Montreal Communication Evaluation Brief Battery - MEC B: reliability and validity / Bateria Montreal de Avaliação da Comunicação Breve - MAC B: fidedignidade e validade

ABSTRACT Purpose Search for reliability and validity evidence for the Montreal Communication Evaluation Brief Battery (MEC B) for adults with right brain damage. Methods Three hundred twenty-four healthy adults and 26 adults with right brain damage, aged 19-75 years, with two or more years of education were evaluated with MEC B. The MEC B Battery contains nine tasks that aim to evaluate communicative abilities as discourse, prosody, lexical-semantic and pragmatic process. Two sources of reliability evidence were used: internal consistency (Cronbach's alpha) and interrater reliability. Construct validity was evaluated comparing the Montreal Communication Evaluation Battery (MEC), expanded version and MEC B tasks. Results Internal consistence was satisfactory and the interrater reliability was considered excellent, as were correlations between MEC Battery and MEC B Battery tasks. Conclusion The MEC B Battery showed satisfactory reliability and validity evidences. It can be used as outcome measure of intervention programs and assist speech therapists to plan rehabilitation programs.

RESUMO Objetivo Buscar evidências de validade e fidedignidade da Bateria Montreal de Avaliação da Comunicação Breve (MAC B) para adultos com lesão do hemisfério direito. Método Trezentos e vinte e quatro adultos saudáveis e 26 adultos com lesão cerebral direita, com idades de 19 a 75 anos, com dois ou mais anos de escolaridade, foram avaliados com a Bateria MAC B. Essa bateria contém nove tarefas que visam avaliar habilidades comunicativas, como: discurso prosódia; processo léxico-semântico e pragmática. Duas fontes de evidências de fidedignidade foram utilizadas, ou seja, a consistência interna (alfa de Cronbach) e a concordância entre avaliadores. A validade foi avaliada comparando as tarefas da Bateria MAC na versão expandida e da MAC B. Resultados Em relação à fidedignidade, a consistência interna foi satisfatória e as taxas de concordância entre os avaliadores foram consideradas excelentes, assim como as correlações entre as tarefas da Bateria MAC e Bateria MAC B. Conclusão A Bateria MAC B apresentou evidências de fidedignidade e validade satisfatórias, podendo ser usada como medida para resultado de programas de intervenção, e também auxiliar o fonoaudiólogo a planejar o programa de reabilitação.

Processamento auditivo da informação em sujeitos com afasia / Auditory information processing in individuals with aphasia

Introdução: Diferentes tipos de alteração no sistema nervoso central (SNC) podem resultar em diversos tipos de distúrbios de linguagem e/ou fala. Havendo alguma alteração em nível central, é possível que algumas habilidades auditivas estejam alteradas. Objetivo: Avaliar ashabilidades do processamento auditivo de modo comportamental e eletrofisiológico em sujeitos com afasia de expressão e identificar a correlação entre as avaliações. Métodos: Participaram do estudo sujeitos com idade entre 29 e 72 anos, com afasia de expressão decorrente de lesão encefálica (acidente vascular cerebral ou traumatismo crânio encefálico). Esses indivíduos foram submetidos a uma avaliação audiológica básica, além da avaliação comportamental e eletrofisiológica do processamento auditivo, que contemplou os seguintes testes: localização sonora, memória sequencial para sons verbais e não verbais, padrão de frequência e duração, dicótico de dígitos, fala comprimida, identificação de sentenças sintéticas e dicótico não verbal, além do Potencial Evocado Auditivo de Longa Latência (PEALL) P300. Resultados: Todos os sujeitos avaliados apresentaram alteração na maioria das habilidades comportamentais de processamento auditivo. No PEALL, todos apresentaram os potenciais exógenos (N1, P2) dentro da latência esperada. Apenas um não apresentou o potencial P300 bilateralmente. Os outros cinco afásicos apresentaram P300 bilateralmente. Conclusão: Foi possível avaliar as habilidades do processamento auditivo em quase todos os sujeitos com afasia de expressão de modo comportamental e eletrofisiológico. Não foi observada correlação significativa entre as avaliações, identificando que as avaliações comportamentais foram piores do que as eletrofisiológicas. (AU)

