Predictors of hemorrhagic transformation after acute ischemic stroke based on the experts opinion / Preditores de transformação hemorrágica após acidente vascular cerebral isquêmico agudo a partir da opinião de especialistas

ABSTRACT Background: Hemorrhagic transformation (HT) is a common complication after ischemic stroke. It may be associated to poor outcomes. Some predictors of HT have been previously identified, but there remain controversies. Objective: To describe the risk factors for HT more frequently reported by a panel of experts surveyed for this project. Methods: We sent a standard questionnaire by e-mail to specialists in Vascular Neurology from 2014 to 2018. Forty-five specialists were contacted and 20 of them responded to the invitation. Predictors cited by three or more specialists were included in a table and ranked by the frequency in which they appeared. A review of the literature looking for published predictive scores of HT was performed, comparing to the answers received. Results: The 20 responding specialists cited 23 different risk factors for HT. The most frequent factors in the order of citation were the volume of ischemia, previous use of antithrombotic medication, neurological severity, age, hyperglycemia at presentation, hypertension on admission, and cardioembolism. Most variables were also found in previously published predictive scores, but they were reported by the authors with divergences of frequency. Conclusion: Although many studies have evaluated HT in patients with acute ischemic stroke, the published risk factors were neither uniform nor in agreement with those cited by the stroke specialists. These findings may be helpful to build a score that can be tested with the goal of improving the prediction of HT.

RESUMO Introdução: A transformação hemorrágica (TH) é uma complicação comum após a isquemia cerebral e pode estar associada a desfechos desfavoráveis. Alguns fatores de risco para TH têm sido identificados, mas ainda há controvérsias. Objetivo: Descrever os fatores de risco para TH mais frequentemente reportados por um painel de especialistas consultados para esse projeto. Métodos: Enviamos um questionário padronizado por e-mail para 45 especialistas em Neurologia Vascular no período de 2014 a 2018. Vinte dos 45 especialistas responderam ao convite. Preditores citados por três ou mais especialistas foram incluídos em uma tabela e classificados pela frequência em que foram reportados. Uma revisão de literatura foi realizada em busca de escores preditivos de TH publicados anteriormente, comparando-os com as respostas recebidas. Resultados: Os 20 especialistas citaram 23 diferentes fatores de risco para TH. Os fatores mais frequentemente citados foram, pela ordem, volume da isquemia, uso prévio de medicação antitrombótica, gravidade neurológica, idade, hiperglicemia na apresentação, hipertensão na admissão e cardioembolismo. A maioria das variáveis também foi incluída em escores preditivos de TH já publicados, mas sem a mesma frequência e com divergências entre os especialistas consultados. Conclusão: Embora muitos estudos tenham avaliado a TH em pacientes com isquemia cerebral, os fatores de risco já publicados não foram uniformes na concordância com aqueles reportados pelos neurologistas vasculares consultados. Esses achados podem ser úteis para elaborar um escore que possa ser testado para aperfeiçoar a predição de transformação hemorrágica.

Hemorragia intracerebral temprana como presentación atípica de encefalitis por herpes virus simple tipo 1 / Early intracerebral hemorrhage as an atypical presentation of herpes simplex-1 virus encephalitis

RESUMEN La encefalitis por herpes virus simple es la causa más común de encefalitis esporádica letal en el mundo. Una complicación poco usual es la hemorragia intracerebral. Se describe el caso de un preescolar de tres años que ingresa con cuadro clínico de encefalitis aguda, con hallazgos de hemorragia intracerebral temprana en región occipital y estudio en líquido cefalorraquídeo positivo para herpes virus tipo 1, que recibe tratamiento con aciclovir; sin embargo, cursa con evolución tórpida, incremento de hemorragias intracerebrales y desenlace fatal.

