurocirúrgico em pacientes com aneurisma intracraniano não-roto. Palavras-chave: Função cognitiva; Aneurisma cerebral; Clipagem neurocirúrgica. 1 World Federation of Neurosurgical Societies (WFNS) International Fellowship Program, Department of Neurosurgery - New York University Langone Medical Center, New York, NY, USA. 2 Residency Training Program, Department of Neurosurgery, New York University Langone Medical Center, New York, NY, USA. 3 Department of Radiology Division of Interventional Neuroradiology, New York University Langone Medical Center, New York, NY, USA. 4 World Federation of Neurosurgical Societies - Education and Training Program, Department of Neurosurgery - Division of Cerebrovascular Surgery, New York University Langone Medical Center, New York, NY, USA. Recebido em junho de Aceito em agosto de FILHO AAP, KANG MM, BECSKE T, NELSON PK, JAFAR JJ - Cognitive function in neurosurgical clipping of patients with unruptured intracranial aneurysms: a systematic literature review J Bras Neurocirurg 19 (3): 15-19, 2008

16 16 INTRODUCTION In recent years, a substantial debate over the best treatment for patients with unruptured intracranial aneurysms has developed. Incomplete and conflicting data about the natural history of these lesions and the risks associated with their repair have complicated this discussion 15,16,38. There is a consensus that most unruptured intracranial aneurysms can be treated with reasonably low morbidity and mortality 10,28,32. In 1998, the International Study of Unruptured Intracranial Aneurysms ISUIA 15 suggested that the high surgical morbidity could be attributable to impaired cognitive status. The same study suggested that the endovascular treatment might be associated with less immediate risk. Recently, a series of well designed, methodologically sound studies appeared with contradictory results. While some showed that neurosurgical clipping of unruptured intracranial aneurysms was not associated with cognitive dysfunction, others reported a high neuropsychological decline after neurosurgical clipping 27,28,36. Due to the contradictory data available to date, the purpose of this report is to review and discuss some aspects of the surgical morbidity, and cognitive function of neurosurgically clipped unruptured intracranial aneurysms. UNRUPTURED INTRACRANIAL ANEURYSMS: AN OVERVIEW Cerebral aneurysms are relatively common lesions, with autopsy, imaging, and epidemiological studies placing their prevalence at 2 to 6% 12,20,23,33. The most recent and possibly the most complete systematic review assessing the prevalence of intracranial aneurysms was published by Rinkel, et al. 33 in The authors reviewed both autopsy and angiographic studies, and concluded that adults with no risk factors for subarachnoid hemorrhage have an approximately 2% prevalence of unruptured aneurysms. Aneurysms can adversely affect the quality of life if they rupture, cause mass effect, embolize or have a treatment complication 18,19. Many investigators have evaluated the incidence of subarachnoid hemorrhage in particular patient populations with reported estimates of as low as 6 per , to as high as 96 per in the Japanese population 21. However, in the majority of studies involving non-japanese, the incidence of subarachnoid hemorrhage is estimated to be approximately 10 per population. Subarachnoid hemorrhage and its sequelae are the most comzmon cause of unfavorable outcomes, including sudden death in 8 to 15% 1,14,30 and permanent deficits in up to 75% of survivors 8,11,13,17,31. The annual risk of rupture from an unruptured cerebral aneurysm has been estimated by various investigators to range from 0.1 to 8% or higher, depending on aneurysm size, location, and other risk factors such as high blood pressure and smoking. These issues raise the question as to what is the most appropriate management of unruptured intracranial aneurysms 22,38. Intracranial aneurysms can be treated by either direct neurosurgical clipping or endovascularly. Clipping has been the most established management 5. In the past decade, endovascular treatment has grown in popularity as another viable alternative with the potential advantage of sparing invasive intracranial surgery 5,24. However, because of the lack of long-term followup studies and the high cost of the procedure, most neurosurgeons still prefer direct clipping 7. UNRUPTURED INTRACRANIAL ANEURYSMS: SURGICAL MORBIDITY AND MORTALITY STUDIES Traditionally, the efficacy and safety of neurosurgical clipping techniques have been evaluated by comparing them to the neurological morbidity and mortality of different treatments 2,24,35. Although the morbidity and mortality of aneurysm clipping clearly depends on the particular