Introduction: Different types of change in the Central Nervous System (CNS) can result in many types of language disorders and/or speech. If there is any change in the central level, it is possible that some auditory abilities are altered. Objective: To evaluate the auditory processing abilities of behavioral and electrophysiological so in subjects with aphasia of s peech and identify the correlation between assessments. Methodology: The study subjects aged between 29 and 72 years, expression aphasia resulting from brain injury (stroke or traumatic brain injury). They underwent audiometric assessment beyond the behavioral and electrophysiological assessment of auditory processing, which included the following tests: sound localization, sequential memory for verbal and nonverbal sounds, default frequency and duration, dichotic digits, compressed speech, identification of synthetic and non-verbal dichotic sentences, plus Auditory Evoked Potential Long Latency P300. Results: All subjects evaluated had abnormalities in the majority of behavioral auditory processing skills. In LLAEP, all showed potential exogenous (N1, P2) within the expected latency. Only one did not have the potential P300 bilaterally. The other five aphasic showed P300 bilaterally. Conclusion: It was possible to assess auditory processing abilities in nearly all subjects with aphasia expression of behavioral and electrophysiological mode. No significant correlation was observed between assessments, identifying the behavioral assessments were worse than electrophysiologic. (AU)

Classificação Internacional de funcionalidade, incapacidade e saúde e afasia: um estudo da participação social / International classification of functioning, disability and health, and aphasia: a study of social participation

RESUMO Objetivo Este estudo identifica e analisa o impacto das afasias na participação social e nas atividades cotidianas das pessoas por elas acometidas, bem como visa conhecer as implicações dos fatores ambientais nas limitações e restrições da participação, segundo os critérios estabelecidos pela Classificação Internacional de Funcionalidade, Incapacidade e Saúde. Método São apresentados e discutidos dados de 12 pessoas de ambos os sexos com afasia que participavam de um Grupo Interdisciplinar de Convivência. Os dados foram coletados entre outubro de 2011 e março de 2013 e analisados com base na check list da Classificação Internacional de Funcionalidade, Incapacidade e Saúde. Resultado Todos os sujeitos apresentaram restrições no desempenho e para a participação em suas atividades cotidianas, seja por determinantes biológicos, ambientais ou socioculturais. Conclusão A restrição na participação foi a mais evidente, decorrente mais dos fatores ambientais do que das sequelas advindas das lesões cerebrais.

ABSTRACT Purpose To identify and analyze the impact of aphasia on social participation and daily activities of people affected by this disease, as well as to understand implications of environmental factors on limitations and restrictions of participation according to the criteria established by the International Classification of Functioning, Disability and Health. Method Data presented and discussed were collected from 12 people of both sexes with aphasia participating in an Interdisciplinary Group for Coexistence. Data were collected between October 2011 and March 2013 and analyzed based on the International Classification of Functioning, Disability and Health checklist. Results All subjects had restrictions on performing and participating in their daily activities, either by biological, environmental or socio-cultural factors. Conclusions The restriction in participation was the most evident, mostly due to environmental factors than sequels resulting from the brain injury.

Cardiovascular Effects of Shock and Trauma in Experimental Models. A Review

Abstract Experimental models of human pathology are useful guides to new approaches towards improving clinical and surgical treatments. A systematic search through PubMed using the syntax (shock) AND (trauma) AND (animal model) AND (cardiovascular) AND ("2010/01/01"[PDat]: "2015/12/31"[PDat]) found 88 articles, which were reduced by manual inspection to 43 entries. These were divided into themes and each theme is subsequently narrated and discussed conjointly. Taken together, these articles indicate that valuable information has been developed over the past 5 years concerning endothelial stability, mesenteric lymph, vascular reactivity, traumatic injuries, burn and sepsis. A surviving interest in hypertonic saline resuscitation still exists.

Personality Change due to Brain Trauma Caused by Traffic Accidents and Its Assessment of Psychiatric Impairment / 法医学杂志

OBJECTIVE@#To explore the main performance of personality change in people with mild psychiatric impairments which due to the brain trauma caused by traffic accidents and its value in assessment of psychiatric impairment.@*METHODS@#The condition of personality change of patients with traumatic brain injury caused by traffic accident was evaluated by the Scale of Personality Change Post-traumatic Brain Injury (SPCPTBI). Furthermore, the correlation between the personality change and the degrees of traumatic brain injury and psychiatric impairment were explored. Results In 271 samples, 239 (88.2%) with personality changes. Among these 239 samples, 178 (65.7%), 46 (17.0%), 15 (5.5%) with mild, moderate and severe personality changes, respectively. The ratio based on the extent of personality changes to the degree of brain trauma was not significant (P > 0.05), but the total score difference between the groups was significant (P < 0.05). There was no statistical significance between the medium and high severity brain trauma groups. The higher degree of personality changes, the higher rank of mental disabilities. The total score difference of the scale of personality change among the different mild psychiatric impairment group was significant (P<0.05). The difference between other psychiatric impairment levels had statistical significance (P < 0.05) except level 7 and 8.@*CONCLUSION@#The occurrence of personality change due to traumatic brain injury caused by traffic accident was high. Correlations exist between the personality change and the degree of psychiatric impairment. Personality change due to brain trauma caused by traffic accident can be assessed effectively by means of SPCPTBI, and the correlation between the total score and the extent of traumatic brain injury can be found.