ABSTRACT Herpes simplex encephalitis is the most common cause of sporadic lethal encephalitis in the world. Intracerebral hemorrhage is an uncommon complication. The case of a 3-year-old preschooler who was admitted with acute encephalitis clinical picture is described. The patient presents findings of early in tracerebral hemorrhage in the occipital region and a positive cerebrospinal fluid study for herpes virus type 1, which is treated with acyclovir; however, it presents a torpid evolution, increased intracerebral hemorrhages and fatal outcome.

Caracterización clínica de la hemorragia intracerebral en pacientes ingresados en Hospital Faustino Pérez. 2012-2013 / Clinical characterization of the intracerebral hemorrhage in patients admitted in the Hospital Faustino Perez. 2012-2013

RESUMEN Introducción: las enfermedades cerebrovasculares son un problema de salud mundial, constituyen la tercera causa de muerte, la primera de discapacidad en el adulto y la segunda de demencia en el planeta Objetivo: caracterizar la hemorragia intracerebral en estos pacientes en relación con edad y sexo, factores de riesgo, letalidad según localización y extensión de la hemorragia. Materiales y métodos: se realizó un estudio observacional retrospectivo en pacientes ingresados con hemorragia intracerebral en el Hospital Faustino Pérez en los años 2012 y 2013. El universo del estudio fue de 86 pacientes ingresados con hemorragia intracerebral. Resultados: predominó el sexo masculino y el grupo de edades de 70-79 años con 54,65% y 34,88% respectivamente, la raza negra con 40,7% y el factor de riesgo más frecuente fue la hipertensión arterial con 82,55% seguido de la diabetes mellitus con 23.25. La letalidad fue más elevada en los pacientes mayores de 80 años con 41,66%. Según la localización la subcortical fue más frecuente con 34,88% y la más letal el tallo encefálico con 100%. Según la extensión predominó la intraparenquimatosa pura con 69,76% y fue más letal intraventricular con 55%. Conclusión: la hemorragia intracerebral fue más frecuente en pacientes del sexo masculino, del grupo de edades de 70-79 años y de raza negra. El factor de riesgo más frecuente fue la hipertensión arterial, la localización más frecuente fue la subcortical y la extensión la intraparenquimatosa pura. La letalidad fue más alta en pacientes mayores de 80 años, con localización en tronco encefálico y extensión intraventricular.

ABSTRACT Introduction: cerebrovascular diseases are a health problem around the world, being the third cause of death, the first one of disability in adults, and the second cause of dementia in the world. Objective: to characterize intracerebral hemorrhage in these patients in relation to age and sex, risk factors, lethality according to its location and hemorrhage extension. Materials and methods: an observational, retrospective study was carried out in patients admitted in the Hospital Faustino Perez with intracerebral hemorrhage in 2012 and 2013. The universe of the study was 86 patients admitted due to intracerebral hemorrhage. Results: male sex (54.65 %), 70-79-years-old age group (34.88 %) and black race (49.7 %) predominated. The most frequent risk factor was arterial hypertension (82.55 %), followed by diabetes mellitus (23.25 %). Lethality was higher in patients elder than 80 years old (41.66 %). According to location, the subcortical one was the most frequent (34.88 %), and the most lethal was the one of the brainstem (100 %). According for the extension, the pure intraparenchimatous one predominated (69.76 %), and the intraventricular one was the most lethal (55 %). Conclusion: the intracerebral hemorrhage was more frequent in male sex, 70-79-years-old age group and black race. The most frequent risk factor was arterial hypertension; the most frequent location was the subcortical one, and the one with larger extension was the pure intraparenchimatous one. Lethality was higher in patients aged more than 80 years, located in the brainstem and with intraventricular extension.

