Association between blood pressure and acute phase stroke case fatality rate: a prospective cohort study / Associação entre níveis de pressão arterial e letalidade na fase aguda do acidente vascular cerebral: estudo de coorte prospectivo

ABSTRACT Objective ed to investigate the association between blood pressure and acute phase stroke lethality in a Brazilian intensive care unit. Methods This was an observational, prospective cohort study of hemorrhagic and ischemic stroke intensive care patients. The primary outcome was all-cause mortality during the first seven days. Results There were 146 patients, aged 66 ± 13.4 years, 56% men, 89% Caucasian, 69% had ischemic stroke, and 80% were hypertensive. The median of the National Institutes of Health Stroke Scale score was 16. There were 101 ischemic stroke patients and 45 hemorrhagic stroke patients. In the ischemic stroke patients, logistic regression analysis identified low systolic blood pressure as an independent ominous prognostic factor and the optimal cut off was a mean of systolic blood pressure ≤ 131 mmHg during the first 48 hours from admission for prediction of death. No association was found for hemorrhagic stroke. Conclusions There was a negative association between systolic blood pressure and case fatality ratio of acute phase stroke in ischemic stroke intensive care patients.

RESUMO Objetivo Investigar a associação entre pressão arterial e letalidade do acidente vascular cerebral (AVC) em uma unidade de terapia intensiva brasileira. Métodos estudo de coorte prospectivo de pacientes com AVC hemorrágico (AVC-H) ou isquêmico (AVC-I) internados em terapia intensiva. O desfecho primário foi a letalidade por todas as causas nos primeiros sete dias. Resultados Avaliados 146 pacientes, idade: 66 ± 13,4 anos, 56% homens, 89% brancos, 69% AVC-I e 80% hipertensos. A mediana do NIH foi de 16. Os pacientes com AVC-I foram 101 e 45 com AVC-H. Para AVC-I, a análise de regressão logística identificou baixa pressão arterial sistólica como um fator prognóstico negativo e o melhor corte foi uma média da pressão arterial sistólica nas primeiras 48 h de admissão ≤ 131 mmHg para a predição da morte. Para o AVC-H, nenhuma correlação foi encontrada. Conclusões houve associação negativa entre a pressão arterial sistólica e a letalidade do AVC-I em fase aguda em pacientes de terapia intensiva.

Paralisia da mirada lateral relacionada a cavernoma da ponte / Horizontal gaze palsy due to pontine cavernous malformation

Paralisia da mirada lateral por hemorragia pontina, secundária a cavernoma, o qual apresenta prevalência estimada de 0,4% a 0,6%. O risco de sangramento de tal entidade é considerado baixo (0,1 a 3,1% ao ano). Relatamos o caso de paciente feminino, 38 anos, admitida no setor de emergência com quadro de cefaleia, vertigem, hipertensão (PA 200/120mmHg), rebaixamento do nível de consciência (Glasgow 13) e paralisia do olhar conjugado lateral à direita, com 24 horas de evolução. A tomografia de crânio revelou hemorragia pontina e a angiorressonância evidenciou a presença de cavernoma no tegmento pontino. Foi optado por tratamento conservador e a paciente evoluiu com síndrome do encarceramento (Locked-in syndrome) por piora da hemorragia e edema perilesional. Os cavernomas são malformações vasculares que podem cursar assintomáticas e passar despercebidas pelos exames de imagem até o evento hemorrágico. Apesar de raro, quando este ocorre no tronco encefálico pode apresentar alta morbimortalidade. Isso reforça a importância de se avaliar a chance de sangramento dessas lesões e instituir a melhor abordagem para cada caso. (AU)

Horizontal gaze palsy due to hemorrhage of a pontine cavernous malformation, which prevalence ranges from 0.4% to 0.6%. The risk of bleeding is considered low (0.1 to 3.1% per year). It is reported a case of a 38-year-old woman admitted to the emergency department with headache, vertigo, hypertension (200/120mmHg), decreased level of consciousness (Glasgow 13) and horizontal gaze palsy to the right side, that started suddenly 24h before admission. CT scan revealed a pontine hemorrhage and MRI showed the presence of a cavernous malformation in the pontine tegmentum. Conservative treatment was chosen and the patient developed locked-in syndrome due to worsening bleeding and perilesional edema. Cavernoma are vascular malformations that can be asymptomatic and remain undetected by imaging until the hemorrhagic event. Although rare, when bleeding occurs in the brain stem, it can cause high morbidity and mortality. This report reinforces the importance of evaluation these injuries' bleeding risk and establish the best approach for each case. (AU)