Progress on Correlation between the Expression of CDK5 and Brain Injury Time / 法医学杂志

Cyclin-dependent kinase 5 (CDK5) is a member of cyclin-dependent kinase family, which does not directly regulate cell cycle. Through phosphorylation of target protein, CDK5 plays an irreplaceable role in the development, reparation and degeneration of neurons. Brain injury refers to the organic injury of brain tissue caused by external force hit on the head. Owing to the stress and repair system activated by our body itself after injury, various proteins and enzymes of the brain tissues are changed quantitatively, which can be used as indicators for estimating the time of injury. This review summarizes the progress on the distribution, the activity mechanism and the physiological effects of CDK5 after brain injury and its corresponding potential served as a marker for brain injury determination.

The role of necroptosis in neurosurgical diseases

Programmed necrosis or necroptosis is an alternative form of cell death that is executed through a caspase-independent pathway. Necroptosis has been implicated in many pathological conditions. Genetic or pharmacological inhibition of necroptotic signaling has been shown to confer neuroprotection after traumatic and ischemic brain injury. Therefore, the necroptotic pathway represents a potential target for neurological diseases that are managed by neurosurgeons. In this review, we summarize recent advances in the understanding of necroptotic signaling pathways and explore the role of necroptotic cell death in craniocerebral trauma, brain tumors, and cerebrovascular diseases.

Expression of Zonula Occludens-1 in Cerebral Cortex Following Traumatic Brain Injury / 法医学杂志

OBJECTIVE@#To observe the time-course expression of zonula occludens-1 (ZO-1) in cerebral cortex after traumatic brain injury (TBI).@*METHODS@#The TBI model of mouse was established. The mice were divided in 1 h, 3 h, 6 h, 12 h, 24 h, 3 d, 7 d after TBI, sham and control groups. The permeability of the blood brain barrier was evaluated by measuring the extravasation of Evans blue (EB) dye. The expression of ZO-1 in cerebral cortex in the injured area was detected by Western blotting and immunohistochemistry.@*RESULTS@#The extravasation of EB dye of injured cortex gradually increased from 1 h, peaked at 1-3 d and approximately decreased to normal at 7 d after TBI. Western blotting revealed that the expression of ZO-1 gradually decreased after 1 h, was at the lowest at 1-3 d, and then significantly increased after 7 d but was still lower than that of normal and sham groups. The result of immunohistochemistry showed that ZO-1 had strong expression in vessel of normal cortex, gradually decreased after TBI, and almost disappeared at 3 d after TBI and gradually recovered to normal level later.@*CONCLUSION@#The expression of ZO-1 in the injured cortex after TBI initially decreases and then increases. The negative correlation between ZO-1 expression and EB extravasation after TBI could be used as a new indicator for wound age estimation.

Consenso Latinoamericano sobre el uso del Doppler transcraneal en el diagnóstico de muerte encefálica / Latin American consensus on the use of transcranial Doppler in the diagnosis of brain death

El Doppler transcraneal evalúa la hemodinámica cerebral en el paciente neurocrítico. Se destaca su aporte como técnica auxiliar en el diagnóstico del paro circulatorio cerebral, que habitualmente presenta el paciente en muerte encefálica. Este Consenso Latinoamericano se conformó por un grupo de 26 médicos con experiencia en el uso de Doppler transcraneal en el contexto de muerte encefálica. El propósito de este consenso es realizar recomendaciones en relación a las indicaciones, técnica e interpretación del estudio de la ultrasonografía transcraneal en el paciente con diagnóstico clínico de muerte encefálica o en aquel paciente cuyo diagnóstico clínico presenta dificultades; formar un grupo de trabajo que permita profundizar conocimientos y consolidar lazos entre médicos latinoamericanos trabajando en el mismo tema. Se revisó la literatura, se intercambiaron conceptos y experiencias en dos encuentros presenciales y vía Internet. Se contestaron preguntas sobre fisiopatología, equipo, técnica, hallazgos, problemas frecuentes e interpretación del Doppler transcraneal en el contexto de muerte encefálica. Las declaraciones fundamentales del consenso son: El paro circulatorio cerebral es la última etapa en la evolución de la hipertensión intracraneana progresiva, donde se visualiza con el Doppler transcraneal un "patrón de paro circulatorio cerebral". Se acepta como patrón de paro circulatorio cerebral: patrón reverberante, espigas sistólicas y ausencia de flujo previamente evidenciado. Se debe insonar - en condiciones hemodinámicas aceptables - sector anterior bilateralmente (arterias cerebrales medias) y sector posterior (arteria basilar). De no encontrarse ninguna imagen ultrasonográfica en éstas, las arterias proximales (carótida interna ipsilateral en sifón o ambas vertebrales respectivamente) son aceptables para el diagnóstico de paro circulatorio cerebral.