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)

Intracerebral hemorrhage with a favorable outcome in a patient with childhood primary angiitis of the central nervous system / Hemorragia intracerebral com evolução favorável em paciente com angiíte primária do sistema nervoso central juvenil

ABSTRACT Childhood primary angiitis of the central nervous system (cPACNS) is a rare inflammatory brain disease of unknown etiology. Of note, brain hemorrhage has been rarely reported in cPACNS patients, generally associated with a delayed clinical diagnosis, or with a diagnosis only at necropsy. We present the case of a boy with cPACNS that previously suffered an ischemic stroke. At the age of 7 years and 10 months, he presented a sudden and severe headache, vomiting and reduction in consciousness level (Glasgow coma scale 7), requiring prompt tracheal intubation. Brain computed tomography demonstrated intraparenchymal hematoma in the right parieto-occipital lobe and a small focus of bleeding in the right frontal lobe, vasogenic edema, herniation of the uncus and a 10 mm deviation to the left from the midline. C-reactive protein (9.2 mg/dL) and von Willebrand factor (vWF) antigen (202%) were elevated. Decompressive craniotomy was performed and methylprednisolone and cyclophosphamide were administered. One week later, the patient had left hemiparesis without other sequelae. Importantly, motor deficits have been improving progressively. Our case reinforces the inclusion of this vasculitis as a differential diagnosis in children and adolescents with CNS hemorrhage.

RESUMO Angiíte primária do sistema nervoso central juvenil (APSNCJ) é uma doença inflamatória cerebral rara e de etiologia desconhecida. Hemorragia cerebral tem sido raramente reportada em pacientes com APSNCJ, geralmente associada com atraso diagnóstico, ou com um diagnóstico somente por necrópsia. Relata-se um caso de um paciente do gênero masculino com APSNCJ e que previamente sofreu um acidente vascular cerebral isquêmico. Aos 7 anos e 10 meses de idade, o menino apresentou subitamente cefaleia intensa, vômitos e redução do nível de consciência (escala de coma de Glasgow 7), requerendo imediata intubação traqueal. Uma tomografia computadorizada cerebral demonstrou hematoma intraparenquimatoso no lobo parieto-occipital direito e um pequeno foco de sangramento no lobo frontal direito, edema vasogênico, herniação do úncus e um desvio de 10 mm da linha média para a esquerda. A proteína C-reativa (9.2 mg/dL) e o fator antígeno de von Willebrand (202%) estavam elevados. Foi realizada uma craniotomia descompressiva, seguida pela administração de metilprednisolona e ciclofosfamida. Transcorrida uma semana, o paciente apresentava hemiparesia esquerda, sem outras sequelas. É digno de nota que o déficit motor tem melhorado progressivamente. Nosso caso reforça a inclusão dessa vasculite como diagnóstico diferencial em crianças e adolescentes com hemorragia do sistema nervoso central.

Factores pronósticos de mortalidad por hemorragia intracerebral en el periodo agudo / Predictors of mortality due To intracerebral hemorrhage during the acute period

INTRODUCCIÓN: en Cuba la enfermedad cerebro vascular ocupa la tercera causa de muerte seguida por las cardiovasculares y por las neoplasias y constituye también la quinta causa de años de vida saludables perdidos. Dentro de la enfermedad cerebro vascular, la hemorragia intracerebral es la de mayores complicaciones. OBJETIVO: determinar los factores relacionados con la mortalidad a corto plazo de la hemorragia intracerebral. MÉTODO: estudio de cohorte, retrospectivo y analítico con los pacientes ingresados por hemorragia intracerebral en los servicios de urgencia y terapias del Hospital. Se utilizaron factores clínicos, demográficos e imagenológicos hipotéticamente pronósticos de muerte por hemorragia intracerebral. RESULTADOS: el grupo comprendido entre 70 - 79 años presentó mayor mortalidad con 76,2 % de defunciones y el mayor número de casos con hemorragia intracerebral (59 pacientes). El 60 % de los pacientes que consumieron anticoagulantes previo a la hemorragia intracerebral fallecieron, mientras que el 67 % de los noconsumidores sobrevivieron. La relación entre cardiopatía isquémica y hemorragia intracerebral se asocia de manera independiente al evento muerte (p=0,00), mientras que en los pacientes con infección respiratoria tuvieron la mayor proporción los fallecidos con un (73,1 %). Por otro lado los pacientes que llegaron inconscientes y con incontinencia urinaria se relacionaron directamente con la mortalidad con (77,5 %) y (69,1 %) respectivamente. Los que tuvieron extensión ventricular del hematoma y volumen mayor de 50 ml presentaron 8 y 13 veces más posibilidades de fallecer que los restantes, respectivamente. CONCLUSIONES: los factores pronósticos de mortalidad por hemorragia intracerebral fueron: el consumo de anticoagulantes orales, la cardiopatía isquémica, la presencia de infección respiratoria, el estado de inconsciencia al ingreso, la presencia de incontinencia urinaria, la extensión ventricular del hematoma y la hemorragia intracerebral con volumen mayor de 50 ml.