neurosurgeon and medical centers being evaluated, several studies have attempted to formulate generalized results. While no consensus has been reached, there is agreement that most unruptured intracranial aneurysms can be managed with acceptably low morbidity and mortality 10,22,28,32. Systematic analysis of the literature reveals historically interesting morbidity and mortality rates. In 1983, Wirth et al. 37 published a 6-year retrospective analysis of the outcomes of surgical clipping in 107 incidentally discovered unruptured intracranial aneurysms. They reported a 7% permanent, and 8% transient morbidity rate after surgery. There was no operative mortality. In 1991, Hadeishi et al. 9 reported 18 of 72 patients (25%) undergoing unruptured aneurysm clipping developed neurological deficits postoperatively. However, the overwhelming majority (17 of 18) had resolution of their symptoms within 2 weeks. In 1994, Solomon et al. 34 documented the outcomes after 202 consecutive surgeries for microsurgical clipping of unruptured cerebral aneurysms. Excellent or good outcome was achieved in 100% of patients with aneurysms less than 10 mm in diame- FILHO AAP, KANG MM, BECSKE T, NELSON PK, JAFAR JJ - Cognitive function in neurosurgical clipping of patients with unruptured intracranial aneurysms: a systematic literature review J Bras Neurocirurg 19 (3): 15-19, 2008

17 17 ter, 95% with aneurysms 11 to 25 mm, and 79% with aneurysms greater than 25mm. Overall, minor and major complications and deaths occurred in 5, 7, and 3.5% of patients, respectively. Additional cohort analysis showed that in patients with incidental aneurysms (17%), the mortality rate was 2.9%. Also in 1994, Dickey et al. 4 published a retrospective analysis of a series with 86 patients with the diagnosis of intracranial aneurysms. Of a total of 82 patients who underwent neurosurgical clipping, 44 patients had treatment for unruptured aneurysms. The authors reported a major surgical morbidity of 2% with no procedure-related deaths. Another study, published in 1996 by Deruty et al. 3, reported the surgical results on 83 unruptured cerebral aneurysms in 62 patients. The overall outcome of clipping was: good recovery in 94%, moderate morbidity 1.5%, severe morbidity 1.5% and a mortality of 3%. Two years later, in 1998, Raaymakers et al. 32 published a remarkable meta-analysis of 61 studies that involved 2460 patients who underwent surgical treatment for unruptured intracranial aneurysms. Through Medline and additional searches, they analyzed studies published from 1966 through June 1996 and found that clipping was associated with a mortality of 2.6% and a morbidity of 10.9%. In both reports from the ISUIA 15,16, prospective assessments of the morbidity and mortality rates associated with surgical intervention were obtained. In the initial report published in , the authors prospectively analyzed a cohort of 798 patients with newly diagnosed unruptured intracranial aneurysms. The overall surgical morbidity and mortality rates for patients one month and one year after surgery were 17.5% and 15.7% respectively. Surgery-related death was reported in 30 patients (3.8%) at a one year follow-up. In the second part of ISUIA 16, published in 2003, centers in the USA, Canada and Europe enrolled 1591 patients who underwent open surgery for unruptured intracranial aneurysms. This prospective study reported a surgical morbidity and mortality rates of 13.7% one month after surgery and 12.6% at a one year follow-up. Surgery-related death was reported in 43 patients (2.7%) one year after surgery. In 2003, Ogivy and Carter [26] studied 493 patients with 604 unruptured intracranial aneurysms who were submitted for clipping between 1992 and These authors` rates of morbidity and mortality for the entire group were 15.9 and 0.8% respectively. More particularly, they reported that small aneurysms in the anterior circulation in young patients carry a very low treatment risk (approximately 1%), and treatment in elderly individuals (ages 70 years and older) with large lesions (greater than 10mm), carried a significant risk of poor outcome (5% in the anterior circulation, 15% in the posterior circulation). Finally, in 2005, Moroi et al. 25 published their results after treating 549 unruptured aneurysms. Their reported outcomes were remarkable for an overall 0.3% mortality, and 2.2% morbidity. More specifically, in aneurysms smaller than 10mm, the mortality and morbidity rates were 0.0 and 0.6 %, and for aneurysms larger than 10mm, these rates were 1.2 and 6.1%. Our review of the literature revealed interesting and informative results about morbidity and mortality rates associated with unruptured intracranial aneurysm repair. With the