Keywords
history of medicine - neurosurgery - aneurysm - glioma - meningioma
Introduction
The large number of public hospitals from the three governmental levels in Rio de
Janeiro allowed the emergence of several departments of neurosurgery over the years,
which, on one hand, expanded the distribution of specialists in most units but, on
the other hand, reduced superspecialization in certain subareas, besides restricting
the correct allocation of resources in possible centers of reference of the specialty.
Most of the units practiced the same general neurosurgery, with a low surgical volume,
without becoming a reference in any subarea. Several authors have emphasized the importance
and impact of the management of complex pathologies in high-volume centers, especially
in large cities.[1]
[2]
[3]
[4]
[5]
[6]
Conceived in 2011 and inaugurated 2 years later, the Instituto Estadual do Cérebro
Paulo Niemeyer (IECPN, in the Portuguese acronym), in the city of Rio de Janeiro,
is the first thematic public neurosurgery hospital in the country. The objective of
the present study is to present the structure, organization, functioning, difficulties
and surgical results of the first 24 months of operation of this unit.
Fundamentals
Current public health policies seek the maximum care of the population at the lowest
possible cost. The development of reference centers in several subspecialties in large
cities, with a high volume of care, has enabled a better use of the public resources,
with lower rates of complication, mortality and a possible reduction in the length
of hospital stay. In 1987, Hughes et al[1] were pioneers in revealing that a greater hospital volume is directly related to
better results.
European and American systematic reviews have also revealed a positive association
between the volume of care and the evolution in AIDS, oncologic surgery, coronary
angioplasty, cerebral aneurysm and carotid endarterectomy, among other pathologies.
Using the hospital admissions database in the United States, Barker et al[4] found better mortality, hospitalization, costs, and hospital stay until the definitive
discharge in trans-sphenoidal surgery for tumors of the pituitary gland in high-volume
hospitals. Likewise, the main guideline for the management of subarachnoid hemorrhage
suggests the management of this pathology in centers with a high volume of care (more
than 35 subarachnoid hemorrhages annually), evidence-base class I.[5] Building a hospital unit wholly dedicated to neurosurgery would allow the training
and perfection of neurosurgical, neuroanesthetic, neurointensive, and neuroradiological
medical support, rehabilitation and nursing staff for mass, repeated assistance, and
treatment of certain pathologies.
Infrastructure
The first part of the facilities was inaugurated in June 2013, consisting of 2 buildings,
1 of assistance and the other administrative. The clinic has four floors, with an
outpatient clinic, a surgical center, a hemodynamics center, a three-stage intensive
care unit, a two-way magnetic resonance imaging center, a fixed multichannel computer
tomograph and a portable tomograph, an epilepsy center, clinical analysis laboratories,
pathology and basic research in neurosciences.
The second part of the facilities will provide a teaching and an extension area, with
an amphitheater and an auditorium, a radiosurgery unit with a Gamma Knife Perfexion
(Elekta Instruments AB, Stockholm, Sweden), as well as another 12-story building that
will house hospitalization units (rooms), a major neuropediatric intensive care unit
(ICU) and a rehabilitation floor.
Surgical and Hemodynamic Center
Surgical and Hemodynamic Center
The IECPN has four integrated and automated surgical rooms, all with a surgical microscope,
two of them with an endoscopy system. One of the rooms is a hybrid, with intraoperative
magnetic resonance imaging (iMRI) of 1.5T ([Fig. 1]), which, when not in surgical application, is used in three shifts a day for internal
and outpatient exams. The hemodynamic service has a fluoroscope dedicated to the investigation
and treatment of cerebrovascular diseases in total harmony with the microsurgical
team.
Fig. 1 (A) Surgery in the hybrid room, preparing the patient for intraoperative magnetic
resonance imaging, with neuronavigation. The surgical site is covered with new sterile
fields, the coils are coupled, as well as the device for immediate neuronal navigation
with the new images to be obtained. (B) With the attached room door open, the special
magnetic resonance transport stretcher is connected to the surgical table for direct
transport of the patient to the apparatus by sliding.