Transcranial Doppler evaluates cerebral hemodynamics in patients with brain injury and is a useful technical tool in diagnosing cerebral circulatory arrest, usually present in the brain-dead patient. This Latin American Consensus was formed by a group of 26 physicians experienced in the use of transcranial Doppler in the context of brain death. The purpose of this agreement was to make recommendations regarding the indications, technique, and interpretation of the study of transcranial ultrasonography in patients with a clinical diagnosis of brain death or in the patient whose clinical diagnosis presents difficulties; a working group was formed to enable further knowledge and to strengthen ties between Latin American physicians working on the same topic. A review of the literature, concepts, and experiences were exchanged in two meetings and via the Internet. Questions about pathophysiology, equipment, techniques, findings, common problems, and the interpretation of transcranial Doppler in the context of brain death were answered. The basic consensus statements are the following: cerebral circulatory arrest is the final stage in the evolution of progressive intracranial hypertension, which is visualized with transcranial Doppler as a "pattern of cerebral circulatory arrest". The following are accepted as the standard of cerebral circulatory arrest: reverberant pattern, systolic spikes, and absence of previously demonstrated flow. Ultrasonography should be used - in acceptable hemodynamic conditions - in the anterior circulation bilaterally (middle cerebral artery) and in the posterior (basilar artery) territory. If no ultrasonographic images are found in any or all of these vessels, their proximal arteries are acceptable to be studied to look for a a pattern of cerebral circulatory arrest.

Progress of the recovery mechanism of brain injury associated with the gene polymorphism of apolipoproteins E / 法医学杂志

Brain injury is a kind of wound by violence on head, which is a mechanical distortion of skull, meninx, cerebral vascular and brain tissue due to outside force acting on head. Apolipoproteins E (ApoE) is a major kind of apolipoproteins, participating in the metabolism of lipid and regulating balance of cholesterol. Some recent investigations show that gene polymorphism of ApoE is associated with various kinds of diseases. Also its immunoreactivity is changed regularly with brain injury. In addition, ApoE has remarkable effect in neurological normal growth and reparative process after brain injury. This article reviews the biological characteristics and mechanism of ApoE in the repair of brain injury and application prospect in forensic medicine, which may be able to provide new ideas for estimation of the brain injury time and related experimental research.

Associacao entre o indice de respiracao rapida e superficial e o sucesso da extubacao em pacientes com traumatismo cranioencefalico / Association between the rapid shallow breathing index and extubation success in patients with traumatic brain injury

OBJETIVO: Verificar a associação entre o índice de respiração rápida e superficial e o sucesso da extubação em pacientes com traumatismo cranioencefálico. MÉTODOS: Estudo prospectivo, formado por pacientes com traumatismo cranioencefálico, de ambos os gêneros, ventilados mecanicamente por pelo menos 2 dias, que obtiveram sucesso no teste de respiração espontânea. Foram mensurados, por meio da ventilometria, o volume-minuto e a frequência respiratória, sendo calculado o índice de respiração rápida e superficial (frequência respiratória/volume corrente). A variável dependente foi o resultado da extubação: reintubação em 48 horas (falha da extubação) ou não (sucesso da extubação). A variável independente foi o índice de respiração rápida e superficial mensurado após o sucesso no teste de respiração espontânea. RESULTADOS: A amostra foi constituída por 119 pacientes, sendo 111 (93,3%) do gênero masculino. A média da idade foi de 35,0±12,9 anos. O tempo médio de ventilação mecânica foi de 8,1±3,6 dias. Cento e quatro (87,4%) pacientes obtiveram sucesso na extubação. Não foi observada associação entre o índice de respiração rápida e superficial e o sucesso da extubação. CONCLUSÃO: O índice de respiração rápida e superficial não esteve associado ao sucesso da extubação em pacientes com traumatismo cranioencefálico. .