advent of improved technology and operative techniques, it is certain that these negative rates have trended down over time. However, increased attention must be paid to newly reported morbidities, such as cognitive impairment following neurosurgical treatment. COGNITION AND UNRUPTURED INTRACRANIAL ANEURYSMS Recently, some authors have suggested that cognitive decline might represent a form of an underdiagnosed morbidity related to unruptured intracranial aneurysm clipping. The first reference to cognitive outcomes after surgery for unruptured intracranial aneurysms was in the first part of ISUIA 15 published in The authors reported that, in a group of 798 patients who were submitted to craniotomy, 93 (11.6%) had impaired cognitive status at a 30 days follow-up. However, there was no preoperative baseline evaluation. It is, therefore, unknown what proportion of impaired cognition was present preoperatively. Fukunaga et al. 6 in 1999 designed a different methodology for their cognitive study. They evaluated the cognitive function of 30 patients with the diagnosis of unruptured intracranial aneurysms before and after neurosurgical clipping. The tests used for neuropsychological assessment were the Mini Mental State Examination, the Kana-Hiroi test and the Maze test. The authors reported a significant deterioration in cognitive testing in 17 patients (55%) at one month, however all patients recovered to preoperative levels at a second cognitive assessment three months after the operation. In a study published in 2000, Hillis et al. 10 performed detailed cognitive evaluations in 12 patients with the diagnosis of unruptured intracranial aneurysms. All patients were submitted to a battery of neuropsychological test before and after surgical clipping of aneurysms. They evaluated the following criteria: attention, memory, language, parietal lobe function, frontal lobe function, motor/psychomotor function and mood. The authors noted questionable significant differences between preoperative and postoperative performance in only a few tests (measures of word fluency, verbal recall, and frontal lobe function). FILHO AAP, KANG MM, BECSKE T, NELSON PK, JAFAR JJ - Cognitive function in neurosurgical clipping of patients with unruptured intracranial aneurysms: a systematic literature review J Bras Neurocirurg 19 (3): 15-19, 2008

18 18 The second part of ISUIA published in also deserves special attention in terms of cognition analysis. In this report, the authors suggested that the surgical morbidity could be attributable to cognitive impairment, as determined by the Mini-Mental State Examination and the telephone interviews for cognitive status. Patients who underwent postoperative cognitive evaluation were found to have a 5.5% incidence of impaired cognitive status at 1 year follow-up. Nevertheless, no preoperative evaluation was obtained (same methodology as the first ISUIA), and these cognitive results cannot be considered reliable. In another interesting study dealing with cognitive function and clipping performed in 2003 by Ohue et al. 27, the authors analyzed the cognitive aspects in 43 patients with the diagnosis of unruptured intracranial aneurysms before and after surgery. The tests applied were: Mini Mental State Examination, Kana- Hiroi test, Kohs Block Design test and Miyake`s Memory test. They found that in 40% of patients (n=17), the neuropsychological function had deteriorated 1 month after surgery. However, on follow-up studies 6 months later, six patients had completely recovered, five patients partially recovered, and three patients did not recover. Good postsurgical neuropsychological outcomes have also been reported. Tuffiash et al. 36 recently reported that neurosurgical clipping of unruptured intracranial aneurysms was not associated with cognitive dysfunction. These authors studied 25 consecutive patients who underwent surgical clipping of unruptured intracranial aneurysms. The patients were submitted 1 week preoperatively, and again postoperatively (before hospital discharge and at 3-month follow-up if they had deficits at discharge), to a battery of neuropsychological tests. The tests used were: Weschler Memory Scale-Revised Test, Rey-Osterreith Complex Figure Test, Trail Making Test, Grooved Pegboard Test and Controlled Word Association Test. The authors found that, there was no significant change between preoperative and postoperative scores on most tests. A significant decline in accuracy before hospital discharge was found only in figure copying and associative learning. A significant slowing was found on one test. Even with these tests, only 3 of 25 patients showed significant deterioration. They also found that all but one patient returned to baseline