Supine sleep and positional sleep apnea after acute ischemic stroke and intracerebral hemorrhage

OBJECTIVE: Obstructive sleep apnea is frequent during the acute phase of stroke, and it is associated with poorer outcomes. A well-established relationship between supine sleep and obstructive sleep apnea severity exists in non-stroke patients. This study investigated the frequency of supine sleep and positional obstructive sleep apnea in patients with ischemic or hemorrhagic stroke. METHODS: Patients who suffered their first acute stroke, either ischemic or hemorrhagic, were subjected to a full polysomnography, including the continuous monitoring of sleep positions, during the first night after symptom onset. Obstructive sleep apnea severity was measured using the apnea-hypopnea index, and the NIHSS measured stroke severity. RESULTS: We prospectively studied 66 stroke patients. The mean age was 57.6±11.5 years, and the mean body mass index was 26.5±4.9. Obstructive sleep apnea (apnea-hypopnea index >5) was present in 78.8% of patients, and the mean apnea-hypopnea index was 29.7±26.6. The majority of subjects (66.7%) spent the entire sleep time in a supine position, and positional obstructive sleep apnea was clearly present in the other 23.1% of cases. A positive correlation was observed between the NIHSS and sleep time in the supine position (r s = 0.5; p<0.001). CONCLUSIONS: Prolonged supine positioning during sleep was highly frequent after stroke, and it was related to stroke severity. Positional sleep apnea was observed in one quarter of stroke patients, which was likely underestimated during the acute phase of stroke. The adequate positioning of patients during sleep during the acute phase of stroke may decrease obstructive respiratory events, regardless of the stroke subtype.

Acquired hepatocerebral degeneration and hepatic encephalopathy: correlations and variety of clinical presentations in overt and subclinical liver disease / Degeneração hepatocerebral adquirida e encefalopatia hepática: correlações e variedade de apresentações clínicas na doença hepática evidente e subclínica

Acquired hepatocerebral degeneration (AHD) and hepatolenticular degeneration can have similar clinical presentations, but when a chronic liver disease and atypical motor findings coexist, the distinction between AHD and hepatic encephalopathy (HE) can be even more complicated. We describe three cases of AHD (two having HE) with different neuroimaging findings, distinct hepatic diseases and similar motor presentations, all presenting chronic arterial hypertension and weight loss before the disease manifestations. The diagnosis and physiopathology are commented upon and compared with previous reports. In conclusion, there are many correlations among HE, hepatolenticular degeneration and AHD, but the overlapping of AHD and HE could be more common depending on the clinical knowledge and diagnostic criteria adopted for each condition. Since AHD is not considered a priority that affects the liver transplant list, the prognosis in AHD patients remains poor, and flow interruption in portosystemic shunts must always be taken into account.

A degeneração hepatocerebral adquirida (AHD) e a degeneração hepatolenticular podem ter apresentações clínicas semelhantes, mas quando uma doença hepática crônica e achados motores atípicos coexistem, a distinção entre AHD e encefalopatia hepática (HE) pode ser ainda mais complicada. Descrevemos três casos de AHD (dois tendo HE) com diferentes achados em neuroimagem, doenças hepáticas distintas e apresentações motoras semelhantes, todos com hipertensão arterial e perda de peso antes das manifestações motoras. O diagnóstico e a fisiopatologia são comentados e comparados com relatos prévios. Concluímos que existem muitas correlações entre HE, degeneração hepatolenticular e AHD, mas a sobreposição de HE e AHD pode ser mais comum dependendo do conhecimento clínico e da acurácia dos critérios diagnósticos adotados para cada enfermidade. Como a AHD não é considerada prioridade na lista de transplante hepático, o prognóstico dos pacientes com AHD permanece ruim, e a interrupção do fluxo nos shunts portossistêmicos deve ser sempre considerada.

