Traumatismo craneal leve y síndrome postconmocional / Mild cranial traumatism and postconcussional syndrome

El traumatismo craneoencefálico (TCE) leve es uno de los trastornos neurológicos más comunes sólo superado por la cefalea migrañosa, sin embargo suele estar infradiagnosticado al no acudir los pacientes a un servicio sanitario. Su causa más frecuente en nuestro país es la caída casual. Si se considera al TCE leve aquél con puntuaciones en la GCS de 13-15, hay que destacar que los pacientes con GCS inicial de 13 presentan claramente peor pronóstico e incluso muerte relacionada directamente con el TCE, por lo que algunos autores consideran que deberían incluirse entre los moderados. El sustrato neuropatológico del TCE leve es la lesión axonal difusa causada en la masa encefálica por fuerzas de cizallamiento por deceleración brusca. La zona de unión sustancia gris-sustancia blanca parece la más susceptible a sufrir lesión. El TCE leve puede ser difícil de evidenciar con las pruebas habituales de tomografía computarizada (TC) y electroencefalografía. La TC es la prueba complementaria a utilizar durante el período agudo, pero una vez superado este período hay otras pruebas más útiles como la resonancia magnética (RM), la RM espectroscópica, la 'magnetic source imaging', que integra los datos anatómicos de la RM con los electrofisiológicos de la magnetoencefalografía, y las imágenes dinámicas de 'single-photon emission tomography' (SPECT) y 'positron emission tomography' (PET). No existe una constelación de síntomas clínicos que permita definir al TCE leve o al síndrome postconmocional, pero la cefalea de múltiples etiologías es el síntoma más prominente seguido del vértigo. El pronóstico del TCE leve es todavía incierto y no todos los que han sufrido un TCE leve van a desarrollar un síndrome postconmocional. En el período agudo casi el 50 por ciento de los pacientes presentan un síndrome postconmocional y a los tres meses de la lesión decrece hasta un tercio. La organicidad de este síndrome cada vez está más documentada en estudios neurorradiológicos, de perfusión cerebral, electrofisiológicos y neuropsicológicos, así como también se han demostrado alteraciones objetivas de las pruebas vestibulares. El tratamiento debe ser individualizado según las quejas específicas del paciente. A nivel del tratamiento neurofarmacológico todavía no se ha descubierto la 'pócima milagrosa' que pueda mejorar al TCE leve, sin embargo las investigaciones recientes parecen prometedoras. (AU)

Tratamiento neurofarmacológico tras un traumatismo craneoencefálico / Neuropharmacological treatment after cranioencephalic traumatism

La manipulación neurofarmacológica representa un área importante para la intervención terapéutica de los pacientes con traumatismo craneoencefálico (TCE). Todavía hay pocos estudios relevantes específicos de la población con TCE y muchas de las estrategias neurofarmacológicas empleadas se han extrapolado de otras poblaciones clínicas con déficit funcionales similares, por lo que el manejo farmacológico ha sido principalmente dirigido a los síntomas, empírico y basado en ensayo-error, en lugar de racional. Los avances en la biología molecular, bioquímica y la neuroimagen funcional se han trasladado en un incremento de fármacos de 'diseño' que debieran ser útiles para crear un acercamiento más 'racional' en el tratamiento del paciente con TCE. Los fármacos más empleados actualmente para tratar los problemas conductuales son anticomiciales, antidepresivos, beta-bloqueantes, benzodiacepinas y neurolépticos. En el tratamiento de los déficits cognitivos se emplean psicoestimulantes, antidepresivos y colinérgicos/nootropos. En el artículo se realiza una revisión exhaustiva de las bases neuroanatómicas y neuroquímicas de los fármacos empleados en el tratamiento del TCE así como una descripción de los mismos. (AU)

Hypertension in traumatic brain injury.

The incidence and natural history of hypertension associated with traumatic brain injury were studied using a cohort of 80 patients discharged from a brain-injury rehabilitation centre. Although a significant incidence (15%) of hypertension is documented in traumatic brain-injured patients, the problem appears transient for most patients. Nonetheless, hypertension after brain injury merits treatment while it is an ongoing process for the anticipated few patients in whom it might persist.

The Quadriplegia Index of Function (QIF): sensitivity and reliability demonstrated in a study of thirty quadriplegic patients.

The Quadriplegia Index of Function (QIF) was originally developed by the authors in 1980 because the popular Barthel Index was deemed too insensitive to document the small but significant functional gains made by quadriplegics (tetraplegics) during medical rehabilitation. The QIF has now been tested on a group of 30 complete quadriplegic patients at admission to and discharge from inpatient medical rehabilitation. Resultant scores were compared to those simultaneously obtained by the Barthel Index and the Kenny Self-Care Evaluation. The QIF was found to be more sensitive (46 per cent improvement as opposed to 30 per cent by the Kenny Self Care Evaluation and 20 per cent by the Barthel Index). The QIF was also tested for reliability. Ratings by three different nurses, working independently, were found to be significantly positively correlated for all sub-scores (p less than .001). We conclude that the QIF provides a useful option in choosing a functional assessment instrument for use with quadriplegic patients.

Hand function in osteoarthritis.

The effect of osteoarthritis (OA) on hand function of 67 institutionalized subjects was evaluated. Osteoarthritis changes were scored using the radiographic criteria of Kellgren and Lawrence. The total number of joints involved and average severity of affected joints were computed and then related to hand functions as measured by: (1) grip strength, and (2) mean times in completing maneuvers of Jebsen's test for hand function. Grip strength was significantly less in those with OA than in those without OA. Performance on the Jebsen maneuvers was less consistent. Compared with published normal values, mean times for the whole sample were longer. However, mean times between those with and without OA were not significantly different. A multiple regression of the effects of average severity rather than number of involved joints that accounts for the greater proportion of variance in the dominant hand. While OA of the hands is positively correlated with reduced function, the resulting disability appears to be relatively benign.

Psychosocial disability in physically restored long-term stroke survivors.

Three parameters of social function-socialization in the home, socialization outside to the home, and hobbies and interests--were analyzed to determine social reintegration of long-term survivors of documented completed stroke, who had already achieved satisfactory levels of physical function as measured by the Kenny self-care evaluation. A significant proportion of survivors manifested social disability, despite complete physical restoration. Much of this disability cannot be accounted for by age, physical impairment or specific neurologic deficits. The distribution of functional disabilities documented suggests that psychosocial factors, as well as organic deficits, are major determinants.

ADL status in stroke: relative merits of three standard indexes.

Independence in activities of daily living (ADL) in 148 Framingham Study stroke survivors was scored using 3 standard indexes--the Katz Index of ADL, the Barthel Index, and the Kenny Self-Care Evaluation. Complete independence was designated in 35.1% by the Barthel Index, 39.2% by the Katz Index of ADL, and 41.9% by the Kenny Self-Care Evaluation. These differences in frequency are not statistically significant. There is also a high degree of agreement between the scores derived by the 3 indexes as measured by the Kappa Coefficient of Agreement ands the Spearman Rang-Order Correlation Coefficient. In general, each index adequately classifies stroke survivors as dependent or independent. Of the 3, the Barthel Index appears to possess certain advantages which include completeness, sensitivity to change, amenability to statistical manipulation, and greater familiarity due to more widespread use.