at the 3-month follow-up. Another recent study with favorable cognitive results was published by Otawara et al. 28 in The authors performed detailed cognitive analysis before and after surgery for unruptured aneurysms in 44 patients. The tests applied were: Weschler Adult intelligence Scale-Revised Test, Weschler Memory Scale and Rey-Osterreith Complex Figure Test. After analyzing the results, the authors concluded that neurosurgical clipping did not impair cognition. In our review of the literature we have found that while some publications showed that neurosurgical clipping of unruptured intracranial aneurysms was not associated with cognitive dysfunction, other well designed studies reported a high neuropsychological decline after neurosurgical clipping. Presently, there is no definitive study that vigorously compares the neurocognitive outcome of direct surgical versus endovascular treatment of unruptured intracranial aneurysms. We, therefore, strongly believe that a large randomized clinical trial with full cognitive analysis would be helpful. REFERENCES 1. Bonita R, Thomson S. Subarachnoid hemorrhage: epidemiology, diagnosis, management, and outcome. Stroke 1985; 16: Byrne JV, Sohn MJ, Molyneux AJ, Chir B. Five-year experience in using coil embolization for ruptured intracranial aneurysms: outcomes and incidence of late rebleeding. J Neurosurg 1999; 90: Deruty R, Pelissou-Guyotat I, Mottolese C, Amat D. 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20 20 Spot-the-Word Test como instrumento neuropsicológico para avaliação de inteligência pré-mórbida em idosos: revisão da literatura Spot-the-Word Test as a neuropsychological instrument to assess premorbid intelligence in elderly people: a review of the literature Eliane Correa Miotto 1 Glaucia Rosana Guerra Benute 2 Catarina Andréa Santana Teixeira 3 Mara Cristina Souza de Lucia 4 Paulo Henrique Pires de Aguiar 5 Milberto Scaff 6 SUMÁRIO Objetivo: Esta revisão teve o objetivo de investigar estudos publicados na literatura sobre a utilização do teste Spot-the- Word (STW), um instrumento neuropsicológico que avalia a inteligência pré-mórbida, em pacientes idosos. Método: Os estudos selecionados para esta revisão pertencem às classes de evidencia I e II, ou seja, estudos com grupos controles e grupos não controlados. Foram excluídos estudos Classe III ou relatos de caso. Resultados: Estudos com idosos e pacientes com Alzheimer em fase leve mostraram correlação positiva do STW com outras medidas que avaliam a inteligência pré-mórbida. Conclusão: Pelo fato de ser um teste de decisão lexical com ênfase na inteligência cristalizada e menos suscetível a alterações decorrentes da idade, o STW é utilizado como teste de inteligência pré-mórbida em idosos. Palavras-chaves: inteligência pré-mórbida, decisão lexical, Alzheimer, idosos. ABSTRACT Objective: This review aimed at investigating studies published in the literature about the use of the Spot-the-Word (STW) test, a neuropsychological instrument that assesses premorbid intelligence, in elderly patients. Method: The studies included in this review were class I and II of evidence, i.e. controlled group studies and group studies not controlled. Class III studies, i.e. case reports were not included. Results: Studies with elderly people and patients with mild Alzheimer disease showed a positive correlation between STW and other measures that evaluate premorbid intelligence. Conclusion: Because the STW is a lexical decision test with emphasis on crystallized intelligence and less susceptible to cognitive alterations associated with normal aging, it is used as a premorbid intelligence test in elderly people. Key-words: premorbid intelligence, lexical decision, Alzheimer, elderly people. 1 PhD em Neuropsicologia pela Universidade de Londres, Diretora Técnica de Serviço de Saúde da Divisão de Psicologia do Instituto Central do Hospital das Clínicas da FMUSP. 2 Diretora de Pesquisa da Divisão de Psicologia do Instituto Central do Hospital das Clínicas da FMUSP. 3 Estagiária de neuropsicologia da Divisão de Psicologia do Hospital das Clínicas da FMUSP. 4 Diretora da Divisão de Psicologia do Instituto Central do Hospital das Clínicas da FMUSP. 5 Professor Livre Docente da Disciplina de Neurocirurgia, Coordenador do Grupo de Neuro-oncologia, Departamento de Neurologia, Hospital das Clinicas da FMUS. 6 Professor Titular do Departamento de Neurologia, Instituto Central, Hospital das Clinicas, FMUSP. Recebido em maio de Aceito em julho de MIOTTO EC, BENUTE GRG, TEIXEIRA CAS, LUCIA MCS, AGUIAR PHP, SCAFF M - Spot-the-Word Test como instrumento neuropsicológico para avaliação de inteligência pré-mórbida em idosos: revisão da literatura J Bras Neurocirurg 19 (3): 20-25, 2008