A comparison between magnetic resonance angiography at 3 teslas (time-of-flight and contrast-enhanced) and flat-panel digital subtraction angiography in the assessment of embolized brain aneurysms

PURPOSE: To compare the time-of-flight and contrast-enhanced- magnetic resonance angiography techniques in a 3 Tesla magnetic resonance unit with digital subtraction angiography with the latest flat-panel technology and 3D reconstruction in the evaluation of embolized cerebral aneurysms. INTRODUCTION: Many embolized aneurysms are subject to a recurrence of intra-aneurismal filling. Traditionally, imaging surveillance of coiled aneurysms has consisted of repeated digital subtraction angiography. However, this method has a small but significant risk of neurological complications, and many authors have advocated the use of noninvasive imaging methods for the surveillance of embolized aneurysms. METHODS: Forty-three aneurysms in 30 patients were studied consecutively between November 2009 and May 2010. Two interventional neuroradiologists rated the time-of-flight-magnetic resonance angiography, the contrast-enhanced-magnetic resonance angiography, and finally the digital subtraction angiography, first independently and then in consensus. The status of aneurysm occlusion was assessed according to the Raymond scale, which indicates the level of recanalization according to degrees: Class 1: excluded aneurysm; Class 2: persistence of a residual neck; Class 3: persistence of a residual aneurysm. The agreement among the analyses was assessed by applying the Kappa statistic. RESULTS: Inter-observer agreement was excellent for both methods (K = 0.93; 95 percent CI: 0.84-1). Inter-technical agreement was almost perfect between time-of-flight-magnetic resonance angiography and digital subtraction angiography (K = 0.98; 95 percent CI: 0.93-1) and between time-of-flight-magnetic resonance angiography and contrast-enhanced-magnetic resonance angiography (K = 0.98; 95 percent CI: 0.93-1). Disagreement occurred in only one case (2.3 percent), which was classified as Class I by time-of-flight-magnetic resonance angiography and Class II by digital subtraction angiography. The agreement between contrast-enhanced-magnetic resonance angiography and digital subtraction angiography was perfect (K = 1; 95 percent CI: 1-1). In three patients, in-stent stenosis was identified by magnetic resonance angiography but not confirmed by digital subtraction angiography. CONCLUSION: Digital subtraction angiography and both 3T magnetic resonance angiography techniques have excellent reproducibility for the assessment of aneurysms embolized exclusively with coils. In those cases also treated with stent remodeling, digital subtraction angiography may still be necessary to confirm eventual parent artery stenosis, as identified by magnetic resonance angiography.

Endovascular therapy for selected (most non-surgical) intracranial aneurysms in a Brazilian University Hospital / Tratamento endovascular de aneurismas selecionados (maioria não cirúrgicos) em um hospital universitário brasileiro

OBJECTIVE: The objective of this study was to evaluate technical, clinical and angiographic results of a nonsurgical series of intracranial aneurysms treated by endovascular approach at Hospital das Clínicas of Medical School of Ribeirão Preto - University of São Paulo. METHOD: Between August 2005 and November 2008, 137 aneurysms in 106 patients were endovascularly treated. Of these, 101 were unruptured in 75 patients and 36 aneurysms in 31 patients were treated during the acute phase. The data were prospectively studied. RESULTS: Sixty three aneurysms (46 percent) were treated with coils alone, 52 (38 percent) with balloon remodeling, 15 (10.9 percent) with stent remodeling, and 7 (5.1 percent) with therapeutic occlusion of the internal carotid artery. Six clinical complications (5.7 percent) were related to the procedures, 3 (2.8 percent) transitory and 3 (2.8 percent) permanent. Angiographic follow-up was available for 97 aneurysms (70.8 percent), clinical monitoring for 77 patients (72.6 percent) and telephone contact for 97 (91.5 percent). CONCLUSION: The technical, clinical and angiographic results found in this study are similar to those reported in the literature.

OBJETIVO: Nosso objetivo foi avaliar os resultados técnicos, clínicos e angiográficos de uma série de aneurismas intracranianos não cirúrgicos tratados por via endovascular no Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo e comparar com os dados disponíveis na literatura atualmente. MÉTODO: Entre agosto de 2005 e novembro de 2008, 137 aneurismas foram tratados por via endovascular em 106 pacientes. Destes, 101 eram não rotos em 75 pacientes e 36 aneurismas foram tratados em 31 pacientes durante a fase aguda de ruptura. Os dados foram incluídos de maneira prospectiva. RESULTADOS: Sessenta e três aneurismas (46 por cento) foram tratados com técnica simples, 52 (38 por cento) com remodelagem por balão, 15 (10,9 por cento) com remodelagem por stent e 7 (5,1 por cento) por oclusão terapêutica da carótida interna. Seis complicações clínicas ocorreram (5,7 por cento), 3 (2,8 por cento) transitórias e 3 (2,8 por cento) permanentes. Seguimento angiográfico foi realizado para 97 aneurismas (70,8 por cento), clínico para 77 pacientes (70,8 por cento) e contato telefônico para 97 pacientes (91,5 por cento). CONCLUSÃO: Os resultados encontrados nesta série, em termos técnicos, clínicos e angiográficos, são semelhantes aos encontrados na literatura.