Cerebrospinal fluid drainage options for posthemorrhagic hydrocephalus in premature neonates / Opções de drenagem liquórica em neonatos prematuros com hidrocefalia pós hemorrágica

ABSTRACT Objective The literature describes various cerebrospinal fluid (CSF) drainage techniques to alleviate posthemorrhagic hydrocephalus in preterm newborns; however, consensus has not been reached. The scope of this study was describing a case series of premature neonates with posthemorrhagic hydrocephalus and assessing the outcomes of different approaches used for CSF diversion. Methods A consecutive review of the medical records of neonates with posthemorrhagic hydrocephalus treated with CSF drainage was conducted. Results Forty premature neonates were included. Serial lumbar puncture, ventriculosubgaleal shunt, and ventriculoperitoneal shunt were the treatments of choice in 25%, 37.5% and 37.5% of the cases, respectively. Conclusion Cerebrospinal fluid diversion should be tailored to each case with preference given to temporary CSF drainage in neonates with lower age and lower birth-weight, while the permanent ventriculoperitoneal shunt should be considered in healthier, higher birth-weight neonates born closer to term.

RESUMO Objetivo A literatura descreve várias opções de drenagem liquórica (DL) para alivio da hidrocefalia pós-hemorrágica (HPH) em neonatos prematuros; contudo, não existe um consenso sobre a melhor abordagem. O escopo deste estudo foi descrever uma série de casos de neonatos prematuros, portadores de HPH, verificando os resultados de diferentes técnicas utilizadas para DL. Métodos Revisão consecutiva dos prontuários de neonatos com diagnostico de HPH submetidos a DL. Resultados Quarenta recém-nascidos prematuros foram incluídos. A punção lombar seriada (PL), a derivação ventriculosubgaleal (VSG) e a derivação ventrículo peritoneal (VP) foram o tratamento escolhido em 25%, 37,5% e 37,5% dos casos, respectivamente. Conclusão As opções de DL devem ser avaliadas caso a caso, sendo dada preferência às drenagens temporária em prematuros com idade e peso mais baixos ao nascer, enquanto o shunt definitivo (derivação VP) pode ser considerado naqueles prematuros mais saudáveis, com idade e peso superiores.

Tratamiento quirúrgico en las hemorragias intracerebrales lobares espontáneas supratentoriales sin extensión ventricular / Surgical treatment for supratentorial spontaneous lobarintracerebral hemorrhage without ventricular extension

Objetivo: Evaluar los resultados en el manejo de pacientes con hemorragias intracerebrales lobares espontaneas, supratentoriales y sin extensión ventricular a través de la comparación entre el tratamiento quirúrgico y el tratamiento médico. Material y Método: Se realizó un estudio de casos y controles en el Hospital General “Roberto Rodríguez Fernández” de Morón, Ciego de Ávila, Cuba, en el período comprendido entre enero de 2009 y diciembre de 2013. La muestra quedó conformada por aquellos que reunieron los siguientes criterios de inclusión: 1) Edad de 18-60 años; 2) 48 horas de inicio de las manifestaciones clínicas; 3) volumen de la hemorragia entre 20 y 60 cm3 ; 4) Escala de coma de Glasgow al ingreso superior a 4 puntos. Se constituyeron dos grupos, en el Grupo I fueron incluidos los enfermos que recibieron tratamiento quirúrgico y médico. En el Grupo II se incluyeron los que recibieron tratamiento médico solamente. La inclusión en uno de los dos grupos quedó sujeta al criterio del médico que recibió al paciente en el departamento de emergencias, no existió aleatorización en el proceso. Resultados: Se incluyeron en el estudio un total de 147 pacientes 54 (36,73 por ciento) en el Grupo I y 93 (63,27 por ciento) en el Grupo II. En el Grupo I la mortalidad a los seis meses del egreso fue de 16 pacientes (29,64 por ciento), mientras que en el grupo II murieron 33 (35,48 por ciento). Conclusiones: Se obtuvo un discreto pero relevante predominio de los resultados satisfactorios en el grupo de pacientes operados y la mortalidad fue también menor en este grupo.

