Manejo quirúrgico de ependimomas en médula cervical: A propósito de un caso clínico / Surgical management of ependymomas in the cervical spine: Apropos of a clinical case

Introducción: los ependimomas son tumores cerebrales que surgen de células ependimarias, células de soporte en el cerebro y la médula espinal. Representan entre el 2 y el 3% de todos los tumores cerebrales primarios. Son el cuarto tumor cerebral más común en los niños, donde el 90% de los mismos se localizan en la fosa posterior. En adultos, el 60% de estos tumores se encuentran en la médula espinal pudiendo presentarse a cualquier nivel de ésta; el caso a continuación reporta un ependimoma cervical. Objetivo: reportar un caso de ependimoma medular de ubicación poco frecuente, con resección total, sin recidiva porterior a 2 años de seguimiento.Descripción del caso: se reporta el caso de un paciente adulto, 44 años, masculino, con un síndrome medular cervical completo, progresivo, provocado por un ependimoma cervical. Intervención: se realizó laminectomía de dos espacios [C7 a T1], apertura dural, mielotomía posterior logrando exéresis total de la lesión con durorrafia a sello de agua y posterior cierre por planos sin complicaciones, con seguimiento de 2 años de sobrevida. Conclusiones: la resección total macroscópica de este tipo de tumores es muy importante para poder evitar residiva. El ependimoma cervical puede recidivar, sobre todo cuando existen residuales de la lesión. El manejo oportuno depende de gran manera de que los pacientes acudan tempranamente a valoración especializada; la resección guiada con monitorización neurofisiológica transoperatoria provee mayor oportunidad a los pacientes a no presentar secuelas permanentes y permite asimismo, mejores resultados de la rehabilitación neurológica postoperatoria

Introduction: ependymomas are brain tumors that arise from ependymal cells, supporting cells in the brain and spinal cord. They represent between 2 and 3% of all primary brain tumors. They are the fourth most common brain tumor in children, where 90% of them are located in the posterior fossa. In adults, 60% of these tumors are found in the spinal cord and can occur at any level of the spinal cord; the case below reports a cervical ependymoma. Objective: to report a case of medullary ependymoma of rare location, with total resection, without recurrence after 2 years of follow-up. Case description: a 44-year-old male adult patient with a progressive, complete cervical spinal cord syndrome, caused by a cervical ependymoma, is reported.Intervention: two-space laminectomy [C7 to T1], dural opening and posterior myelotomy were performed, achieving total excision of the lesion with water-seal durorrhaphy and subsequent closure by planes without complications, with a 2-year survival follow-up. Conclusions: macroscopic total resection of this type of tumor is very important to avoid residual. Cervical ependymoma can recur, especially when there is residual lesion. Timely management depends to a great extent on the patients attending early for a specialized evaluation; guided resection with intraoperative neurophysiological monitoring provides a greater opportunity for patients to not present permanent sequelae and also allows better results of postoperative neurological rehabilitation.

Convulsiones neonatales: Diagnóstico clínico y electroencefalográfico / Neonatal seizures. Clinical and electroencephalographic diagnosis

Las convulsiones neonatales son una expresión común de lesiones cerebrales agudas durante el periodo perinatal y podrían incrementar el daño neuronal. La mayoría son electroencefalográficas y las clínicas pueden ser sutiles y difíciles de identificar por el personal médico. Las convulsiones neonatales son usualmente cortas pero frecuentes al inicio y tienden a desaparecer en un periodo corto. El video-EEG continuo es el test ideal para detectar estas convulsiones, pero el EEG de amplitud es útil cuando el EEG convencional no está disponible. El monitoreo con EEG no solo es necesario para evaluar la frecuencia y duración de estas convulsiones, también puede proporcionar información pronóstica importante.

Neonatal seizures are common expression of acute brain injury in the perinatal period and could potentiate the degree of neuronal injury. The majority of events are electroencephalographic and the clinical seizures can be subtle and difficult to identify by medical personnel. Neonatal seizures are usually short and frequent at onset and have a tendency to subside after a short period. Continuous video-EEG monitoring is the gold standard to detect seizures, but amplitude integrated EEG is a useful tool when conventional EEG is not available. EEG monitoring is important not only to monitor frequency and duration of seizures but to provide important prognostic information.