Intensive Care Units
There are three floors of neurological ICUs, and the second floor has 10 beds of immediate
short-stay neurosurgical postoperative ICUs. The third floor has 6 beds of neuropediatric
ICUs and 11 beds of semi-intensive neurological unit. The fourth floor is the unit
of critical patients, mainly those transferred from other units, with subarachnoid
hemorrhage. There are 17 beds in this unit, which is equipped with bed computed tomography
(CT), transcranial Doppler, bed electroencephalography, monitoring of intracranial
pressure (ICP), partial tissue oxygenation (PTiO2), point of care ultrasonography and pulse contour cardiac output (PiCCO) monitoring.
Equally important is the presence of active teams of respiratory, motor, and day and
night phonoaudiology.
Epilepsy Center
Within the IECPN, there is a center dedicated to the investigation and support of
epilepsy refractory to clinical treatment. Counting with an outpatient clinic and
two video-electroencephalography rooms, a multidisciplinary team defines weekly surgical
cases. It has become one of the main focuses of attention of the institution for the
suppressed demand of these patients in the state of Rio de Janeiro.
Basic Research and Biobank Laboratories
Basic Research and Biobank Laboratories
Two basic research laboratories linked to neurosurgery produce constant material that
can translate into our practice. A molecular genetics laboratory for tumors of the
central nervous system, coordinated by neuropathologists Prof. Dr. Leila Chimelli
and Prof. Dr. Monica Gadelha, and a laboratory of cerebral biomedicine focused on
the culture of tumor cells of gliomas and meningiomas, coordinated by Prof. Dr. Vivaldo
Moura Neto.
A large biobank stores pieces collected during procedures in the IECPN, with the consent
of the patients and their families, and promotes the most diverse researches in these
laboratories.
Organization
Assistance
As the existence of numerous emergency units in the state with a neurosurgeon on duty
meets the demand for the care of traumatic brain injury (TBI) and spinal cord injury
(SCI), the focus of care of the IECPN is non-traumatic cranial neurosurgery. Other
hospitals in the public network are responsible for the management of large-scale
spine surgery, such as Instituto Nacional de Traumatologia e Ortopedia (INTO, in the
Portuguese acronym) and Hospital Estadual Adão Pereira Nunes (HEAPN, in the Portuguese
acronym).
The character of the hospital is mainly elective, except for the treatment of subarachnoid
hemorrhages. The patients arrive at the unit only through state regulation, either
by ambulatory care or by direct transfer from any unit, already with an established
surgical diagnosis. Neurosurgery has a primary team responsible for elective surgeries,
a daily attendant for intercurrences, and an outpatient team for surgical screening,
postoperative evaluation, and clinical follow-up of non-surgical lesions. In total,
the surgical team consists of 21 neurosurgeons.
Other thematic outpatient clinics complement the screening and follow-up of the patients
in a more comprehensive and specialized manner, including epilepsy rooms, movement
disorders, neuroendocrinology, neuro-oncology, pediatric neurosurgery, and neurovascular
surgery.
The establishment of a robust department of neuroendocrinology allowed the reference
of large-scale patients and the exchange of experiences with two other renowned institutions
in the care of the sellar pathologies, the Hospital Universitário Clementino Fraga
Filho of Universidade Federal do Rio de Janeiro (UFRJ, in the Portuguese acronym)
and the Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE, in
the Portuguese acronym). In addition to outpatient screening and preoperative preparation
specific to each pathology, patients with hypophyseal adenomas, craniopharyngiomas
and other sellar pathologies have immediate postoperative follow-up in the neurosurgery
UTI and follow-up with the same team.
Teaching and Research
The IECPN began to host the 5-year postgraduate course in neurosurgery under the tutelage
of the Pontifícia Universidade Católica do Rio de Janeiro (PUC-Rio, in the Portuguese
acronym) and the direction of Prof. Dr. Paulo Niemeyer Filho, whose students make
their rotation in TBI, SCI and spinal surgery in the HEAPN. At the moment, we have
15 postgraduates, 9 of whom started training at the Santa Casa de Misericórdia in
Rio de Janeiro. There are daily morning sessions after the round in the ICUs, in neurovascular,
neuroendocrinology, neuro-oncology, pediatric neurosurgery, and epilepsy surgery departments,
in addition to the magazine club.
Likewise, the neurosurgery UTI offers a 1-year postgraduate program in neurointensivism,
in addition to regular courses of transcranial doppler and bedside electroencephalography.