The aim of this paper was to evaluate the surgical versus medical treatment in patients with supratentorial spontaneous intracerebral hemorrhage without ventricular extension. Methods: A case-control study was carried out in the “Roberto Rodríguez Fernández” general hospital in Moron, Ciego de Avila, Cuba, in the period between January 2009 and December 2013. The sample was conformed by those patients that gathered the following inclusion criteria: 1) Age of 18-60 years; 2) 48 hours of beginning of clinical manifestation; 3) Volume of the hemorrhage between 20-60 cm3; 4) GCS superior to 4 points. Two groups were constituted. In the group I the patients whom received medical and surgical treatment were included. In the group II were included patients whom received medical treatment only. The inclusion in one of the two groups was subject to the doctor´s criteria in the emergency department, randomization didn’t exist in the process. Results: They were included in the study a total of 147 patients, 54 (36,73 percent) in the Group I and 93 (63,27 percent) in the Group II. The mortality at 6 month of discharge was 29,64 percent in Group I and 35,48 percent in Group II. Conclusions: A discreet but outstanding of the satisfactory results was obtained in the group of operated patients and the mortality was also smaller in this group.

Interrelationship between implant and orthognathic surgery for the rehabilitation of edentulous cleft palate patients: a case report

A 43-year-old woman with a unilateral cleft lip and palate, presenting a totally edentulous maxilla and mandible with marked maxillomandibular discrepancy, attended the Prosthodontics section of the Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo for treatment. She could not close her mouth and was dissatisfied with her complete dentures. Treatment planning comprised placement of six implants in the maxilla, four in the mandible followed by prostheses installation and orthognathic surgery. The mandibular full arch prosthesis guided the occlusion for orthognathic positioning of the maxilla. The maxillary complete prosthesis was designed to assist the orthognathic surgery with a provisional prosthesis (no metal framework), allowing reverse treatment planning. Maxillary and mandibular realignment was performed. Three months later, a relapse in the position of the maxilla was observed, which was offset with a new maxillary prosthesis. This isa complex interdisciplinary treatment and two-year follow-up is presented and discussed. It should be considered that this type of treatment could also be applied in non-cleft patients.

Principales características clinicopatológicas de pacientes con hemorragia cerebral / Main clinical and pathological characteristics of patients with brain hemorrhage

Se realizó un estudio descriptivo y transversal de 106 pacientes con hemorragia cerebral, ingresados en el Servicio de Enfermedades Cerebrovasculares del Hospital Provincial Docente Clinicoquirúrgico Saturnino Lora Torres de Santiago de Cuba durante el 2011, a fin de analizar las principales características clinicopatológicas de esta afección. En la casuística predominaron el grupo etario de 61 años y más (29,2 por ciento), los afectados de piel negra, el sexo masculino (71,6 por ciento), la hipertensión arterial como principal factor de riesgo (67,0 por ciento), además de la bronconeumonía bacteriana y el edema cerebral como complicaciones no neurológica y neurológica (36,0 y 29,0 por ciento, respectivamente)

A descriptive and cross-sectional study was conducted in 106 patients with brain hemorrhage, admitted to the Department of Cerebrovascular Diseases of Saturnino Lora Torres Provincial Teaching Hospital in Santiago de Cuba during 2011, in order to analyze the main clinical and pathological characteristics of this condition. Age group of 61 years and over (29.2 percent), black patients, male sex (71.6 percent), hypertension as main risk factor (67.0 percent) prevailed in the case material, besides bacterial bronchopneumonia and brain edema as non-neurological and neurological complications (36.0 and 29.0 percent, respectively)

Asociación entre lesiones placentarias y lesiones isquémico hemorrágicas cerebrales precoces detectadas por ecografía en prematuros menores de 1500 gramos y 32 semanas / [The relationship between placental lesions and early hemorrhagic-ischemic cerebral injury in very low birth weight infants].