Spinal Deformity Surgery : It Becomes an Essential Part of Neurosurgery

Among the spinal disorders, the treatment approach for spinal deformities has been discussed least among department of neurosurgery. But nowadays, more and more neurosurgeons are interested in spinal deformities as well as complex spinal disorders and are doing not a few surgeries for these kinds of disease. Nevertheless, it is mandatory to understand the course of spinal deformity, principles of treatment, and surgical outcomes and complications. Understanding of the biology, biomechanics and metallurgy of the spine and instrumentation are also required for successful spinal deformity surgery. We need senior mentors and good surgical and neurophysiologic monitoring team. Knowledge of spinal deformity may be augmented with spine fellowships and surgical experience. Step by step training such as basic knowledge, orthopedic as well as neurosurgical disciplines and surgical skills would be mandatory. Neurosurgeons can have several advantages for spinal deformity surgeries. By high-level technical ability of the spinal cord handling to preserve neurological function and familiarity with microscopic surgery, better synergistic effect could be expected. A fundamental understanding of pediatric spinal deformity and growing spine should be needed for spinal deformity surgery.

Clinical and Radiological Outcomes of Posterior Vertebral Column Resection for Severe Spinal Deformities

OBJECTIVE: The aim of this study was to investigate clinical and radiological outcomes of patients who underwent posterior vertebral column resection (PVCR) by a single neurosurgeon in a single institution.METHODS: Thirty-four consecutive patients with severe spinal deformities who underwent PVCR between 2010 and 2016 were enrolled. The radiographic measurements included a kyphotic angle of PVCR levels (VCR angle), sagittal vertical axis (SVA), thoracic kyphosis, lumbar lordosis (LL), and spinopelvic parameters. The data of surgical time, estimated blood loss, duration of hospital stay, complications, intraoperative neurophysiologic monitoring, and the Scoliosis Research Society (SRS)-22 questionnaire were collected using a retrospective review of medical records.RESULTS: The VCR angle, LL, and SVA values were significantly corrected after surgery. The VCR and LL angle were changed from the average of 38.4±32.1° and −22.1±39.1° to −1.7±29.4° (p < 0.001) and −46.3±23.8° (p=0.001), respectively. The SVA was significantly reduced from 103.6±88.5 mm to 22.0±46.3 mm (p=0.001). The clinical results using SRS-22 survey improved from 2.6±0.9 to 3.4±0.8 (p=0.033). There were no death and permanent neurological deficits after PVCR. However, complications occurred in 19 (55.9%) patients. Those patients experienced a total of 31 complications during- and after surgery. Sixteen reoperations were performed in twelve (35.3%) patients. The incidence of transient neurological deterioration was 5.9% (two out of 34 patients).CONCLUSION: Severe spinal deformities can be effectively corrected by PVCR. However, the PVCR technique should be utilized limitedly because surgery-related serious complications are relatively common.

Spinal Deformity Surgery : It Becomes an Essential Part of Neurosurgery

Among the spinal disorders, the treatment approach for spinal deformities has been discussed least among department of neurosurgery. But nowadays, more and more neurosurgeons are interested in spinal deformities as well as complex spinal disorders and are doing not a few surgeries for these kinds of disease. Nevertheless, it is mandatory to understand the course of spinal deformity, principles of treatment, and surgical outcomes and complications. Understanding of the biology, biomechanics and metallurgy of the spine and instrumentation are also required for successful spinal deformity surgery. We need senior mentors and good surgical and neurophysiologic monitoring team. Knowledge of spinal deformity may be augmented with spine fellowships and surgical experience. Step by step training such as basic knowledge, orthopedic as well as neurosurgical disciplines and surgical skills would be mandatory. Neurosurgeons can have several advantages for spinal deformity surgeries. By high-level technical ability of the spinal cord handling to preserve neurological function and familiarity with microscopic surgery, better synergistic effect could be expected. A fundamental understanding of pediatric spinal deformity and growing spine should be needed for spinal deformity surgery.