The neuroradiology department also offers the fourth year of residence to general
radiologists, and the physiotherapy department also has a specific postgraduate course
on preoperative and postoperative management of the neurosurgical patient.
The high volume of care and procedures in the IECPN has allowed each department to
lead basic and clinical scientific studies, mainly in the most managed pathologies
in the unit—hypophyseal adenomas, gliomas, meningiomas, subarachnoid hemorrhages,
cavernomas and epilepsy surgeries.
Key epidemiological data are being prospectively maintained on the REDCap (Research
Eletronic Data Capture, Vanderbilt University, Nashville, Tennessee) data platform
to facilitate subsequent data collection and analysis. A medical epidemiologist is
part of the unit only for the orientation and follow-up of several studies in each
department. And finally, a research nurse in neurosurgery completes the academic pillar
of the unit and has a strategic function in four points: (1) assisting physicians
in collecting data in different studies, (2) feeding the unit's general database,
(3) making contact with patients, and (4) assisting in the organization of meetings
of research groups.
Initial Results
A total of 19,717 patients were seen from June 2013 to July 2015 (26 months) in different
outpatient clinics—–[Table 1] discriminates care by sector. The overall volume of monthly care increased 18% between
2014 (monthly average of 843.17) and 2015 (monthly average of 995.29).
Table 1
|
Outpatient unit
|
2013
|
2014
|
2015
|
Total
|
|
Adult neurosurgery
|
474
|
2,269
|
1,549
|
4,292
|
|
Pediatric epilepsy
|
340
|
1,421
|
899
|
2,660
|
|
Adult epilepsy
|
312
|
1,386
|
916
|
2,614
|
|
Neuroendocrinology
|
288
|
1,065
|
775
|
2,128
|
|
General medicine
|
231
|
486
|
346
|
1,063
|
|
Neurovascular
|
82
|
584
|
390
|
1,056
|
|
Pediatric neurosurgery
|
98
|
514
|
403
|
1,015
|
|
Anesthesiology
|
258
|
450
|
305
|
1,013
|
|
Neuro-oncology
|
0
|
392
|
469
|
861
|
|
Involuntary movement
|
131
|
307
|
183
|
621
|
|
Psychiatry
|
76
|
299
|
199
|
574
|
|
Psychology
|
61
|
247
|
196
|
504
|
|
Neuropsychology
|
113
|
210
|
94
|
417
|
|
Nutritionist
|
43
|
194
|
61
|
298
|
|
Pediatrics
|
43
|
87
|
46
|
176
|
|
Genetics
|
26
|
78
|
69
|
173
|
|
Metabolism
|
27
|
59
|
42
|
128
|
|
Phonoaudiology
|
29
|
70
|
25
|
124
|
|
Total
|
2,632
|
10,118
|
6,967
|
19,717
|
A total of 2,272 patients were operated on in the IECPN from August 2013 to July 2015
(24 months), 229 of which were by endovascular intervention. Considering the 2,043
procedures performed at the surgical center, the monthly average was 87.52 ± 12.70
(60–115) surgeries per month (excluding the 1st month of operations of the operating
rooms, when only 1 room was open). There was an evolving progression in the monthly
average, with 78.75 ± 16.44 (60–94) surgeries per month in 2013 and 96.4 ± 13.90 (70–115)
in 2015. The daily average of surgeries during working days in this range was 4.0
(1–8).
[Fig. 2] shows the division of procedures by macroareas. There is a clear predominance in
the management of neoplastic lesions, with 48.6% of the total. Vascular neurosurgery
represented the 2nd major area undergoing surgical movement, with 20.4%, while the
sum of the procedures for hydrocephalus management represented the 3rd position (13.1%).
We will now describe the specific volume of the main lesions covered in the IECPN
by macroarea.
Fig. 2 In the first 24 months of operation, 2,272 procedures were performed in the IECPN.
Of this total, 229 endovascularly. There was a clear predominance of surgery of tumors
of the central nervous system and skull. The “Other” category included decompressive
craniectomies, cranioplasties, intracranial hematoma surgeries, abscesses and empyemas,
Chiari malformations, and wound revisions. Abbreviations: IECPN, Instituto Estadual
do Cérebro Paulo Niemeyer.
