RICARDO FERRARETO IGLESIO
Projetos de Pesquisa
Unidades Organizacionais
Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Faculdade de Medicina - Médico
LIM/62 - Laboratório de Fisiopatologia Cirúrgica, Hospital das Clínicas, Faculdade de Medicina
LIM/62 - Laboratório de Fisiopatologia Cirúrgica, Hospital das Clínicas, Faculdade de Medicina
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- Routine postoperative computed tomography scan after craniotomy: systematic review and evidence-based recommendations(2021) BLUMRICH, Lukas; TELLES, Joao Paulo Mota; SILVA, Saul Almeida da; IGLESIO, Ricardo Ferrareto; TEIXEIRA, Manoel Jacobsen; FIGUEIREDO, Eberval GadelhaOver the last few years, the role of early postoperative computed tomography (EPOCT) after cranial surgery has been repeatedly questioned, but there is yet no consensus on the practice. We conducted a systematic review to address the usefulness of EPOCT in association with neurological examination after elective craniotomies compared to the neurological examination alone. Studies were eligible if they provided information about the number of patients scanned, how many were asymptomatic or presented neurological deterioration before the scan and how many of each of those groups had their management changed due to imaging findings. CTs had to be performed in the first 48 h following surgery to be considered early. Eight studies were included. The retrospective studies enrolled a total of 3639 patients, with 3737 imaging examinations. Out of the 3696 CT scans performed in asymptomatic patients, less than 0.8% prompted an intervention, while 100% of patients with neurological deterioration were submitted to emergency surgery. Positive predictive values of altered scans were 0.584 for symptomatic patients and 0.125 for the asymptomatic. The number of altered scans necessary to predict (NNP) one change in management for the asymptomatic patients was 8, while for the clinically evident cases, it was 1.71. The number of scans needed to diagnose one clinically silent alteration is 134.75, and postoperative imaging of neurologically intact patients is 132 times less likely to issue an emergency intervention than an altered neurological examination alone. EPOCT following elective craniotomy in neurologically preserved patients is not supported by current evidence, and CT scanning should be performed only in particular conditions. The authors have developed an algorithm to help the judgment of each patient by the surgeon in a resource-limited context.
conferenceObject Lateral Insertion of Leads and Treatment Outcomes in Ventral Capsule/Ventral Striatum Deep Brain Stimulation for Obsessive-Compulsive Disorder(2020) LOPES, Antonio; GODINHO, Fabio; MURAKAMI, Mario; IGLESIO, Ricardo; LEEMANS, Alexander; FONOFF, Erich; MIGUEL, Euripedes; TEIXEIRA, Manoel; ARANTES, Paula- Should the Globus Pallidus Targeting Be Refined in Dystonia?(2022) LAPA, Jorge Dornellys da Silva; GODINHO, Fabio Luiz Franceschi; TEIXEIRA, Manoel Jacobsen; LISTIK, Clarice; IGLESIO, Ricardo Ferrareto; DUARTE, Kleber Paiva; CURY, Rubens GisbertBackground and Study Aims Deep brain stimulation (DBS) of the globus pallidus internus (GPi) is a highly effective therapy for primary generalized and focal dystonias, but therapeutic success is compromised by a nonresponder rate of up to 20%. Variability in electrode placement and in tissue stimulated inside the GPi may explain in part different outcomes among patients. Refinement of the target within the pallidal area could be helpful for surgery planning and clinical outcomes. The objective of this study was to discuss current and potential methodological (somatotopy, neuroimaging, and neurophysiology) aspects that might assist neurosurgical targeting of the GPi, aiming to treat generalized or focal dystonia. Methods We selected published studies by searching electronic databases and scanning the reference lists for articles that examined the anatomical and electrophysiologic aspects of the GPi in patients with idiopathic/inherited dystonia who underwent functional neurosurgical procedures. Results The sensorimotor sector of the GPi was the best target to treat dystonic symptoms, and was localized at its lateral posteroventral portion. The effective volume of tissue activated (VTA) to treat dystonia had a mean volume of 153mm (3) in the posterior GPi area. Initial tractography studies evaluated the close relation between the electrode localization and pallidothalamic tract to control dystonic symptoms. Regarding the somatotopy, the more ventral, lateral, and posterior areas of the GPi are associated with orofacial and cervical representation. In contrast, the more dorsal, medial, and anterior areas are associated with the lower limbs; between those areas, there is the representation of the upper limb. Excessive pallidal synchronization has a peak at the theta band of 3 to 8Hz, which might be responsible for generating dystonic symptoms. Conclusions Somatotopy assessment of posteroventral GPi contributes to target-specific GPi sectors related to segmental body symptoms. Tractography delineates GPi output pathways that might guide electrode implants, and electrophysiology might assist in pointing out areas of excessive theta synchronization. Finally, the identification of oscillatory electrophysiologic features that correlate with symptoms might enable closed-loop approaches in the future.