Clinical and Radiological Outcomes of Posterior Vertebral Column Resection for Severe Spinal Deformities

OBJECTIVE: The aim of this study was to investigate clinical and radiological outcomes of patients who underwent posterior vertebral column resection (PVCR) by a single neurosurgeon in a single institution. METHODS: Thirty-four consecutive patients with severe spinal deformities who underwent PVCR between 2010 and 2016 were enrolled. The radiographic measurements included a kyphotic angle of PVCR levels (VCR angle), sagittal vertical axis (SVA), thoracic kyphosis, lumbar lordosis (LL), and spinopelvic parameters. The data of surgical time, estimated blood loss, duration of hospital stay, complications, intraoperative neurophysiologic monitoring, and the Scoliosis Research Society (SRS)-22 questionnaire were collected using a retrospective review of medical records. RESULTS: The VCR angle, LL, and SVA values were significantly corrected after surgery. The VCR and LL angle were changed from the average of 38.4±32.1° and −22.1±39.1° to −1.7±29.4° (p < 0.001) and −46.3±23.8° (p=0.001), respectively. The SVA was significantly reduced from 103.6±88.5 mm to 22.0±46.3 mm (p=0.001). The clinical results using SRS-22 survey improved from 2.6±0.9 to 3.4±0.8 (p=0.033). There were no death and permanent neurological deficits after PVCR. However, complications occurred in 19 (55.9%) patients. Those patients experienced a total of 31 complications during- and after surgery. Sixteen reoperations were performed in twelve (35.3%) patients. The incidence of transient neurological deterioration was 5.9% (two out of 34 patients). CONCLUSION: Severe spinal deformities can be effectively corrected by PVCR. However, the PVCR technique should be utilized limitedly because surgery-related serious complications are relatively common.

Amplitude-Integrated Electroencephalography Predicts Outcome in Patients with Coma After Acute Brain Injury / 神经科学通报·英文版

Prognostication of coma patients after brain injury is important, yet challenging. In this study, we evaluated the predictive value of amplitude-integrated electroencephalography (aEEG) for neurological outcomes in coma patients. From January 2013 to January 2016, 128 coma patients after acute brain injury were prospectively enrolled and monitored with aEEG. The 6-month neurological outcome was evaluated using the Cerebral Performance Category Scale. aEEG monitoring commenced at a median of 7.5 days after coma onset. Continuous normal voltage predicted a good 6-month neurological outcome with a sensitivity of 93.6% and specificity of 85.2%. In contrast, continuous extremely low voltage, burst-suppression, or a flat tracing was correlated with poor 6-month neurological outcome with a sensitivity of 76.5% and specificity of 100%. In conclusion, aEEG is a promising predictor of 6-month neurological outcome for coma patients after acute brain injury.

Noninvasive intracranial pressure monitoring for HIV-associated cryptococcal meningitis

Mortality and adverse neurologic sequelae from HIV-associated cryptococcal meningitis (HIV-CM) remains high due to raised intracranial pressure (ICP) complications. Cerebrospinal fluid (CSF) high opening pressure occurs in more than 50% of HIV-CM patients. Repeated lumbar puncture with CSF drainage and external lumbar drainage might be required in the management of these patients. Usually, there is a high grade of uncertainty and the basis for clinical decisions regarding ICP hypertension tends to be from clinical findings (headache, nausea and vomiting), a low Glasgow coma scale score, and/or fundoscopic papilledema. Significant neurological decline can occur if elevated CSF pressures are inadequately managed. Various treatment strategies to address intracranial hypertension in this setting have been described, including: medical management, serial lumbar punctures, external lumbar and ventricular drain placement, and either ventricular or lumbar shunting. This study aims to evaluate the role of a non-invasive intracranial pressure (ICP-NI) monitoring in a critically ill HIV-CM patient.