Central Nervous System and Skull Tumor Surgery
The mean monthly tumor surgeries were 36.0 ± 6.7 (22–46), excluding the 1st month
of operations. Using the 2007 World Health Organization (WHO) classification, gliomas
were the main group of tumors managed in the IECN, representing 29.0% of the total
number of tumors ([Table 2]). Glioblastoma multiforme alone accounted for 59.9% of the 227 astrocytic tumors,
43.2% of the total gliomas and 12.5% of the total number of tumors in this series.
Table 2
|
Gliomas
|
Total
|
|
Astrocytic tumor
|
227
|
|
Glioblastoma multiforme
|
136
|
|
Pilocytic astrocytoma
|
36
|
|
Astrocytoma grade II
|
24
|
|
Astrocytoma grade III
|
21
|
|
Gliosarcoma
|
9
|
|
Subependymal astrocytoma
|
1
|
|
Oligodendroglial tumors
|
42
|
|
Oligodendroglioma II
|
21
|
|
Oligodendroglioma III
|
21
|
|
Neuronal and glioneuronal mixed tumors
|
31
|
|
Malignant glioneuronal
|
13
|
|
Ganglioglioma I
|
12
|
|
Ganglioglioma III
|
4
|
|
Papillary glioneuronal tumors
|
1
|
|
Ganglioglioma II
|
1
|
|
Ependymal tumors
|
15
|
|
Ependymoma grade III
|
12
|
|
Ependymoma grade II
|
3
|
|
Total
|
315
|
Pituitary adenoma represented 23.1% of the operated tumors; [Table 3] shows the distribution of these lesions. The 249 meningeal tumors constituted 22.9%
of all neoplasms – [Table 4] reveals the distribution, while [Fig. 3] stratifies the meningiomas by location. Of the 236 meningiomas, 85.6% were benign
WHO I, 10.6% were atypical (WHO II) and 3.8% were anaplastic (WHO III).
Fig. 3 Topographic distribution of the 236 meningiomas operated on in the first 2 years
of the IECPN. Meningiomas of convexity were the most prevalent in the unit, representing
almost 30% of the total. Skull base meningiomas accounted for 55.1% of the total.
Abbreviations: IECPN, Instituto Estadual do Cérebro Paulo Niemeyer.
Table 3
|
Adenomas
|
Total
|
|
Nonfunctioning
|
135
|
|
GH secretors
|
60
|
|
ACTH secretors
|
38
|
|
Prolactinomas
|
13
|
|
Thyrotropinomas
|
5
|
|
Total
|
251
|
Table 4
|
Meningeal tumor
|
Total
|
|
Meningioma
|
236
|
|
Hemangioblastoma
|
6
|
|
Hemangioma
|
2
|
|
Hemangiopericytoma
|
2
|
|
Osteoma
|
1
|
|
Solitary fibrous tumor
|
2
|
|
Total
|
249
|
Seventy-six brain metastases were operated on, accounting for 7.0% of all neoplasms.
The highest incidence was of pulmonary focus metastases (43.4%), followed by those
with no primary focus (19.7%), and breast metastases (14.5%). Tumors of the cranial
and peripheral nerves represented the 5th position among the neoplasms, with 75 schwannomas
and 1 intradural Neurofibroma of the C1 root. Of these, 69 were vestibular (90.8%);
2 were trigeminal; 2 were of the hypoglossal nerve; 1 was of the nerves of the jugular
foramen; and 1 was of the facial nerve. The other histopathological diagnoses will
be detailed in another article.
Vascular Neurosurgery
In total, 464 microsurgical and endovascular procedures were performed. Treatment
of intracranial aneurysms accounted for 80.6% of the vascular procedures. There were
203 microsurgeries and 171 embolizations for the treatment of aneurysms. Subarachnoid
hemorrhage occurred in 50.5% of the patients. Exactly 50% of the patients submitted
to clipping had middle cerebral artery aneurysms (MCAs), while 27.3% had posterior
communicating artery aneurysms, and 18.7% had anterior communicating artery aneurysms.
Among the embolized aneurysms, the distribution was less disparate, with prevalence
of the anterior communicating artery (19.1%).