OBJECTIVE: To investigate the association between the rapid shallow breathing index and successful extubation in patients with traumatic brain injury. METHODS: This study was a prospective study conducted in patients with traumatic brain injury of both genders who underwent mechanical ventilation for at least two days and who passed a spontaneous breathing trial. The minute volume and respiratory rate were measured using a ventilometer, and the data were used to calculate the rapid shallow breathing index (respiratory rate/tidal volume). The dependent variable was the extubation outcome: reintubation after up to 48 hours (extubation failure) or not (extubation success). The independent variable was the rapid shallow breathing index measured after a successful spontaneous breathing trial. RESULTS: The sample comprised 119 individuals, including 111 (93.3%) males. The average age of the sample was 35.0±12.9 years old. The average duration of mechanical ventilation was 8.1±3.6 days. A total of 104 (87.4%) participants achieved successful extubation. No association was found between the rapid shallow breathing index and extubation success. CONCLUSION: The rapid shallow breathing index was not associated with successful extubation in patients with traumatic brain injury. .

Enfoque práctico para el diagnóstico y tratamiento de los estados poliúricos en pacientes con injuria cerebral aguda / Diagnosis and therapy of polyuric states in patients with acute cerebral injury

In patients with acute cerebral injury, polyuric states can potentially trigger, maintain and aggravate the primary neurological damage, due to hypovolemia, arterial hypotension and alterations of osmolarity. The true incidence of the condition in this population is unknown. A widely validated definition of polyuric state is lacking and its etiology is multifactorial. There are two principal classes of polyuria: a) aqueous polyuria with diabetes insipidus as the main cause; and b) osmotic polyuria in which sodium, glucose or ureaplay the main role. Polyuric states are in close association with disorders of water and sodium metabolism and with alterations in acid-base balance. A detailed analysis of the history, clinical picture and simple laboratory determinations in blood and urine, are required for an adequate assessment of these polyuric states. The problem must be faced with pathophysiological reasoning and a systematic and sequential approach, because each disorder needs a specific therapy.

Translation and cultural adaptation of the Game Dice Task to Brazilian population / Tradução e adaptação transcultural do "Game Dice Task" para população brasileira

OBJECTIVE: The Game Dice Task (GDT) was developed to measure decision making under known risk. The aim of this study was to translate and adapt the GDT to a Brazilian population. METHOD: After the GDT was translated and back-translated to Brazilian Portuguese and evaluated by eight bilingual judges, 175 Brazilian adults were divided into two groups - 160 healthy volunteers and 15 traumatic brain injury (TBI) patients - and had completed the GDT. RESULTS: Differences between genders, but not age, were observed in the healthy volunteer sample. Males more frequently chose a combination of three dice while females preferred four dice. TBI patients were more impulsive than healthy volunteers; they less frequently chose a combination of three dice and made more risky decisions. CONCLUSION: Because of the rigorous process used to translate and adapt the GDT and the differences observed between patients with TBI and healthy volunteers, the Brazilian GDT was considered satisfactory for research purposes.

OBJETIVO: O Game Dice Task (GDT) foi desenvolvido para avaliar a tomada de decisão de indivíduos sob situações específicas de risco conhecido. O objetivo deste estudo foi traduzir e adaptar o GDT para a população brasileira. MÉTODOS: Após ter sido traduzido e retrotraduzido para o português e ter sido avaliado por oito juízes bilíngues, 175 adultos brasileiros completaram o GDT - 160 adultos saudáveis e 15 pacientes com traumatismo cranioencefálico (TCE). RESULTADOS: Foram observadas diferenças no desempenho quanto ao gênero, mas não quanto à idade, nos adultos saudáveis. Homens escolheram mais frequentemente a combinação com três dados, enquanto as mulheres preferiram quatro dados. Pacientes com TCE foram mais impulsivos, escolheram com menor frequência a combinação de três dados e tomaram decisões mais arriscadas. CONCLUSÃO: Por causa do rigoroso processo utilizado pra traduzir e adaptar o teste GTD e do poder de discriminação entre as amostras de adultos saudáveis e com TCE, a versão brasileira desse teste foi considerada satisfatória para utilização em pesquisa.