Una revisión sistemática del monitoreo de la presión intracraneana en adultos con trauma craneoencefálico severo / A systematic review of intracranial pressure monitoring in adults with severe traumatic brain injury

Objetivos: Revisar sistemáticamente la evidencia relacionada con el monitoreo de la presion intracraneana en unidades de cuidado neurocrítico en el contexto de trauma craneoencefálico severo. Criterios de elección: Ensayos clínicos aleatorizados que comparen el uso del monitoreo de la presión intracraneana (PIC) que muestren un estimado de mortalidad/discapacidad a 6 meses, en pacientes mayores de 12 años de edad con trauma craneoencefálico severo (escala de Glasgow menor a 8). Método de búsqueda: En Medline, el Registro Central de Ensayos Controlados (CENTRAL); PubMed, HINARI, EMBASE; Grupo Cochrane de Lesiones y las listas de referencias de artículos. De acuerdo con el Manual Cochrane para meta-análisis y revisión sistemática. Resultados: No hubo diferencias entre el grupo de PIC y el control en el pronóstico de discapacidad (RR [Riesgo Relativo]1.01, 95 por ciento CI 0.87 to 1.18). Sin embargo, el monitoreo de la PIC reduce la estancia en UCI en comparación con otros métodos. La estancia en UCI con tratamiento cerebral específico también se redujo en comparación con grupo control. Conclusiones: En pacientes con trauma craneoencefálico, no hubo diferencia entre el monitoreo de la PIC y el examen clínico sin embargo, para mantener una PIC baja, hubo una sustancial reducción de requerimiento de solución salina hipertónica y un descenso en la hiperventilación trayendo consigo beneficios para pacientes en UCI.

Objectives: To systematically review the evidence of intracranial pressure monitoring in neuro critical care unit in the context of a severe head injury. Study eligibility criteria: Patients were older than 12 years ,had a severe traumatic brain injury (Glasgow coma scale < 8), that compared the use of ICP monitoring with control, that presented an estimate of mortality/ disability prognosis 6 months after injury.only randomized clinical trials. Methods: Searched MEDLINE, the Central Registerof Controlled Trials (CENTRAL); PubMed, HINARI,EMBASE; Cochrane Injuries group and the reference lists of articles. In accordance with the Cochrane handbook for meta-analysis and systematic review. Results: In the ICP and control groups there was no difference in the prognosis of disability (RR [Relative Risk]1.01, 95 percent CI 0.87 to 1.18). However, ICP monitoring reduced the duration of stay in ICU compared to other surveillance methods. The stay in the ICU with specific medical support for brain injury was also reduced compared to the control group. Conclusions: In patients with severe traumatic brain injury, the ICP monitoring was not difference to imaging and clinical examination. However, by keeping the ICP low there was a substantial reduction in the requirement for hypertonic saline and a decrease in hyperventilation providing benefits to thepatient in the ICU.

Vasoespasmo cerebral y déficit isquémico tardío en la hemorragia subaracnoídea aneurismática: guías para su manejo clínico / Cerebral vasospasm and delayed ischemic deficit in the aneurysmal subarachnoid hemorrhage: guidelines to its clinical management

La presente revisión del tema Vasoespasmo y Déficit Isquémico Cerebral tardío (DIT) en la Hemorragia subaracnoidea aneurismática tiene como objetivo actualizar su manejo, basado en las hipótesis mas aceptadas que se han logrado para explicar su patogénesis. Se efectúa una introducción con conceptos generales, se revisan las bases patogénicas del Vasoespasmo y se plantea su manejo, tomando en cuenta su diagnóstico, monitorización, profilaxis y manejo avanzado de acuerdo a las últimas Guías de Manejo Clínico y según medicina basada en las evidencias.

The objective of the present review on cerebral vasospasm and cerebral delayed isquemic deficit due to subarachnoid haemorrhage secondary to ruptured cerebral aneurysm, is to update their management, based on the most accepted pathophysiological hypotesis explaining their pathogenetic mechanisms. An introduction is performed presenting general concepts, review of the most recent research works explaining their pathogenesis, and the management is stated touching diagnosis, monitoring, prophylaxis, and advanced management according with the last clinical guidelines for his management using medicine based on evidences.