INTRODUCTION: The histopathological features of the placenta are central for screening a lot of pregnancy related disorders associated to hemorrhagic-ischemic cerebral injury in preterm infants that can jeopardize his long term neurodevelopment. The objective of this study was to examine the relationship between placental lesions and early hemorrhagic-ischemic cerebral injury in very low birth weight infants (VLBW). METHODS: This is a case-control study of VLBW born at Sardá Maternity Hospital, Buenos Aires, between 2006 and 2012. Inclusion criteria’s were gestational age ÔëÑ 24 and Ôëñ 32 weeks and birth weight between 500 g and 1500 g, Exclusion criteria’s were multiple pregnancy, congenital anomalies, intrauterine infections and mortality before 24 hours of life. RESULTS: 198 VLBW were included, 49 cases and 149 controls. There was no significant difference in the incidence of histopathological lesions between the groups, although inflammatory placental lesions predominated in cases (67,3

) compared with controls (48

, p= 0.018). Intraventricular hemorrhage was the most common injury. On bivariate analysis inflammation was the only placenta lesion associated with early hemorrhagic-ischemic cerebral injury (OR 7.0, 95

CI 1.54 - 31.71) whereas the risk of severe hemorrhagic-ischemic cerebral injury was twofold greater in the presence of inflammation (p= 0.20). After adjusting for perinatal variables, placental lesions were not independently associated with increased risk of hemorrhagic-ischemic cerebral injury. There was a trend towards lesser risk of hemorrhagic-ischemic cerebral injury with increasing gestational age. CONCLUSION: Placental injuries were not independently associated with hemorrhagic-ischemic cerebral injury within 72 hours of life, although inflammation showed a clear predominance un cases.

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.

Hipotermia intravascular prolongada en un paciente con hipertensión endocraneana refractaria / Prolonged hypothermia in refractory intracranial hypertension. Report of one case

The use of hypothermia after cardiac arrest caused by ventricular fibrillation is a standard clinical practice, however its use for neuroprotection has been extended to other conditions. We report a 23-year-old male with intracranial hypertension secondary to a parenchymal hematoma associated to acute hydrocephalus. An arterial malformation was found and embolized. Due to persistent intracranial hypertension, moderate hypothermia with a target temperature of 33°C was started. After 12 hours of hypothermia, intracranial pressure was controlled. After 13 days of hypothermia a definitive control of intracranial pressure was achieved. The patient was discharged 40 days after admission, remains with a mild hemiparesia and is reassuming his university studies.

Statistical Mapping Analysis of Brain Metabolism in Patients with Subcortical Aphasia after Intracerebral Hemorrhage: A Pilot Study of F-18 FDG PET Images

PURPOSE: This study was aimed to evaluate the brain metabolism in patients with subcortical aphasia after intracerebral hemorrhage (ICH) and the relationship between the severity of aphasia and regional brain metabolism, by using statistical mapping analysis of F-18 fluorodeoxyglucose positron emission tomography (F-18 FDG PET) images. MATERIALS AND METHODS: Sixteen right-handed Korean speaking patients with subcortical aphasia following ICH were enrolled. All patients underwent Korean version of the Western Aphasia Battery and the brain F-18 FDG PET study. Using statistical parametric mapping analysis, we compared the brain metabolisms shown on F-18 FDG PET from 16 patients with subcortical aphasia and 16 normal controls. In addition, we investigated the relationship between regional brain metabolism and the severity of aphasia using covariance model. RESULTS: Compared to the normal controls, subcortical aphasia after ICH showed diffuse hypometabolism in the ipsilateral cerebrum (frontal, parietal, temporal, occipital, putamen, thalamus) and in the contralateral cerebellum (P corrected <0.001), and showed diffuse hypermetabolism in the contralateral cerebrum (frontal, parietal, temporal) and in the ipsilateral cerebellum (P FDR corrected <0.001). In the covariance analysis, increase of aphasia quotient was significantly correlated with increased brain metabolism in the both orbitofrontal cortices, the right hippocampal and the right parahippocampal cortices (P uncorrected <0.01). CONCLUSION: Our findings suggest that frontal, parietal, and temporal cortices, which are parts of neural network for cognition, may have a supportive role for language performance in patients with subcortical aphasia after ICH.

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.

Letter to the Editor: The Supernumerary Phantom Limb and Phantom Limb Pain-Important Facts

No abstract available.

Atypical Supernumerary Phantom Limb and Phantom Limb Pain in Two Patients with Pontine Hemorrhage

Phantom limbs are usually observed after amputation of extremities. In patients after a stroke, a similar but rarely occurring phenomenon consisting of the patient experiencing the presence of an additional limb has been described. This phenomenon, generally called supernumerary phantom limb (SPL), may be caused by lesions in the right or left cerebral hemisphere, but has been predominantly reported in patients who have had a right hemispheric stroke. We report two cases of atypical SPL and phantom limb pain (PLP) after pontine hemorrhage. The patients were treated conservatively and their symptoms lasted more than 1 month. This is the first report of SPLs after left pontine hemorrhage, and phantom perception and pain lasted longer than those in previously observed cases. Our results indicate that SPL may be more common than reported; therefore, thorough examinations are essential for the care of stroke patients.