INTRODUCTION: in Cuba cerebrovascular disease occupies the third cause of death, followed by cardiovascular diseases and neoplasms and it is the fifth leading cause of years of healthy life lost. Inside the cerebrovascular disease, intracerebral hemorrhage is the major complication. OBJECTIVE: determine the factors associated with short-term mortality of intracerebral hemorrhage. METHOD: a cohort-retrospective and analytical study was conducted with intracerebral hemorrhage patients admitted in hospital emergency and therapies services. Clinical, demographic and imaging factors were considered for the hypothetical forecasts of death from intracerebral hemorrhage. RESULTS: the age group 70-79 has higher mortality (76.2%) and the highest number of cases of intracerebral hemorrhage (59 patients). 60% of patients taking anticoagulants prior to intracerebral hemorrhage, died; while 67% of non consumers survived. The relationship between intracerebral hemorrhage and ischemic heart disease is independently associated to death event (p = 0.00), while patients with respiratory infection had the highest proportion with deceased patients (73.1%). On the other hand, patients who arrived unconscious and urinary incontinence were directly related to mortality (77.5%) and (69.1%) respectively. Those who had ventricular hematoma extension and volume higher than 50 ml presented 8 and 13 times more probabilities to die than the others, respectively. CONCLUSIONS: the mortality predictors of intracerebral hemorrhage were: use of oral anticoagulants, ischemic heart disease, the presence of respiratory infection, unconscious on admission, the presence of urinary incontinence, ventricular extension of the hematoma and intracerebral hemorrhage with higher volume than 50 ml.

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.

Detection of acute cerebral hemorrhage in rabbits by magnetic induction

Acute cerebral hemorrhage (ACH) is an important clinical problem that is often monitored and studied with expensive devices such as computed tomography, magnetic resonance imaging, and positron emission tomography. These devices are not readily available in economically underdeveloped regions of the world, emergency departments, and emergency zones. We have developed a less expensive tool for non-contact monitoring of ACH. The system measures the magnetic induction phase shift (MIPS) between the electromagnetic signals on two coils. ACH was induced in 6 experimental rabbits and edema was induced in 4 control rabbits by stereotactic methods, and their intracranial pressure and heart rate were monitored for 1 h. Signals were continuously monitored for up to 1 h at an exciting frequency of 10.7 MHz. Autologous blood was administered to the experimental group, and saline to the control group (1 to 3 mL) by injection of 1-mL every 5 min. The results showed a significant increase in MIPS as a function of the injection volume, but the heart rate was stable. In the experimental (ACH) group, there was a statistically significant positive correlation of the intracranial pressure and MIPS. The change of MIPS was greater in the ACH group than in the control group. This high-sensitivity system could detect a 1-mL change in blood volume. The MIPS was significantly related to the intracranial pressure. This observation suggests that the method could be valuable for detecting early warning signs in emergency medicine and critical care units.