Twenty-one cavernous malformations were operated on during the period covered in the
present study. Twelve of them were supratentorial (5 frontal, 2 in the caudate, 2
temporal, 1 in the rotation of the Cingulate gyrus, 1 in the radiated crown, and 1
parietal); 7 in the brainstem; and 2 cerebellar.
Nine arteriovenous malformations were addressed, seven of which with hybrid treatment—embolization
associated with microsurgery. Three were frontal, three occipital, two parietal, and
one cerebellar. As for the Spetzler-Martin classification, four were grade III; four
were grade II; and one was grade I.[7]
Six cerebral bypasses were made, all extra and intracranial. Of these, five were from
the superficial temporal artery to the middle cerebral artery (branches M3 or M4);
and one was from a high-flow, external carotid artery to M3, using a radial artery
graft.
Functional Neurosurgery
Although it represented 5.9% (n = 133) of the surgical movement, the mass treatment of movement disorders became
one of the great differentials of the institute. The surgical management of Parkinson
disease prevailed, accounting for 51.9% of surgical care; trigeminal neuralgia accounted
for 24.1%; dystonia, 10.5%; facial spasm, 4.5%; essential tremor, 3.0%; and glossopharyngeal
neuralgia, 2.3% and revision of DBS system 3.7%.
Pediatric Neurosurgery
With only six beds, the pediatric neurosurgical movement was significantly lower.
A total of 264 procedures were performed on children and adolescents. We have verified
that 122 (46.2%) of these procedures were tumor resections; 41 (15.5%) were procedures
for hydrocephalus management; 20 vascular surgeries (9 aneurysms, 4 arteriovenous
malformations [AVMs], 2 trunk cavernomas, 2 supratentorial cavernomas, 1 low-flow
bypass for Moya-Moya disease,1 dural arteriovenous fistula and 1 Galene malformation);
9 craniosynostosis; 7 tethered spinal cord; 1 Chiari malformation; and 1 encephalocele;
among others general procedures.
Epilepsy Surgery
The surgical treatment of temporal lobe epilepsy accounted for most of the surgeries
in this group, with 36.2% of the 58 procedures. Twelve were selective amygdalohippocampectomies,
and nine included anterior lobectomy. The vagus nerve stimulator implant corresponded
to 20.7% of the total; callosotomies, 12.1%; and hemispherectomies, 5.2%. There was
also a deep cerebral electrode implant in one case.
Discussion
The last decades saw the superconcentration of selected specialties in their own units
to provide integral treatment in a single environment or institution as well as to
promote excellence in teaching and research, generating national epidemiology. The
Instituto Nacional de Cardiologia (National Institute of Cardiology; INC, in the Portuguese
acronym), Instituto Nacional do Câncer (National Institute of Cancer; INCA, in the
Portuguese acronym) and the INTO, in Rio de Janeiro, as well as the Instituto do Câncer
do Estado de São Paulo (Cancer Institute of the State of São Paulo; ICESP, in the
Portuguese acronym) and Instituto do Coração (Heart Institute; InCor, in the Portuguese
acronym), in São Paulo, promote their specialties through mass assistance, training
of specialists and the generation of specific public policies.[8]
[9]
The fragmentation of neurosurgical departments in several Brazilian states, both within
and outside universities, in a context of restriction of investments within the Unified
Health System (SUS, in the Portuguese acronym), contradicts the worldwide tendency
to concentrate high-complexity procedures in high-volume centers.[1]
[2]
[3]
[4]
[5]
[6]
[8]
[9] There is extensive evidence in the literature that morbidity and mortality are lower
when patients are treated at high-volume reference centers by superspecialized physicians.[4]
[6] Still, in 2002, Birkmeyer et al[10] showed a significant reduction of operative mortality in complex abdominal and cardiovascular
procedures when operated in high-volume versus low-volume institutions in the USA.