Perfil clínico epidemiológico de pacientes con accidente cerebrovascular en el Instituto Hondureño de Seguridad Social / Clinical and epidemiological profile of patients with stroke at The Honduran Social Security Institute

Introducción: En Honduras los accidentes cerebro vasculares (ACV) son la octava causa de muerte a nivel nacional y cuarta causa de muerte en hospitales estatales. Es la primera causa neurológica de ingresos en el Hospital Escuela. El objetivo del estudio fue determinar el perfil clínico epidemiológico de los pacientes con ACV atendidos en el Instituto Hondureño de Seguridad Social (IHSS) en Tegucigalpa. Pacientes y métodos: Se realizó un estudio transversal descriptivo incluyendo a 56 pacientes con diagnóstico de ACV durante el período enero a diciembre del año 2006. Resultados. Predominó el ACV isquémico (68%). Los hombres sufrieron ACV de tipo hemorrágico más que las mujeres (34% vs. 25% respectivamente). La hipertensión arterial fue el antecedente de riesgo predominante (66%, 37/56), seguido de la diabetes mellitus (26.7%, 15/56). El 55% de las mujeres y el 36% de los hombres habían presentado un ACV previo. Discusión. Los resultados muestran que el principal factor de riesgo para ACV en pacientes del IHSS continúa siendo la hipertensión arterial, predominando el ECV Isquémico. Los pacientes requirieron ser atendidos en diversas unidades de tratamiento hospitalario...

Predisposing factors and outcome of stroke in childhood.

This prospective study was done to determine the predisposing factors and outcome of stroke in Bangladeshi children. It was carried out in Khulna Medical College Hospital from July 2002 to June 2007. Admitted children with acute neurological deficit attributable to a vascular cause were included in the study. Forty two children were finally diagnosed with stroke; 73.8% were male. Apart from paresis/paralysis in 35 (83.3%) cases, headache/vomiting/convulsion was the presenting problem in 28 (66.7%) cases at the onset. Infection in 17 (40.5%) children and trauma in 11 (26.2%) were the important predisposing factors. CT scan revealed ischemia and hemorrhage in 18 (42.8%) and 8 (19.1%) cases, respectively. Twenty two (52.4%) of the children recovered fully and 3 (7.2%) expired.

Manejo de malformaciones arterio venosas en servicio de neurocirugía Hospital Escuela Lenin Fonseca / Management of arterio venous malformations in neurosurgery service Lenin Fonseca Hospital School

El objetivo del trabajo es conocer el manejo de las malformaciones arteriovenosas en Nicaragua .queremos demostrar la vigencia del tratamiento quirúrgico de esta patología. Se analizo un periodo de cinco año del 2004 al 2008, se excluyeron todas las malformaciones epicraneales , cavernomas y telengectasia. Se recogió la información de 62 expedientes, llenando una ficha previamente elaborada, se analizaron los resultados en epiinfo versión 3.5.1. Se encontró un ligero predominio del sexo masculino, la edad predominante fue entre los 15 a 40 año . La principal forma de presentación fue la hemorragia intracraneal, la escala de espetzler predominante fue el grado III, la principal complicación postquirúrgica fue la hemorragia intracerebral, 24 de los 62 pacientes se trato de forma conservadora, la principal complicación transquirurgica fue la hemorragia masiva, las principales complicaciones se asociaron a la mala condición clínica al ingreso y escala de espetzler III, IV, V. Se recomienda protocolizar el tratamiento de este tipo de patología según la escala de espetzler...

Muerte cerebral en una embarazada y sobrevida del feto / Brain death in a pregnant woman and fetus survival

Se presenta el caso de una mujer de 29 años de edad que a consecuencia de una hemorragia cerebelosa presentó un cuadro de muerte cerebral mientras cursaba la 17 semana de su embarazo. Durante 56 días se mantuvo con sostén vital artificial, corrección de déficit hormonal, nutrición enteral y tratamiento de las infecciones. Durante la 25 semana de embarazo, por paro cardíaco se debió practicar una cesárea, naciendo un niño de 450 gramos. Se realizó una revisión de los casos similares publicados y se discuten algunos aspectos médicos, éticos y legales derivados de esta situación.