Definições de pontos craniométricos em imagens multiplanares de ressonância magnética (rm) para fins de reconstrução facial forense / Craniometric landmarks definitions from multiplanar magnetic resonanceimages (mri) regarding forensic facial reconstruction

A reconstrução facial pode ser uma ferramenta útil dentro do processo de identificação médico-legal. O método tem apresentado uma evolução contínua ao longo dos anos, tornando-se mais acurado. A sua fidelidade deve-se em parte as medidas de tecidos moles que são empregadas para se reconstituir o rosto a partir de um crânio. A proposta deste estudo foi a de investigar e conhecer dados sobre a correta localização e definição de 22 pontos craniométricos estabelecidos na literatura a partir de estruturas anatômicas e adaptá-los para imagens obtidas em exames digitais de ressonância magnética (RM), de forma a permitir a futura mensuração da espessura dos tecidos moles crânio-faciais de brasileiros vivos com alta precisão e confiabilidade. Ficou evidenciada a necessidade de mudança na forma de localizar as referências anatômicas ósseas e seus correspondentes em tecidos moles, especialmente em três pontos, onde o conhecimento detalhado de anatomia dental é requerido. O estabelecimento dessas definições poderá fundamentar as bases da elaboração de uma tabela antropomórfica contendo as espessuras de tecidos moles da face de brasileiros com vista à aplicação em reconstituição facial forense, para preencher esta lacuna do conhecimento médico-legal no Brasil.

Facial reconstruction can be a useful tool in the process of medico-legal identification. The method has presented a continuous evolution through the years, becoming more accurate. Its reliability is, in part, due to the facial soft tissues measurements that are applied to reconstruct a face from a skull. The aim of this study was investigating and knowing data about the correct localization and definitions of 22 craniometric landmarks established in the literature from anatomical structures and adapt them to images obtained from digital exams of magnetic resonance imaging(MRI), allowing the future measurements of cranio-facial soft tissues thickness of living Brazilians with high precision and reliability. It was evidenced the necessity of changing the localization methods of bone anatomical references and their soft tissues correspondents, especially in three landmarks, where detailed knowledge about dental anatomy is required. The establishment of these definitions will give support to the setting of an anthropomorphic table containing the facial soft tissues thickness of Brazilians regarding their utilization in forensic facial reconstruction, to fill this gap in the Brazilian medico-legal knowledge.

Memory tests are not good predictors of surgical outcome in patients with mesial temporal lobe epilepsy associated with hippocampal sclerosis

One of the objectives of pre-surgical evaluation in mesial epilepsy associated to hippocampal sclerosis is the identification of patients with bad surgical prognosis for seizure ccontrol. At least theoretically, neuropsychological tests could be used in this venue. To evaluate whether verbal and visual memory tests can be used as isoleted predicotrs of the post-surgical sizure outcome in patients wit mesial temporal lobe epilepsy associated with hippocampal sclerosis refractory to pharmacological treatment. In a retrospective cohort study using the control of epileptic seizres as end-point, we evaluated 187 patients and calculated the correlation of clinical variables, cognitive evaluation, neuroimaging data, demographic data and electrophysiological findings with the result of seizure control after lobectomy in these patients. An unfavorable prognosis during the postoperative period was observed only in association with low visual reproduction scores (visual memory). However, afterBonferrroni corrections, which was necessary to reduce the chance of type I error this result was found to be spurious. We conclude that neuropsychological tests of verbal and visual memory such as those used in the routine presurgica evaluation of our patients with temporal lobe epilepsy are not good isolated predictors of surgical outcome

Teste de esforço em hipertensos em uso de diferentes inibidores da enzima conversora da angiotensina / Exercise testing in hypertensive patients taking different angiotensin-converting enzyme inhibitors