A decade later, analyzing the results of 3.2 million patients undergoing oncological
or cardiovascular surgeries, Finks et al[11] ratified that management in high-volume centers reduces surgical mortality in various
pathologies. But these authors also reinforce the need for safe surgery initiatives,
constant improvement in quality, outcome measures and constant prognosis (all of which
are more easily performed in a specialized unit). In short-term results, morbidity
and mortality are consistently lower in trans-sphenoidal surgery for sellar lesions
in high-volume hospitals, with lower rates of hospitalization and even a lower cost
trend.[4] Similar impacts were revealed in the microsurgical management of trigeminal neuralgia
and ventriculoperitoneal shunting in children in centers with a high volume of treatment.[12]
[13]
High-volume neurosurgery centers may be located within universities (The department
of neurosurgery at the Karolinska Institutet, Sweden, and the neurosurgery service
of Universidade de São Paulo [USP, in the Portuguese acronym] Medical School), linked
to private institutions but operating in independent buildings (Barrow Neurological
Institute, Phoenix, AZ, USA; Burdenko Institute, Moscow, Russia).[14]
[15]
[16] As an example, the Karolinska Institutet had already performed 3,000 neurosurgeries
annually with four surgical rooms, Gamma Knife and hemodynamics, two decades ago.[15] The Barrow Neurological Institute has demonstrated how a high volume produces better
results in pathologies once rare in other centers, such as cavernous malformation
of the brainstem, encouraging teams from all departments to produce knowledge in genetics,
molecular biology and radiology.[17]
[18]
The IECPN was conceived in January 2011 as a model of rapid resolution, both for ambulatory
neurosurgical patients and for transfers from another center, based on a high volume
of approach to cranial neurosurgical pathologies. Inaugurated in June 2013, it was
named after Paulo Niemeyer, one of the founders of the Sociedade Brasileira de Neurocirurgia
(Brazilian Society of Neurosurgery—1957), who introduced the surgical microscope in
the specialty in Brazil, and author of the description of the amygdalohippocampectomy
(1958).[19]
By concentrating specialists such as neuroanesthetists, neuroendocrinologists, specialists
in neurointensive care, neuropathologists, neuro-oncologists and neuroradiologists,
as well as physiotherapists, speech therapists, psychologists, nutritionists and nurses
deeply specialized in neurosurgery, all working in a high volume of cases, using specific
protocols, a more agile and complete treatment to each patientis provided. The identification
of complications inherent to each disease or procedure, and the management of these,
is significantly faster. In parallel, an environment conducive to basic and multidisciplinary
clinical research in neurosurgery will result in a greater knowledge development and
in a specific national literature, will highlight the most incidental pathologies
to guide society, and will allow the promotion of public agencies with data for aid
in the development of specific public policies, together with other major national
institutions.
Tumor microsurgery represented 48.6% of the surgical movement in the first 24 months
of operations of the IEPCN. Gliomas accounted for 29% of all tumors; pituitary adenomas,
23.1%; and meningeal tumors, 22.9%. Hybrid vascular neurosurgery represented 20.4%
of the total movement, and it is worth highlighting the perfect balance between microsurgery
and endovascular therapy, either because of the number of clusters versus embolizations,
or because of the 9 open rotated AVMs operated, 8 were submitted to preoperative embolization.
The greater development of functional and epilepsy surgeries in the state of Rio de
Janeiro, although they occupy the fourth and fifth positions in volume, respectively,
may represent one of the greatest impacts of the institute's installation. Of a total
of 133 patients operated by the functional neurosurgery group, 30 received deep brain
stimulators—53.3% for Parkinson disease. The multidisciplinary group of the epilepsy
center, meanwhile, performed 280 monthly visits to screen 58 patients operated on
in the period covered by the present study (except for lesionectomies with neoplasic
outcome).
Limitations
The evaluation of other external specialists, mainly urologists, hematologists, vascular
and plastic surgeons, is not always as ideally ready as in a university hospital,
but in no case has it compromised the multidisciplinary care of the patient. A general
surgery recall team responds promptly in cases of emergency thoracoabdominal procedures.
Conclusion
Following the revolutions caused by the centralization of the integral care of cardiology,
oncology, orthopedics and traumatology in dedicated institutions, with a high volume
in recent decades, Brazilian neurosurgery presents its first step in this model. The
implementation of dedicated institutes allows the government to prioritize investments
in the same unit for maximum use of the entire technological apparatus and increase
productivity. In addition, it creates a great reference for patients, generating a
volume that translates into greater team experience, knowledge generation, and better
training for future generations.
The dissemination of the initial results of the IECPN, the impact on local health
and the future cost-effectiveness analysis of the procedures can guide the development
of other units of the same size in other metropolitan regions with a high demographic
concentration.