A 29 year old woman suffered massive brain injury after a cerebellum hemorrhage at 17 weeks' gestation. Several hours later, and after brainstem test, she was declared brain dead. She was supported with intensive care during 56 days. After a cardiac arrest, on week 25, a 450 g infant was delivered through a cesarean section. The somatic support of mother and fetus according to the expected physiologic changes after brain death and its ethical implications are discussed.

Complications of cerebrovascular accident in two tertiary care hospitals of Peshawar, Pakistan

Stroke is considered as a lethal condition associated with significant mortality and morbidity. After stroke, complications are common and cause devastating effects on rehabilitation. The present study was designed to study the frequency of complications in acute stroke patients in Peshavar, Pakistan. This prospective observational study was conducted from March 2006 to February 2007 in the General Surgery and Neurosurgery Postgraduate Medical Institute, Lady Reading Hospital and Department of General Medicine of Hayatabad Medical Complex in Peshawar, Pakistan in a tertiary health care facility. The study was conducted on 100 consecutive patients of acute stroke, presenting within 7 days of the onset of stroke. All patients fulfilling WHO definition of acute stroke were admitted. The patients with subarachnoid hemorrhage were excluded from study. After initial assessment for the degree of neurological defect and functional disabilities, the patients were investigated for stroke types and cause. Daily assessment of all patients for occurrence of complications was done till discharge from hospital or death of the patient. Fift-eight [58%] patients were male and 42 [42%] were female with a mean age of 59.98 [11.95] years. The patients with intra-cerebral bleeding were 32 while those with cerebral infarction were 64 and cases with lacunar infarction, were 4. The median hospital stay was 6 days. The main complications were aspiration pneumonia in 28 [28%], constipation in 28 [28%], chest infection in 27 [27%], dehydration in 21 [21%] and urinary tract infection [UTI] in 12 [12%]. 16 patients [16%] had no complications and seven patients died. Aspiration pneumonia was the cause of death in four patients [57%] during their hospital stay. Post-stroke complications are very common and these can alter the outcome of stroke patients. Multidisciplinary stroke management is needed to decrease the complications of acute stroke

Ultrasonografía y predicción de parálisis cerebral en prematuros extremos / Ultrasound and prediction of cerebral palsy in extreme premature infants

Introducción: Los prematuros extremos (PE) tienen alto riesgo de morbilidad y secuelas neurológicas. La leucomalacia periventricular (LMPV) y hemorragia intraventricular (HIV) extensa son patologías típicas de la prematurez que se asocian al desarrollo de parálisis cerebral (PC) y fácilmente pesquisables por ultrasonografía cerebral (USC). El objetivo es predecir PC a los dos años de edad corregida en todos los PE dados de alta en base a la presencia e intensidad del daño cerebral diagnosticado por USC. Pacientes y métodos: Se constituyó un equipo neuropediátrico y se protocoliza un plan de seguimiento clínico, neurológico y ultrasonográfico para todos los PE dados de alta nacidos en los años 2001 al 2003. Los resultados de la USC se dividieron en: grupo A (USC normal), grupo B (con lesiones cerebrales favorables) y grupo C (lesiones desfavorables), y se registra el diagnóstico de PC a los dos años de edad corregida. Resultados: 247 niños fueron dados de alta pero sólo 171 (69,2 por ciento) completaron el seguimiento. En el grupo A hubo 3 de 78 niños que presentaron PC (3, 8 por ciento), no se registraron casos en los 45 niños del grupo B, y en el grupo C presentaron PC 15 de 48 niños (31,2 por ciento). En total se registraron 18 casos de PC (10, 5 por ciento), 13 de ellos de carácter invalidante (7,6 por ciento) y 10 casos fueron asociados a HIV. Al juntar los grupos de USC normal y favorable (A y B) y confrontarlos con el grupo de USC desfavorable (C) se observa que la USC para predecir PC tiene sensibilidad de 83,3 por ciento, especificidad de 78,4 por ciento, valor predictivo positivo 31,3 por ciento y negativo 97,6 por ciento. Conclusiones: La prevalencia de PC fue similar a otras publicaciones. La USC demostró utilidad en seleccionar pacientes de mayor riesgo neuromotor aunque no predice PC a largo plazo y no determina el manejo neuro-kinésico posterior. Dado lo trascendente del diagnóstico de PC resulta importante saber que 1 de 3 niños con USC desfav...