conferenceObject Multiple Intracranial Aneurysms: Incidence and Risk Factors(2019) SANTOS, Alexandra; ROSI JUNIOR, Jefferson; SILVA, Saul Almeida da; IGLESIO, Ricardo; CALDAS, Jose Guilherme; TEIXEIRA, Manoel; FIGUEIREDO, Eberval- Multiple and mirror intracranial aneurysms: study of prevalence and associated risk factors(2021) ROSI JUNIOR, Jefferson; SANTOS, Alexandra Gomes dos; SILVA, Saul Almeida da; IGLESIO, Ricardo Ferrareto; CALDAS, Jose Guillherme Mendes Pereira; RABELO, Nicollas Nunes; TEIXEIRA, Manoel Jacobsen; PREUL, Mark C.; SPETZLER, Robert F.; FIGUEIREDO, Eberval GadelhaObjective Multiple intracranial aneurysms (MIA) account for 30% of all intracranial aneurysms, while mirror aneurysms, a subgroup of MIA, are present in 5% of all patients with cerebral aneurysms. We investigated the risk factors associated with the presence of multiple and mirror intracranial aneurysms. Methods 1404 patients, 314 males (22.4%) and 1090 female (77.6%) were enrolled for this study. Diagnosis was performed with a digital subtraction angiography (DSA). Multiplicity was defined as the presence of two or more aneurysms and mirror aneurysms as one pair of aneurysms involving bilateral corresponding arteries. Patients were followed-up from September 2009 till August 2018. Individuals' characteristics such as sex, age, smoking, hypertension and use of contraceptives were evaluated. Results Five hundred and twelve patients (36.4%) were diagnosed with MIA, approximately 4%/year. We observed 203 pairs of mirror aneurysms, accounting for 406 aneurysms (13% of the population). There was an increased frequency of females with multiple (p < 0.001, OR = 1.883, 95% CI = 1.386-2.560) and mirror aneurysms (p < 0.001, OR = 2.828, 95% CI = 1.725-4.636). Smoking was associated with multiplicity (p< 0.001, OR = 1.458, 95% CI = 1.160-1.833), as well as advanced age (p < 0.001, OR = 1.938, 95% CI = 1.438-2.611), but there was no significant relation with presence of mirror aneurysms. We observed higher frequency of baby aneurysms (<3mm) in the group of patients with MIA, while giant aneurysms (>25 mm) were most found in patients with only one aneurysm (p < 0.001). No differences between patients who used contraceptives against patients who did not use were found (p = 0.600). Conclusions Gender and smoking, known risk factors to the development of a single intracranial aneurysm, are proportionally increased in patients with MIA. Hypertension and oral contraceptives were not associated with multiplicity.