Algoritmo para la tomografía secuencial de cráneo en pacientes con traumatismo encéfalocraneano / Algorithm for sequential cranial tomography in patients with encephalocranial trauma

Introducción: el monitoreo imagenológico estructural del encéfalo en pacientes con traumatismo encéfalocraneano se practica habitualmente de forma no protocolizada. Se requieren estrategias fundamentadas en la evidencia científica. Se realizó una investigación con el objetivo de implementar un algoritmo para la realización de tomografía computarizada de cráneo secuencial en pacientes con traumatismo encéfalocraneano. Material y Métodos: Se practicó un estudio cuasiexperimental, con una serie continua de lesionados encéfalocraneanos que fueron estudiados al menos en dos ocasiones durante la fase aguda con tomografía computarizada de cráneo. La variable dependiente fue el cambio imagenológico significativo. Se aplicaron técnicas de Chi-cuadrado, ANOVA y regresión logística. Con los datos obtenidos se diseñó y aplicó un algoritmo de manejo. Resultados: Se estudiaron 84 pacientes, el 16, 7 por ciento de la serie mostró cambios tomográficos significativos en los estudios secuenciales. Las principales variables involucradas en el pronóstico fueron los mecanismos de producción de alta energía, los síntomas persistentes, la escala de Marshall y el puntaje de Rotterdam iniciales. Con esta información se diseñó un algoritmo que homogenizó los criterios en cuanto a los momentos de realización y al grupo de traumatizados en los que no es útil esta práctica. Conclusiones: La aplicación del algoritmo contribuyó a optimizar la tomografía secuencial de cráneo en lesionados encéfalocraneanos.

Introduction: encephalic structural imaging monitoring by means of sequential CT scan of the head is an established practice, although carried out in a heterogeneous way in the different contexts due to inexistence of all necessary evidence to dictate standard. An investigation was performed to implement an algorithm for the application of sequential CT scan of the head in patients with head trauma. Material and Methods: A quasiexperimental study was practiced with all patients who suffer cerebral trauma, were hospital admitted and that were studied by means of head CT scan in two occasions at least in the same period of hospital admission. Systematization of the indications to perform sequential CT scan of the head was carried, then their application and later the evaluation of the behavior of variables by means of exploratory statistic, Chi-square, ANOVA and logistical regression. Based on data obtained and algorithm was designed and applied. Results: 84 patients were studied and the 16, 7 percent of the sample showed significant tomographic changes in the sequential studies. The group of patient more related with these changes was the one that presented persistent symptoms with initial Marshall III or IV. Main variables involved in the prognosis were high-speed mechanisms in the traumatism production, the persistence of symptoms and the initial Rotterdam score. Conclusions: Algorithm applied contributed to optimization of sequential CT scan of the head in patients with cerebral trauma.

Assessment of the usability of a digital learning technology prototype for monitoring intracranial pressure / Avaliação de usabilidade de um protótipo de tecnologia digital educacional sobre monitoração da pressão intracraniana / Evaluación de usabilidad de un prototipo de tecnología digital educacional sobre monitorización de la presión intracraneal

ABSTRACT Objective: to assess the usability of a digital learning technology prototype as a new method for minimally invasive monitoring of intracranial pressure. Method: descriptive study using a quantitative approach on assessing the usability of a prototype based on Nielsen's ten heuristics. Four experts in the area of Human-Computer interaction participated in the study. Results: the evaluation delivered eight violated heuristics and 31 usability problems in the 32 screens of the prototype. Conclusion: the suggestions of the evaluators were critical for developing an intuitive, user-friendly interface and will be included in the final version of the digital learning technology.

RESUMO Objetivo: avaliar a usabilidade de um protótipo educacional digital sobre um novo método para monitoração da pressão intracraniana de forma minimamente invasivo para enfermeiros e médicos. Método: estudo descritivo com abordagem quantitativa sobre a avaliação de usabilidade de um protótipo com base nas dez Heurísticas de Nielsen. Participaram quatro especialistas da área de Interação Humano Computador. Resultados: a avaliação resultou em oito heurísticas violadas e 31 problemas de usabilidade nas 32 telas do protótipo. Conclusão: as sugestões dos avaliadores foram cruciais para o desenvolvimento de uma interface amigável e intuitiva e serão consideradas na versão final da tecnologia educacional digital.