OBJECTIVE: To compare blood pressure response to dynamic exercise in hypertensive patients taking trandolapril or captopril. METHODS: We carried out a prospective, randomized, blinded study with 40 patients with primary hypertension and no other associated disease. The patients were divided into 2 groups (n=20), paired by age, sex, race, and body mass index, and underwent 2 symptom-limited exercise tests on a treadmill before and after 30 days of treatment with captopril (75 to 150 mg/day) or trandolapril (2 to 4 mg/day). RESULTS: The groups were similar prior to treatment (p<0.05), and both drugs reduced blood pressure at rest (p<0.001). During treatment, trandolapril caused a greater increase in functional capacity (+31 percent) than captopril (+17 percent; p=0.01) did, and provided better blood pressure control during exercise, observed as a reduction in the variation of systolic blood pressure/MET (trandolapril: 10.7±1.9 mmHg/U vs 7.4±1.2 mmHg/U, p=0.02; captopril: 9.1±1.4 mmHg/U vs 11.4±2.5 mmHg/U, p=0.35), a reduction in peak diastolic blood pressure (trandolapril: 116.8±3.1 mmHg vs 108.1±2.5 mmHg, p=0.003; captopril: 118.2±3.1 mmHg vs 115.8±3.3 mmHg, p=0.35), and a reduction in the interruption of the tests due to excessive elevation in blood pressure (trandolapril: 50 percent vs 15 percent, p=0.009; captopril: 50 percent vs 45 percent, p=0.32). CONCLUSION: Monotherapy with trandolapril is more effective than that with captopril to control blood pressure during exercise in hypertensive patients

Single photon emission computed tomography (SPECT) in neurocysticercosis

Neurocysticercosis (NC) is a parasitic infectious disease caused by Taenia solium eggs that set in the brain. Its incidence is increasing both in the developing and the developed world, as a result of low economical and hygiene levels and immigration, respectively. Clinical manifestation of disease varies from no symptoms to epilepsy, increased intra-cranial pressure, arachnoiditis and dementia. In order to evaluate function (perfusion) of affected brains, we studied 40 patients (21 females and 19 males, 19-71 yo) by means of SPECT (ECD, ethyl cysteinate dimer, labelled with 99mTc) and with and without contrast CT. SPECT studies were all abnormal. No difference was noted between active and inactive disease. Two SPECT patterns were noted: a) several areas of focally reduced uptake, resulting from coalescent and big lesions and large destruction of brain tissue (small, isolated and symmetric cysts seen in CT were missed by SPECT); b) diffuse atrophy with reduction of the tracer uptake, associated with ventricle dilatation, corresponding to the cases where ventricular NC was important. Interestingly, we noted diffuse hypoperfusion, with the scintigraphic pattern of atrophy in 5 cases of massive parenchymal infection; in such cases, CT signs of atrophy were clearly less prominent. The first scintigraphic aspect can be explained by the destruction of large areas of brain, which produces focal absence of perfusion; generalised vasculitis and the destruction of large portions of brain tissue could explain the difference noted between the SPECT and the CT aspects in the 5 cases of massive parenchimal infection, and this may be interesting for prognosis. Dilatation of ventricles and Sylvian fissures were interestingly prominent in SPECT. SPECT may be of great value to evaluate brain perfusion in NC

Participaçäo das variaçöes anatômicas do complexo ostiomeatal na gênese da rinossinusite crônica, analisadas por tomografia computadorizada / Participation of anatomical variations of the ostiomeatal complex on the genesis of chronic rhinosinusitis, analyzed by computed tomography

Introdução: A introdução da cirurgia endoscópica funcional dos seios paranasais tem renovado o interesse pela cirurgia rinossinusal. Apesar do princípio de que o procedimento cirúrgico deveria ser orientado para abertura dos óstios e assim restabelecer o clearance mucociliar natural, muitas questões relacionadas à fisiopatologia da rinossinusite permanecem não respondidas, o que suscita várias pesquisas nesse campo. Forma do estudo: C1ínico retrospectivo. Material e métodos: Cem exames de tomografia computadorizada (CT) de pacientes atendidos no Ambulatório de Otorrinolaringologia do Hospital das C1ínicas da Faculdade de Medicina de Ribeirão Preto (HC-FMRP-USP) com rinossinusite crônica comprovada, foram comparados com cem exames de CT de pacientes com doença intra-orbital (grupo controle), para verificar a prevalência das variações anatômicas do complexo ostiomeatal e se as mesmas têm papel importante na gênese da rinossinusite crônica. Resultados: Nos 200 exames analisados, somente 50 por cento dos casos apresentaram variações, e apenas 25 por cento mostraram doença crônica instalada nos seios paranasais junto com variações. O corneto médio bolhoso foi a variação mais encontrada. A presença de múltiplas variações também foi considerada. Conclusão: Os dados permitem concluir que as variações anatômicas ósseas do COM não influenciam a prevalência de rinossinusite crônica, sugerindo ser a moléstia intrínseca da mucosa sinusal muito mais importante na etiopatogenia da doença