- Interleaving Stimulation in Parkinson Disease: Interesting to Whom?(2019) FRANCA, Carina; BARBOSA, Egberto Reis; IGLESIO, Ricardo; TEIXEIRA, Manoel Jacobsen; CURY, Rubens GisbertBACKGROUND: Interleaving stimulation (ILS) is a stim-ulation strategy that can help the physician manage more challenging cases of patients with deep brain stimulation (DBS) for Parkinson disease (PD). It consists of altering 2 different programs on the electrode with the same frequency. OBJECTIVES: Our objective was to overview our patients experience with ILS and explore clinical scenarios in which ILS should be considered when programming DBS in patients with PD. METHODS: We retrospectively reviewed medical charts from 120 patients with PD treated with DBS between 2011 and 2018. RESULTS: Eighteen patients received ILS. One was excluded because of the medical chart was incomplete. The remaining 17 patients had subthalamic nucleus DBS (n = 14) and globus pallidus internus DBS (n = 3). Eight patients (47%) received ILS to improve rigidity and bradykinesia, 4 to improve dyskinesias, 4 because of refractory tremor, and 1 for gait management. Until the end of data collection, 13 of 17 patients (70%) were still on ILS, with a mean duration time of 28.8 months (range, 2-44 months) Four patients reported no benefit from ILS and had their program changed. CONCLUSIONS: Overall, ILS is useful 1) to use 2 contacts optimally improve 2 specific symptoms but have different therapeutic windows; 2) to avoid side effects related to current spreading to nearby areas; 3) to increase frequency in a small region; or 4) to stimulate a larger target area.
- Cavernous carotid aneurysms do not influence the occurrence of upstream ipsilateral aneurysm(2024) ROSI JUNIOR, Jefferson; SANTOS, Alexandra Gomes dos; SOLLA, Davi Jorge Fontoura; RABELO, Nicollas Nunes; SILVA, Saul Almeida da; IGLESIO, Ricardo Ferrareto; CALDAS, Jose Guillherme Mendes Pereira; TEIXEIRA, Manoel Jacobsen; FIGUEIREDO, Eberval GadelhaObjective Cavernous carotid aneurysms (CCA) comprehend around 5% of all intracranial aneurysms. The main risk factors for an intracranial aneurysm seem not to influence the incidence of CCAs. The aim of this study was to investigate the association of CCAs and the presence of upstream aneurysms. Methods 1403 patients, admitted in Hospital das Clinicas de Sao Paulo, Brazil, from September 2009 to August 2018, enrolled this study. Diagnosis was performed with Digital Subtraction Angiography (DSA). Upstream aneurysm was defined as an intracranial aneurysm on anterior cerebral circulation, ipsilateral to the CCA (if present) or crossing the midline (e.g. anterior communicating artery). Results 177 individuals were diagnosed with CCA (12.6% of the population), totalizing 225 aneurysms (10% of the total number of aneurysms, 2253). No association was found between CCA and UA (p= .090, OR: 1.323, 95% CI: 0.957-1.828). Studying only patients with CCA, multivariable analysis showed smoking as the only factor associated with UA (p= .010, OR: 0.436, 95% CI: 0.232-0.821). Conclusions Cavernous carotid aneurysms were present in 12% of our population, mostly in female. They seem to be independent of the modifiable risk factors already associated with intracranial aneurysms. A higher frequency of mirror aneurysms was seen in this location. CCA did not influence the presence of ipsilateral and anterior circulation aneurysms.