Pathophysiology of neurodegeneration following traumatic brain injury / Patofisiología de la neurodegeneración tras una lesión traumática del cerebro

Acute neuropathological conditions, including brain and spinal cord trauma, are leading causes of death and disabilities worldwide, especially in children and young adults. The causes of brain and spinal cord injuries include automobile accidents, accidents during recreational activities, falls and violent attacks. In the United States of America alone, around 1.7 million people each year seek medical care for some kind of head injury. About fifty-two thousand of these people will die, while the same number will present with permanent functional disability. Considering the high worldwide prevalence of these acute pathological conditions, research on the mechanisms underlying central nervous system damage is of extreme importance. Nowadays, a number of experimental models of acute neural disorders have been developed and the mechanisms of tissue loss have been investigated. These mechanisms include both primary and secondary pathological events contributing to tissue damage and functional impairment. The main secondary pathological mechanisms encompass excitotoxicity, ionic imbalances, inflammatory response, oxidative stress and apoptosis. The proper elucidation of how neural tissue is lost following brain and spinal cord trauma is fundamental to developing effective therapies to human diseases. The present review evaluates the main mechanisms of secondary tissue damage following traumatic brain and spinal cord injuries.

Las condiciones neuropatológicas agudas, incluyendo los traumas del cerebro y la médula espinal, se hallan entre las principales causas de muerte y discapacidades a nivel mundial, sobre todo en niños y adultos jóvenes. Las causas de las lesiones del cerebro y la médula espinal, incluyen los accidentes automovilísticos, accidentes en actividades recreativas, caídas y ataques violentos. Sólo en los Estados Unidos de Norte América, alrededor de 1.7 millones de personas buscan anualmente atención médica para algún tipo de lesión craneal. Cincuenta y dos mil de estas personas morirán, mientras que un número similar presentará alguna discapacidad funcional permanente. Dada la alta prevalencia de estas condiciones patológicas agudas a nivel mundial, la investigación de los mecanismos que subyacen en los daños al sistema nervioso central, constituye un asunto de suma importancia. Hoy día, se han desarrollado varios modelos experimentales de trastornos neurales agudos, y se han investigado los mecanismos de la pérdida de tejido. Estos mecanismos incluyen tanto las manifestaciones patológicas primarias como las secundarias, que contribuyen al daño del tejido y al deterioro funcional. Los mecanismos patológicos secundarios principales abarcan la excitotoxicidad, los desequilibrios iónicos, la respuesta inflamatoria, el estrés oxidativo, y la apoptosis. Dilucidar correctamente como ocurre la pérdida del tejido neuronal luego del trama del cerebro o la médula espinal, es fundamental para poder desarrollar terapias efectivas en relación con las enfermedades humanas. La presente revisión evalúa los mecanismos principales del daño secundario al tejido, tras las lesiones traumáticas del cerebro y la médula espinal.

Cerebral hemodynamics: concepts of clinical importance / Hemodinâmica encefálica: conceitos de importância clínica

Cerebral hemodynamics and metabolism are frequently impaired in a wide range of neurological diseases, including traumatic brain injury and stroke, with several pathophysiological mechanisms of injury. The resultant uncoupling of cerebral blood flow and metabolism can trigger secondary brain lesions, particularly in early phases, consequently worsening the patient's outcome. Cerebral blood flow regulation is influenced by blood gas content, blood viscosity, body temperature, cardiac output, altitude, cerebrovascular autoregulation, and neurovascular coupling, mediated by chemical agents such as nitric oxide (NO), carbon monoxide (CO), eicosanoid products, oxygen-derived free radicals, endothelins, K+, H+, and adenosine. A better understanding of these factors is valuable for the management of neurocritical care patients. The assessment of both cerebral hemodynamics and metabolism in the acute phase of neurocritical care conditions may contribute to a more effective planning of therapeutic strategies for reducing secondary brain lesions. In this review, the authors have discussed concepts of cerebral hemodynamics, considering aspects of clinical importance.

Alterações hemodinâmicas e metabólicas do encéfalo ocorrem frequentemente em diversas doenças neurológicas, principalmente em condições de traumatismo cranioencefálico e acidente vascular encefálico, com vários mecanismos patofisiológicos lesionais. O desacoplamento resultante do fluxo sanguíneo e do metabolismo encefálico pode resultar em lesões encefálicas secundárias, principalmente nas primeiras fases, e, consequentemente, no agravamento do desfecho neurológico dos pacientes. Diversos fatores influenciam o fluxo sanguíneo encefálico, entre eles, a concentração sanguínea de gases, viscosidade sanguínea, temperatura corpórea, débito cardíaco, altitude, autorregulação cerebrovascular e acoplamento neurovascular, que é mediado por óxido nítrico (ON), monóxido de carbono (CO), eicosanoides, radicais livres derivados do oxigênio, endotelinas, potássio, íons hidrogênio e adenosinas. Melhor compreensão destes fatores é fundamental para o manejo clínico dos pacientes neurológicos críticos. A avaliação hemodinâmica e metabólica do encéfalo nas lesões encefálicas agudas pode contribuir para o planejamento de estratégias de redução das lesões encefálicas secundárias. Nesta revisão, os autores discutiram princípios da hemodinâmica encefálica, considerando os aspectos de importância clínica.