Anticorpos antifosfolípides em 66 pacientes com infarto cerebral entre 15 e 40 anos / Antiphospholipid antibodies in 66 patients with cerebral infarction between 15 and 40 years old

Os anticorpos antifosfolípides (aFLs) constituem grupo heterogêneo de imunoglobulinas que tem sido relacionado com alteraçoes na coagulabilidade. Indivíduos com títulos elevados teriam maior probabilidade de desenvolver tromboses de repetiçao, tanto arterial como venosa, e por conseguinte infarto cerebral (IC). Os testes para detecçao mais utilizados em estudos clínicos sao o inibidor lúpico e a anticardiolipina. Têm-se relatado maiores percentuais de positividade nesses testes em pacientes jovens com IC. Neste estudo procuramos investigar a prevalência desses anticorpos em pacientes com IC entre 15 e 40 anos em nosso Serviço. Examinamos 66 pacientes para presença de aFLs e obtivemos 16,65 por cento de resultados positivos. Confirmamos diagnóstico de síndrome do anticorpo antifosfolípide primária em três (4,55 por cento) casos. Concluímos que a pesquisa de rotina para aFLs em pacientes jovens com IC está indicada neste grupo de pacientes, mas correlacioná-los com o episódio isquêmico nem sempre é possível.

Infartos cerebrais em pacientes jovens relacionados a deficiência de anticoagulantes naturais: proteína C e proteína S / Cerebral infarctions in young patients related to deficiency of natural anticoagulants: protein C and protein S

Infartos cerebrais (IC) em jovens apresentam múltiplas etiologias que diferem do padrao observado nos indivíduos idosos. Deficiências de anticoagulantes naturais têm sido descritas nos últimos anos como causa de IC, principalmente em pacientes com menos de 40 anos. Existe tendência atual de se pesquisar essas deficiências em todos os pacientes jovens com infarto cerebral de causa indeterminada e naqueles com manifestaçoes trombóticas de múltiplos sistemas. Realizamos pesquisa dos níveis de proteína C, proteína S e antitrombina III em pacientes entre 15 e 40 anos com ICs classificados como indeterminados após conclusao protocolo básico de investigaçao. Diagnosticamos dois casos de deficiência de proteína C e um caso de deflciência de proteína S. Concluímos que a investigaçao sistemática de causas hematológicas proporciona decréscimo no número de infartos indeterminados, além de possibilitar a adoçao de condutas específicas que diminuem incidência de novos eventos nos casos diagnosticados.

Vasculopatia cerebral na síndrome do anticorpo antifosfolípide primária: relato de dois casos / Cerebral vasculopathy in the primary antiphospholipid antibody syndrome: report of 2 cases

Os anticorpos antifosfolípides (aFLs) têm sido associados a várias síndromes neurológicas, destacando-se a grande incidência os infartos celebrais. Os mecanismos responsáveis pelo comprometimento vascular encefálico em pacientes com titulos elevados de aFLs permanecem em discussao. A existência de vasculopatia relacionada a este grupo heterogêneo de imunoglobulinas é, no entanto, inquestionável. Relatamos dois casos de síndrome do anticorpo antifosfolípide primário que apresentaram enfartos cerebrais. Os achados angiográficos no primeiro sugeriam vasculite intracraniana, embora houvesse também estenose proximal sugestiva de trombose "in situ". No segundo paciente a angiografia mostrava obstruçao de carótida interna, sem sinais de aterosclerose e na necrópsia foi confirmada a hipótese de vasculopatia trombótica em múltiplos sítios. Nossos achados servem de modelo para discutirmos as controvérsias existentes a respeito da patogênese deste tipo de vasculopatia. Ou seja, se a lesao primária seria vasculite, trombose ou ambas.

Abordagem a tratamento fisiátrico de lesöes agudas de partes moles na prática do esporte / Physiatric aproach and treatment of acute soft tissue injuries from sports

Os autores revisam noçöes atualizadas sobre etiopatogenias das lesöes agudas de partes moles na prática desportiva e seu a manejo através de crioterapia, compreensäo, imobilizaçäo e elevaçäo do local afetado. O uso de drogas antiinflamatórios näo-esteróides é indicado nas primeiras 72 horas do processo inflamatório agudo. A reabilitaçäo para o retorno ao esporte é enfatizada, sendo que a mobilizaçäo precoce assume papel importante considerando-se individualmente o caso e sua variáveis. Por fim, salientam a importância e citam medidas gerais de profilaxia destas lesöes