Ictus hemorrágico en los servicios clínicos del hospital José R López Tabrane: primer cuatrimestre del 2012 / Hemorrhagic ictus at the clinical services of the hospital José R. López Tabrane: First quarter of 2012

Se realizó un estudio descriptivo del seguimiento a 14 pacientes que ingresaron con el diagnóstico clínico y radiológico de enfermedad cerebrovascular hemorrágica en los servicios clínicos del hospital José Ramón López Tabrane de Matanzas, en el periodo de enero a abril del 2012. Se observa que el grupo de 66–75 años predominó con 6 casos para un 42,8 por ciento, siendo el sexo masculino el más afectado con 8 pacientes para un 57,1 por ciento. Se apreció una estrecha relación entre escala de Glasgow, evolución clínica y estado al egreso. Se observó con escala Glasgow 15/15 solo 1 paciente vivo, para un 7,1 por ciento; con escala de 9-14/15 hubo 9 pacientes para un 64,2 por ciento y dentro de estos 4 fallecidos para una letalidad de 44,4 por ciento, con Glasgow de menos de 8/15 se presentaron 4 pacientes que todos fallecieron para una letalidad del 100 por ciento. Se comprueba mediante estudios de neuroimagen que el 24,1 por ciento son hemorragias e infarto sin efecto de masa, el 57,1 por ciento son hemorragias con efecto de masa, el 14,2 por ciento son hemorragias subaracnoideas y el 7,1 por ciento corresponde a la hemorragia intraventricular. El 100 por ciento de los pacientes recibieron tratamiento convencional, la alimentación precoz se utilizó en 10 pacientes para un 71,4 por ciento. La estadía hospitalaria se comportó entre 2 y 15 días. Se muestra la presencia de factores de riesgo en los pacientes estudiados. Se concluye que la escala de Glasgow permite establecer un pronóstico de morbimortalidad de los pacientes que ingresan con enfermedad cerebrovascular hemorrágica.

We carried out a descriptive study of the follow up of 14 patients who entered the clinical services of the hospital José R. López Tabrane, of Matanzas, with the radiological and clinical diagnosis of hemorrhagic cerebral vascular disease, in the period form January to April 2012. We observed that there was a predominance of the 66-75-years-old age group with 6 cases for 42,8 percent, being the male genre the most affected with 6 patients for 57,1 percent. We found a tight relation among Glasgow scale, clinical evolution and health status at discharge. It was observed only one alive patient, 7,1 percent, with Glasgow scale 15/15; with Glasgow scale value 9-14/15 there were 9 patients for 64,2 percent, among them 4 passed away for 44,4 percent lethality; with Glasgow scale of less than 8/15 there were 4 patients; all of them died for 100 percent lethality. Through neuro-imaging studies we verified that 34,1 percent of the cases are hemorrhages and infarct without mass effect, 57,1 percent are hemorrhages with mass effect, 14,2 percent are sub-arachnoid hemorrhages, and 7,1 percent are intra-ventricular hemorrhages. 100 percent of the patients received conventional treatment, precocious feeding was used in 10 patients for 71,4. Hospital staying ranged between 2 and 15 days. It was showed the presence of risk factors in the studied patients. We arrived to the conclusion that the Glasgow scale allows to establish a morbimortality prognosis of the patients entering with hemorrhagic cerebral vascular disease.

Associação da hemorragia peri-intraventricular com o peso ao nascer e uso de ventilação mecânica em neonatos pré-termo / Association of peri-intraventricular hemorrhage with birth weight and use of mechanical ventilation in preterm newborns