Neuroimaging in stroke and non-stroke pusher patients / Análise de neuroimagens de pacientes com síndrome do empurrador decorrente de AVC e outras etiologias

Pusher behavior (PB) is a disorder of postural control affecting patients with encephalic lesions. This study has aimed to identify the brain substrates that are critical for the occurrence of PB, to analyze the influence of the midline shift (MS) and hemorrhagic stroke volume (HSV) on the severity and prognosis of the PB. We identified 31 pusher patients of a neurological unit, mean age 67.4±11.89, 61.3 percent male. Additional neurological and functional examinations were assessed. Neuroimaging workup included measurement of the MS, the HSV in patients with hemorrhagic stroke, the analysis of the vascular territory, etiology and side of the lesion. Lesions in the parietal region (p=0.041) and thalamus (p=0.001) were significantly more frequent in PB patients. Neither the MS nor the HSV were correlated with the PB severity or recovery time.

A síndrome do empurrador (SE) é um distúrbio de controle postural que acomete indivíduos com lesões encefálicas. Os objetivos deste estudo foram identificar as estruturas encefálicas envolvidas na SE, analisar a influência dos desvios de linha média (DLM) e volume do hematoma (VH) na gravidade e duração da SE. Dentre os pacientes internados na enfermaria de neurologia, foram identificados 31 pacientes com SE, idade média 67,4±11,89, 61,3 por cento homens. Foram realizados exames neurológico e funcional. As análises das neuroimagens incluíram medidas de VH em pacientes com doença cerebrovascular (DC) hemorrágica, DLM, análise do território vascular, etiologia e lado da lesão. Lesão nas regiões parietal (p=0,041) e talâmica (p=0,001) foram significativamente mais frequentes nos pacientes com SE. Não foi observada correlação dos DLM e volume do hematoma com a gravidade e duração da SE.

Selective therapeutic hypothermia: A review of invasive and noninvasive techniques / Hipotermia terapêutica seletiva: uma revisão de técnicas invasivas e não invasivas

OBJECTIVE: Therapeutic hypothermia is a promising treatment to prevent secondary neurologic injury. Clinical utility is limited by systemic complications of global hypothermia. Selective brain cooling remains a largely uninvestigated application. We review techniques of inducing selective brain cooling. METHOD: Literature review. RESULTS: Strategies of inducing selective brain cooling were divided between non-invasive and invasive techniques. Non-invasive techniques were surface cooling and cooling via the upper airway. Invasive cooling methods include transvascular and compartmental (epidural, subdural, subarachnoid and intraventricular) cooling methods to remove heat from the brain. CONCLUSION: Selective brain cooling may offer the best strategy for achieving hypothermic neuroprotection. Non-invasive strategies have proven disappointing in human trials. There is a paucity of human experiments using invasive methods of selective brain cooling. Further application of invasive cooling strategies is needed.

OBJETIVO: A hipotermia terapêutica é uma estratégia promissora para prevenção do dano neurológico secundário. Sua utilidade clínica é limitada por complicações sistêmicas da hipotermia global. Resfriamento cerebral seletivo (RCS), entretanto, permanece uma técnica pouco estudada. Revisamos aqui as diferentes técnicas de indução de RCS. MÉTODO: Revisão de literatura. RESULTADOS: As estratégias de indução de RCS foram divididas em invasivas e não-invasivas. Métodos de remoção de calor do cérebro não-invasivos incluem o resfriamento de superfície e o de vias aéreas superiores; as técnicas invasivas incluem resfriamento transvascular e compartimental (epidural, subdural, subaracnóideo e intraventricular). CONCLUSÃO: RCS pode oferecer a melhor estratégia para alcançar neuroproteção hipotérmica. Estratégias não-invasivas têm se mostrado ineficazes em estudos clínicos. Técnicas invasivas foram raramente estudadas em humanos e necessitam ser mais investigadas para tornarem-se úteis.