RESUMEN Objetivo: evaluar la usabilidad de un prototipo educacional digital sobre un nuevo método para monitorización de la presión intracraneal, de manera mínimamente invasiva. Método: estudio descriptivo con abordaje cuantitativo sobre la evaluación de usabilidad de un prototipo con base en las diez reglas Heurísticas de Nielsen. Participaron cuatro especialistas del área de Interacción Humana Computador. Resultados: la evaluación resultó en ocho reglas heurísticas violadas y 31 problemas de usabilidad en las 32 pantallas del prototipo. Conclusión: las sugestiones de los evaluadores fueron cruciales para el desarrollo de una interfaz amigable e intuitiva y éstas serán consideradas en la versión final de la tecnología educacional digital.

Ganglionopatia como manifestação inicial de neoplasia pulmonar: relato de caso / Ganglionopathy as the initial manifestation of neoplastic lung disease: a case report

A ganglionopatia é uma entidade rara que consiste na afecção dos neurônios sensitivos da raiz dorsal, fazendo parte do grupo das polineuropatias periféricas do tipo exclusivamente sensitivo com comprometimento axonal e tendo seu diagnóstico feito através de estudo eletroneuromiográfico. A associação entre a ganglionopatia e outras patologias como neoplasias, doenças autoimunes, doença celíaca, entre outras é amplamente citada na literatura. O objetivo deste trabalho é descrever o caso clínico de um paciente com diagnóstico de neoplasia pulmonar cuja manifestação inicial foi a ganglionopatia, incluindo a descrição detalhada do exame eletroneuromiográfico que auxiliou no processo diagnóstico do médico assistente. Concluímos ser importante que o médico neurofisiologista tenha em mente as possíveis causas da ganglionopatia e saiba apontar o médico assistente para que a investigação possa ser realizada de maneira completa e precoce

Ganglionopathy is a rare condition defined by an injury to the sensory neurons in the dorsal root ganglion. This disease belongs to a group of peripheral polyneuropathies with an exclusively sensory and axonal pattern and its diagnoses can be made by an electromyoneurographic study. The association between ganglionopathy and other underlying pathologies, such as some types of cancer, autoimmune diseases, and celiac disease is often mentioned in published studies. The purpose of this report was to describe the case of a patient suffering from ganglionopathy including a detailed discussion of the electromyoneurographic study that led the attending physician to a diagnosis of neoplastic lung disease. The conclusion therefore was that it is important for the neurophysiology specialist to keep in mind the possible causes of ganglionopathy and, through this diagnosis, to help the attending physician in making an early and full workup of the patient

Multimodal neuromonitoring in pediatric cardiac anesthesia.

Despite significant improvements in overall outcome, neurological injury remains a feared complication following pediatric congenital heart surgery (CHS). Only if adverse events are detected early enough, can effective actions be initiated preventing potentially serious injury. The multifactorial etiology of neurological injury in CHS patients makes it unlikely that one single monitoring modality will be effective in capturing all possible threats. Improving current and developing new technologies and combining them according to the concept of multimodal monitoring may allow for early detection and possible intervention with the goal to further improve neurological outcome in children undergoing CHS.

Update in the management of severe traumatic brain injury

Traumatic brain injury is the main cause of death and disability in the young population, which presumes a large number of years of potential life lost and a great economic impact. Vital and functional outcomes after suffering a traumatic brain injury depend both on the severity of the initial biomechanical impact (primary injury) and on the presence and the severity of systemic or intracranial insults that magnify and/or produce new brain injuries, the so-called secondary injuries. Currently, no treatment in effective in improving functional recovery, except for usual medical care. Therefore, the main purpose of the care provided to a patient with severe cranial trauma is based on preventing and treating secondary brain injuries by maintaining an adequate cerebral perfusion and oxygenation. Increased intracranial pressure is associated with mortality and with unfavorable functional outcomes is patients with severe traumatic brain injury. The main clinical practice guidelines recommend using a number of staggered therapeutic measures. However, although these measures seem to be efficient in reducing intracranial pressure, this effect is not often translated into clinical improvement. This review describes the essential principles of the management of patients with severe traumatic brain injury in intensive care units.