Objetivo: Estudo retrospectivo com o objetivo de verificar a prevalência de hemorragia peri-intraventricular (HPIV) em recém-nascidos (RN) prematuros de um hospital particular de Brasília, no ano de 2007, observando a relação existente entre presença de HPIV e idade gestacional (IG), peso ao nascimento (PN) e uso de ventilação mecânica invasiva (VMI). Métodos: Foram analisados todos os relatórios de alta dos recém-nascidos (n=215) e excluídos os RN com IG ³ 35 semanas e os prontuários incompletos; ao final, a amostra foi composta por 40 bebês. Resultado: A HIPV esteve presente em 27,5% dos casos (n=11). Destes, 69,2% tinham IG £ 30 semanas e 30,8% IG >30 semanas; no entanto, não houve diferença estatisticamente significativa (p=0,24) quanto à IG; 84,6% dos casos de HPIV tinham PN £ 1.250 g e 15,4% > 1.250 g (p=0,01); 100% dos RN com alteração na USG utilizaram VMI (p=0,006). Observou-se, ainda, a correlação positiva entre o tempo de VMI e o resultado da USG (r=0,63). Conclusão: Encontrou-se prevalência de 27,5% de diagnósticos de HPIV em prematuros moderados e extremos. Esse tipo de lesão esteve associado ao baixo peso ao nascimento e à utilização de VMI. Observou-se que a utilização apenas da ventilação não invasiva (VNI) nesta população pode ter efeito protetor e que, quanto maior o tempo de VMI, maior o risco de ocorrência da lesão.

Acidente vascular cerebral hemorrágico associado à acidente ofídico por serpente do gênero bothrops: relato de caso / Hemorrhagic stroke related to snakebite by bothrops genus: a case report

Este trabalho tem como objetivo relatar um caso de acidente vascular cerebral hemorrágico, associado à acidente ofídico por serpente do gênero bothrops e hipertensão arterial sistêmica grave. Apesar do ofidismo botrópico ser frequente no Estado do Pará, tais associações são incomuns, necessitando de uma abordagem especializada e precoce, visando menores complicações.

This research reports a clinical case of hemorrhagic stroke due to envenomation by bothrops snakebite associated with severe hypertension. Although bothrops snakebites are frequent in the State of Pará, such associations are uncommon, requiring specialized and early management to avoid severe complications.

Valor de la tomografía axial computarizada para el diagnóstico precoz del traumatismo craneoencefálico / Value of the computerized axial tomography for early diagnosis of craniocerebral trauma

Se efectuó un estudio descriptivo y transversal de 62 pacientes con traumatismo craneoencefálico, ingresados en el Hospital Provincial Docente Saturnino Lora de Santiago de Cuba, desde enero de 2005 hasta mayo de 2006, a los cuales se les realizó tomografía axial computarizada, indicada en el cuerpo de guardia, con el fin de evaluar la eficacia de esta técnica radiográfica para el diagnóstico precoz de la lesión. En la casuística no hubo asociación entre la procedencia y los resultados imagenológicos, así como tampoco entre la edad y el sexo. Como principales manifestaciones clínicas sobresalieron: vómitos, cefalea y déficit motor; también predominaron: la localización frontal, el hematoma intraparenquimatoso (este último como hallazgo imagenológico más común) y el área hiperdensa como patrón tomográfico. La supervivencia fue de 91,9 por ciento

A descriptive and cross-sectional study was conducted in 62 patients with craniocerebral trauma admitted to "Saturnino Lora" Provincial Teaching Hospital of Santiago de Cuba, from January 2005 to May 2006, in whom computerized axial tomography indicated at the emergency room was performed with the purpose of evaluating the effectiveness of this radiographic technique for early diagnosis of the injury. In the case material there was neither association between the source and imaging results, nor between the age and sex. The main clinical manifestations were vomiting, headache and motor deficit as well as frontal location, intraparenchymatous hematoma (the latter as the most common image finding) and the hyperdense area as tomographic pattern. The survival was of 91,9 per cent

Protein C and protein S: Causative factor for developing a hemorrhagic infarct in a HbE/Beta thalassemia child.

