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

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

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

Noninvasive intracranial pressure monitoring for HIV-associated cryptococcal meningitis

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

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

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

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

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

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

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

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

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

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

Multimodal neuromonitoring in pediatric cardiac anesthesia.

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

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

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

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

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

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

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