Experimental model of intracranial hypertension with continuous multiparametric monitoring in swine / Modelo Experimental de Hipertensao Intracraniana com monitorizacao multiparametrica continua em suinos

Objective Intracranial hypertension (IH) develops in approximately 50% of all patients with severe traumatic brain injury (TBI). Therefore, it is very important to identify a suitable animal model to study and understand the pathophysiology of refractory IH to develop effective treatments. Methods We describe a new experimental porcine model designed to simulate expansive brain hematoma causing IH. Under anesthesia, IH was simulated with a balloon insufflation. The IH variables were measured with intracranial pressure (ICP) parenchymal monitoring, epidural, cerebral oximetry, and transcranial Doppler (TCD). Results None of the animals died during the experiment. The ICP epidural showed a slower rise compared with parenchymal ICP. We found a correlation between ICP and cerebral oximetry. Conclusion The model described here seems useful to understand some of the pathophysiological characteristics of acute IH. .

Objetivo A hipertensão intracraniana (HIC) ocorre em até 50% de todos os pacientes com traumatismo cranioencefálico (TCE). Por isso, é importante estabelecer um modelo animal adequado para estudar a fisiopatologia da HIC refratária, com a perspectiva de desenvolver tratamentos eficazes. Métodos Os animais foram submetidos a um protocolo padrão de anestesia. A hipertensão intracraniana foi estabelecida através de insuflação de um balão. As variáveis HIC foram medidas com a pressão intracraniana (PIC) do parênquima, oximetria, epidural e doppler transcraniano. Resultados A PIC epidural apresentou elevação mais lenta, comparada com a PIC parenquimal. Houve correlação entre a PIC e a oximetria cerebral. O registro da PIC, oximetria e índice de pulsatilidade foi realizado em todos os animais sem dificuldade. Conclusão O modelo descrito parece ser útil para a compreensão de algumas características fisiopatológicas na HIC aguda. .

Evaluation of Neurophysiological Parameters: Autonomic Status and Acute Pain Perception in Migraneurs.

Introduction: Painful conditions are associated with autonomic dysfunction and altered pain perception. However, data regarding autonomic status in migraineurs is not conclusive and there are few studies regarding acute pain perception in these cases. Aims: This study was conducted to assess various neurophysiological parameters namely autonomic functions using the autonomic function tests and acute pain perception using the cold pressor test in migraneurs. Material and methods: 60 migraineurs and 30 age and gender matched control subjects were included in this study after screening for the exclusion criteria and following a written consent. Diagnosis of migraine was made according to the International Classification of Headache Disorders(ICHD) – 2 Criteria. In the pain free state of the subjects, autonomic function tests including basal heart rate variability, E:I ratio, 30:15 ratio, postural challenge test and sustained handgrip test were carried out together with the cold pressor test. Unpaired t-test was used for analysing the data. Result: Migraineurs showed a trend towards increased parasympathetic tone, as compared to the control subjects, though the p-values were not significant. The pain threshold was lower while the pain tolerance was significantly lower in migraineurs as compared to controls (p= 0.00).Conclusion: In our study we observed an increased vagal tone together with lower values of pain threshold and pain tolerance in migraineurs, indicating that certain neurophysiological parameters are affected in painful conditions like migraine.

Cambios neurofisiológicos en el adulto mayor: sensibilidad y reflejos / Neurophysiological changes in the elderly: sensitivity and reflexes