- Safety and Outcomes of Dentate Nucleus Deep Brain Stimulation for Cerebellar Ataxia(2022) CURY, Rubens Gisbert; FRANCA, Carina; DUARTE, Kleber Paiva; PARAGUAY, Isabela; DINIZ, Juliete Melo; CUNHA, Paulina; GALHARDONI, Ricardo; SILVA, Valquiria; IGLESIO, Ricardo; BISSOLI, Andre Bortolon; LEPSKI, Guilherme; BARBOSA, Egberto Reis; TEIXEIRA, Manoel Jacobsen; ANDRADE, Daniel Ciampi deCerebellar symptoms remain orphan of treatment options despite being prevalent and incapacitating. Investigate whether dentate nucleus deep brain stimulation (DN DBS) is safe and leads to improvements in cerebellar symptoms when compared to sham stimulation. This randomized double-blind crossover pilot trial enrolled five patients with spinocerebellar ataxia type 3 or post-lesion ataxia. Active or sham phases were randomly performed three months apart. The primary outcome was ataxia improvement as measured by the Scale for the Assessment and Rating of Ataxia (SARA) after the active compared to the sham period. Secondary outcome measures included safety and tolerability, the Fahn-Tolosa-Marin Tremor Rating Scale (FTMRS), quality of life measurements, and patients' global impression of change. The effects on ataxia were numerically better in four out of five patients after active versus sham stimulation. The composite SARA score did not change after comparing active to sham stimulation (8.6 +/- 3.6 versus 10.1 +/- 4.1; p = 0.223). The FTMRS showed significant improvement after active stimulation versus sham (18.0 +/- 17.2 versus 22.2 +/- 19.5; p = 0.039) as did patients' global impression of change (p = 0.038). The quality of life was not modified by stimulation (p = 0.337). DN DBS was well tolerated without serious adverse events. One patient had the electrode repositioned. DN DBS is a safe and well tolerated procedure that is effective in alleviating cerebellar tremor. In this small cohort of ataxic patients, DN DBS did not achieve statistical significance for ataxia improvement.
- Dentate nucleus stimulation for essential tremor(2021) PARAGUAY, Isabela Bruzzi; FRANCA, Carina; DUARTE, Kleber Paiva; DINIZ, Juliete Melo; GALHARDONI, Ricardo; SILVA, Valquiria; IGLESIO, Ricardo; BISSOLI, Andre Bortolon; MENEZES, Janaina Reis; CARRA, Rafael Bernhart; LEPSKI, Guilherme; BARBOSA, Egberto Reis; ANDRADE, Daniel Ciampi de; TEIXEIRA, Manoel Jacobsen; CURY, Rubens Gisbert
- Exploring the clinical outcomes after deep brain stimulation in Tourette syndrome(2019) BRITO, Manuelina; TEIXEIRA, Manoel Jacobsen; MENDES, Matheus Miranda; FRANCA, Carina; IGLESIO, Ricardo; BARBOSA, Egberto Reis; CURY, Rubens GisbertIntroduction: Deep brain stimulation (DBS) of the thalamic centromedian-parafascicular (CM-Pf) region is the most common target to treat refractory Tourette syndrome (TS), but the improvement among the patients is quite variable. This study describes the outcomes of stimulation in TS patients and attempts to determine whether the volume of tissue activated (VTA) inside the thalamus or the structural connectivity between the area stimulated and different regions of the brain is associated with tic improvement. Methods: The DBS patient response was measured as the percentage change in the Yale Global Tic Severity Scale (YGTSS) before and 12 months after surgery. The sum of the two overlapping VTA/CM-Pf volumes from both hemispheres was correlated with the percent change in YGTSS scores to assess whether the area stimulated inside the CM-Pf affects the clinical outcome. Structural connectivity estimates between the VTA (of each patient) and different regions of the brain were computed using a normative connectome that was taken from healthy subjects. Results: Five male patients aged 26.8 +/- 9.3 years were included. No relationships were found between the areas stimulated and the changes in patient tics (p = .374). However, the right frontal middle gyms (R = 0.564, p =.03), the left frontal superior sulci region (R = 0.900, p =.030) and the left cingulate sulci region (R = 0.821, p = .045) structurally correlated with tic improvement. Conclusion: These data suggests that the volume of thalamic area that is stimulated does not explain the variance in outcomes in TS, however, the pattern of connectivity between the region stimulated and specific brain cortical areas is linked to patient outcome.