A 10-yr-old HbE/Beta thalassemia child who developed subacute to chronic occipitotemporal hemorrhagic infarct with smaller chronic infarct with gliotic changes in the left frontal periventricular white matter. Genetic tests showed that patient was positive for HbE and IVS1-5 mutation and was negative for thrombogenic mutations. Hemorrhagic infarct was confirmed by magnetic resonance imaging study. Antigenic levels of Protein C and Protein S were low. Based on these outcomes, it was concluded that Protein C and Protein S deficiency were the causative factor for developing hemorrhagic infarct in the HbE/ Beta thalassemia patient.

Apresentações de localização atípica de hemorragia no cérebro de recém-nascidos: considerações acerca de dois casos / Atypical locations of cerebral hemorrhage in newborns: considerations about two cases

Estudo retrospectivo de dois casos de hemorragia craniana de localização atípica em 777 recém-natos internados na unidade de terapia intensiva neonatal da Casa de Saúde São José, Rio de Janeiro, RJ. Foram avaliados os aspectos clínicos e o diagnóstico por métodos de imagem. Verificamos que a ultrassonografia foi diagnóstica nos dois casos quando comparada com a ressonância magnética. Em relação à etiologia, esta foi multifatorial, e a manifestação clínica silenciosa independente da localização. Até o presente momento, a avaliação neurológica tem tido curso satisfatório, embora os pacientes ainda tenham baixa idade para a avaliação neurológica definitiva.

Retrospective study of two cases of atypically localized cerebral hemorrhage among 777 newborns admitted to the neonatal intensive care unit at Casa de Saúde São José, Rio de Janeiro, RJ, Brazil. Clinical findings and imaging diagnoses were evaluated. The diagnostic effectiveness of ultrasonography was established by correlation with magnetic resonance imaging findings. Multifactorial etiology was observed, besides silent clinical presentation independently from localization. So far the neurological evaluation has satisfactorily progressed although the patients are still too young to allow a definite neurological evaluation.

Determining ICH Score: can we go beyond? / Determinando o ICH Score: podemos ir além?

Spontaneous intracerebral hemorrhage (SICH) still presents a great heterogeneity in its clinical evaluation, demonstrating differences in the enrollment criteria used for the study of intracerebral hemorrhage (ICH) treatment. The aim of the current study was to assess the ICH Score, a simple and reliable scale, determining the 30-day mortality and the one-year functional outcome. Consecutive patients admitted with acute SICH were prospectively included in the study. ICH Scores ranged from 0 to 4, and each increase in the ICH Score was associated with an increase in the 30-day mortality and with a progressive decrease in good functional outcome rates. However, the occurrence of a pyramidal pathway injury was better related to worse functional outcome than the ICH Score. The ICH Score is a good predictor of 30-day mortality and functional outcome, confirming its validity in a different socioeconomic populations. The association of the pyramidal pathway injury as an auxiliary variable provides more accurate information about the prognostic evolution.

A hemorragia intracerebral (AVCH) espontânea ainda apresenta grande heterogeneidade em sua avaliação clínica, evidenciando diferenças nos critérios de inclusão utilizados nos estudos de tratamento da hemorragia intracerebral (ICH). O objetivo do presente estudo foi avaliar o ICH Score, uma escala simples e confiável, determinando a mortalidade em 30 dias e o resultado funcional após um ano. Pacientes consecutivos com AVCH espontâneo foram incluídos prospectivamente no estudo. O ICH Score variou de 0 a 4 e cada aumento no ICH Score esteve associado com um aumento na mortalidade em 30 dias e com uma progressiva diminuição nas taxas de bom resultado funcional. Entretanto, a ocorrência de injúria da via piramidal esteve melhor relacionada com um pior resultado funcional do que o ICH Score. O ICH Score é um bom preditor de mortalidade em 30 dias e resultado funcional, confirmando sua validade em diferentes populações socioeconômicas. A associação da injúria da via piramidal como variável auxiliar fornece informações mais precisas sobre a evolução prognóstica.