Functional electrical stimulation improves brain perfusion in cranial trauma patients / A terapia com estímulo elétrico funcional pode melhorar a perfusão cerebral no SPECT em pacientes com trauma craniano

OBJECTIVE: Demonstrate brain perfusion changes due to neuronal activation after functional electrical stimulation (FES). METHOD: It was studied 14 patients with hemiplegia who were submitted to a program with FES during fourteen weeks. Brain perfusion SPECT was performed before and after FES therapy. These patients were further separated into 2 groups according to the hemiplegia cause: cranial trauma and major vascular insults. All SPECT images were analyzed using SPM. RESULTS: There was a significant statistical difference between the two groups related to patient's ages and extent of hypoperfusion in the SPECT. Patients with cranial trauma had a reduction in the hypoperfused area and patients with major vascular insult had an increase in the hypoperfused area after FES therapy. CONCLUSION: FES therapy can result in brain perfusion improvement in patients with brain lesions due to cranial trauma but probably not in patients with major vascular insults with large infarct area.

OBJETIVO: Demonstrar mudanças na perfusão cerebral devido à ativação neuronal depois de estimulação elétrica funcional (EEF). MÉTODO: Foram estudados 14 pacientes com hemiplegia submetidos a quatorze semanas de um programa com EEF. O SPECT de perfusão cerebral foi realizado antes e depois da terapia com EEF. Estes pacientes foram separados em 2 grupos com relação à causa da hemiplegia: trauma craniano e acidente vascular cerebral (AVC). As imagens de SPECT foram analisadas usando SPM. RESULTADOS: Houve diferença estatisticamente significativa entre os dois grupos relacionada a idade dos pacientes e extensão da hipoperfusão. Os pacientes com trauma craniano tiveram redução na área de hipoperfusão e pacientes com AVC tiveram aumento na área de hipoperfusão após terapia com EEF. CONCLUSÃO: A terapia com EEF pode levar a melhora na perfusão cerebral em pacientes com lesões cerebrais secundárias a trauma craniano; entretanto, provavelmente não em pacientes com extensas áreas de infarto secundárias a AVC.

Continuous ventricular cerebrospinal fluid drainage with intracranial pressure monitoring for management of posttraumatic diffuse brain swelling / Drenagem contínua de líquido cefalorraquidiano com monitoração intermitente de pressão intracraniana em pacientes com tumefação cerebral difusa pós-traumática

BACKGROUND: Ventricular drainage has played an important role in the management of traumatic brain-injured patients. The aim of the present study was describe outcomes in a series of 57 patients with diffuse brain swelling underwent to intracranial pressure (ICP) monitoring. METHOD: Fifty-eight patients with diffuse posttraumatic brain swelling, were evaluated prospectively. The Glasgow Coma Scale (GCS) scores of patients varied from 4 to 12. Patients groups divided according to GCS and age. Patient neurological assessment was classified as favorable, unfavorable, and death. RESULTS: Mechanisms of injury were vehicle accidents in 72.4 percent and falls in 15.6 percent. 54 percent of patients had GCS scores between 6 and 8. There were no statistical differences, regarding outcome, between groups separated by age. In the adults group (n=47), 44.7 percent evolved favorably. CONCLUSION: Our results indicate a poor prognosis in patients with brain swelling. We believe that continuous ventricular CSF drainage with ICP monitoring is a simple method as an adjunct in the management of these patients.

INTRODUÇÃO: Monitoração da pressão intracraniana (PIC) tem desempenhado um papel importante nos pacientes com lesão cerebral difusa traumática. O objetivo do presente estudo foi descrever os resultados de uma série de 57 pacientes com tumefação cerebral difusa submetidos à monitoração da PIC. MÉTODO: Cinquenta e oito pacientes com lesão axonal difusa foram avaliados prospectivamente. Na Escala de Coma de Glasgow (GCS) os escores variaram de 4 a 12. Os grupos de pacientes, foram divididos de acordo com a GCS e a idade. Avaliação neurológica tardia foi classificada como favorável, desfavorável, e da morte. RESULTADOS: Mecanismos de lesão predominantes foram os acidentes de veículos em 72,4 por cento e quedas em 15,6 por cento; 54 por cento dos pacientes tiveram escores GCS entre 6 e 8. Não houve diferença estatística entre os grupos separados por idade. No grupo de adultos (n=47), 44,7 por cento evoluíram favoravelmente. CONCLUSÃO: As lesões difusas tipo III apresentam resultados funcionais desfavoráveis. Acreditamos que a monitoração intermitente de PIC com drenagem de líquido cefalorraquidiano seja um método simples e aplicável no apoio ao tratamento destes pacientes.