Estudiar la prevalencia de algunos de los signos que se presentan en forma anormal con el envejecimiento del Sistema Nervioso por medio de la exploración de la sensibilidad y los reflejos. Se estudiaron la sensibilidades superficial y profunda y los reflejos osteotendinomusculares en 200 sujetos mayores de 65 años, sin enfermedades neurológicas, cardiovasculares o psiquiátricas, Se utilizó el estadístico Kappa interobservador para cada modalidad. Se clasificaron los hallazgos como normales, alterados y ausentes. Se aplicaron escalas para la sensibilidad y los reflejos y se realizó el cálculo estadístico por tablas de contingencia 2x2, chi cuadrado, con rango de confiabilidad de 95%. La edad fue 65-74 años en 73% y más de 75 en 27%. En sensibilidad térmica y posición segmentaría no hubo anormalidad, pero 37% tenían anormalidad en la discriminatoria. La estereognosia fue anormal en el 16,4% y 29,6 % de acuerdo a los grupos de edad respectivamente. La vibratoria mostróuna disminución de 4,54 hasta 6,96 seg., en miembros inferiores (p < -0,05) y diferencia significativa en los miembros inferiores. Hubo anormalidad para todos los reflejos osteotendinosos, mayor porcentaje en el patelar y aquiliano (21 y 44% respectivamente) y comparados entre si y el grupo de edad con diferencia estadísticamente significativa. Los resultados deben considerarse propios del envejecimiento

To study the prevalence of some abnormal neurologic signs of aging by exploring sensitivity and reflexes. We studied the superficial and deep sensitivity and the muscle stretch reflexes in a sample of 200 subjects older than 65 years without neurologic, cardiovascular or psychiatric disease.The kappa statistic was applied for each group of signs. We classified the findings in normal, abnormal and absent. A scale for sensitivity and reflexes was used. Statistic analysis was done by 2x2 tables of contingency and chi square with a CI of 95 %. The men aged 65 to74 years were 73% of the sample and older than 75 was 27% In thermic sensibility and segmental position there were no abnormalities. Discriminatory sensitivity was abnormeal in 37% stereognosis was abnormal in 16,4% and 29, 6% in the age groups respectively. Palesthesia was decreased by 4,54 to 6,96 seconds in the lower limbs (p 0,05 ) with a significant statistical difference. There were abnormalities in all the reflexes predominantly in the knee-jerk and ankle- jerk (21 and 44% respectively) and comparison with the age groups was statiscally significant. The prevalence of changes in sensitivity and muscle stretch reflexes in subjects more older than 65 years in this study ought to be considered part of the aging process

Complications of Anterior Circulation Aneurysm Surgery / 대한뇌혈관학회지

In this invited review article for the annual continuing medical education, the authors described their experiences regarding the complications and their prevention in surgery on aneurysms of the anterior circulation. The authors reviewed the database as sources for identifying and analyzing patients. From September 1975 to June 2001, among total of 2,270 patients treated for intracranial aneurysms, 2,089 patients were treated by surgery. The frequencies of favorable (good, fair) and unfavorable (poor, dead) outcome were 1,839 (92.3%) and 153 (7.7%), respectively. Of the 153 patients with unfavorable outcome, 25 patients were due to the surgical complications. The complications were vascular occlusion (10), venous infarction (7), intraoperative premature rupture (3), rebleeding due to incomplete clipping (2), bilateral epidural hematoma (1), and unknown (2). We concluded that the surgeon's experience, thorough knowledge of microsurgical anatomy, modern neuroprotection method, perioperative neurosurgical intensive care, computerized neurophysiologic monitoring, and clever surgical clips would be necessary for prevention of the surgical complications in the treatment of the intracranial aneurysms.

Significance of Brain Protection and Neurophysiological Monitoring in Carotid Endarterectomy

We present our results of carotid endarterectomy performed in 12 patients(bilateral in 2 patients) under prospective brain protection-monitoring protocol during the past two years. The protocol consists of induced hypertension, mild hypothermia, and pentothal burst suppression under bipolar two-channel compressed spectral array(CSA) monitoring. Eleven of the 12 patients recovered without any new deficit from the surgery, and this result was expected as their CSA monitoring showed no significant changes. One patient had multiple untreated aneurysms, and therefore, hypertension was not applied. This patient developed significant postoperative neurological deficits correlated well with the CSA changes. One of the major advantages of CSA monitoring is that dosage of thiopental sodium for burst suppression, that varied greatly from 1,016mg to 3,220mg, could be titrated on each patient based upon the CSA findings. Another important benefit of our brain protection-monitoring protocol is that unnecessary shunting procedure could be avoided. In conclusion, brain protection under CSA monitoring could prevent dangerous ischemic insults from circulatory disruption on already vulnerable ischemic hemisphere in patients requiring carotid endarterectomy.