Stroke subtypes on imaging in a Jamaican population a hospital-based study: estudio en un hospital / Subtipos de accidente cerebrovascular en la imagen médica en una población Jamaicana

OBJECTIVE: To examine the pattern of stroke subtypes found on Computed Tomography (CT), Magnetic Resonance Imaging (MRI) at the University Hospital of the West Indies (UHWI), Kingston, Jamaica. METHOD: A retrospective review was conducted for all patients diagnosed with stroke and who were subjected to CT or MRI evaluation at UHWI between January 2001 and December 2004. Data were collected for patient age and gender and type of stroke. RESULTS: Four hundred and thirty-three patients were identified and classified as having cerebral infarct, intra-parenchymal haemorrhage or subarachnoid haemorrhage. There were 414 patients who had CT scans and 19 had MRI scans. Within and across genders, over 80% suffered infarcts with no significant statistical difference between male and female patients. Subarachnoid haemorrhage was the least frequent subtype and occurred in younger patients. CONCLUSION: The pattern of stroke subtypes seen in this population was similar to that of Australian and European cohorts of patients but differed from that reported in Asians. Ischaemic infarct was the most frequent stroke subtype followed by intra- parenchymal haemorrhage and subarachnoid haemorrhage. There was no gender predilection for any specific type of stroke.

OBJETIVO: Examinar el patrón de los subtipos de accidente cerebrovascular encontrados en las imágenes de TAC y MRI en el Hospital Universitario de West Indies (HUWI), Kingston, Jamaica. MÉTODO: Se realizó un examen retrospectivo de todos los pacientes con diagnóstico de accidente cerebrovascular, sometidos a evaluación mediante TAC o MRI, entre enero 2001 y diciembre 2004. Los datos fueron recogidos teniendo en cuenta la edad y el género del paciente, así como el tipo de accidente. RESULTADOS: Cuatrocientos treinta y tres (433) pacientes fueron identificados y clasificados como pacientes con un infarto cerebral, hemorragia intraparenquimal o hemorragia subaracnoidea (HSA). Hubo 414 pacientes examinados con TAC y 19 con MRI. Dentro de ellos, ambos géneros incluidos, más del 80% sufrió infartos sin que hubiese diferencias estadísticas significativas entre hombres y mujeres. La hemorragia subaracnoidea fue el tipo menos frecuente, y se produjo en pacientes jóvenes. CONCLUSIÓN: El patrón de subtipos de accidente cerebrovascular en esta población fue similar al de cohortes de pacientes australianos y europeos, pero diferente al reportado para los asiáticos. El infarto isquémico fue el subtipo de accidente cerebrovascular más frecuente, seguido por la hemorragia intraparenquimal y la hemorragia subaracnoidea. No hubo preferencia de géneros en relación con ninguno de los tipos específicos de accidente cerebrovascular.

Acidente vascular cerebral hemorrágico decorrente de ofidismo por bothrops sp: relato de caso / Hemorrhagic stroke due to bothrops sp snakebite: case report

Objetivo: relatar um caso de hemorragia cerebral consequente a ofidismo por serpente Bothrops sp. Relato do caso: mulher de 62 anos vítima de acidente ofídico por serpente do gênero Bothrops, evoluiu com quadro de hemorragias sistêmicas, déficit neurológico focal e rebaixamento do nível de consciência. Tomografia de crânio revelou hematomas cerebrais intraparenquimatosos. Recebeu soroterapia antibotrópica e suporte clínico, apresentando boa recuperação. Considerações Finais: distúrbios hemorrágicos decorrente de ofidismo são causas potenciais de acidente vascular cerebral.

Purpose: to report a case of cerebral hemorrhage resulting from ophidism by Bothrops sp snake. Case report: a 62-year-old woman, victim of snakebite by Bothrops sp, evolved with systemic hemorrhage, focal neurologic deficit and declining level of consciousness. Tomography of the brain revealed cerebral intraparenchymal hematoma. The victim received bothropic antivenom and clinical support, presenting good recovery. Final considerations: bleeding disorders caused by snakebite are potential causes of stroke.