Evaluación del valor clínico del reflejo nauseoso en la disfagia orofaríngea neurogénica / Apraisal of the diagnostic value of the gag reflex in patients with neurogenic oropharyngeal dysphagia

RESUMEN Introducción. El reflejo nauseoso es un mecanismo de protección que impide que alimentos y agentes no deseados penetren en la vía aérea inferior. Usualmente, hace parte del examen físico de la deglución para detectar la disfagia orofaríngea, pero es un signo potencialmente ambiguo. Objetivo. Evaluar el valor diagnóstico del reflejo nauseoso en pacientes con disfagia orofaríngea neurogénica y en pacientes sin ella. Materiales y métodos. Se trata de un estudio observacional, analítico, en pacientes con disfagia orofaríngea neurogénica (casos) y en personas sin disfagia (controles), en el cual se evaluó por visualización directa la ausencia o la presencia del reflejo nauseoso de forma bilateral. Este resultado se ajustó por sexo, edad y otras variables de interacción. Resultados. Se evaluaron 86 pacientes con disfagia orofaríngea neurogénica y 80 personas sin ella. En el examen físico de la deglución, la presencia del reflejo mostró una relación positiva con los pacientes (lado derecho: OR = 3,97; IC95%: 2,01-7,84; lado izquierdo: OR = 4,84; IC95%: 2,41-9,72), pero una asociación negativa con los controles. En ambos grupos, ni el sexo ni la edad, ni otras variables de interacción modificaron el reflejo nauseoso. Conclusiones. La ausencia o la presencia del reflejo nauseoso no confirma ni excluye la existencia de una disfagia orofaríngea por causas neurológicas o neuromusculares; por lo tanto, no es recomendable que los profesionales de la salud se fíen del resultado de este reflejo. Los médicos tratantes deben ir más allá de una simple revisión del reflejo nauseoso, incluso en pacientes neurológicos en quienes se supone que debería estar ausente.

ABSTRACT Introduction. The gag reflex is a protection mechanism that prevents food and unwanted agents from entering the lower airways. It is usually part of the physical examination of swallowing to detect oropharyngeal dysphagia, but it is a potentially ambiguous sign. Objective. To evaluate the diagnostic value of the gag reflex in patients with neurogenic oropharyngeal dysphagia and adults without it. Materials and methods. We conducted an analytical observational study in patients with neurogenic oropharyngeal dysphagia (cases) and patients without dysphagia (controls). We evaluated the absence or presence of the reflex bilaterally, by direct visualization, and adjusted it according to sex, age, and other interaction variables. Results. We included 86 patients with neurogenic oropharyngeal dysphagia and 80 control subjects. The gag reflex on swallowing physical examination showed a positive relationship with the patients (right side: OR = 3.97; 95 % CI: 2.01-7.84; left side: OR = 4.84; 95 % CI: 2.41-9.72), but a negative association with the control group. In both groups, neither sex, nor age, nor other interaction variables modified the gag reflex. Conclusions. The gag reflex absence or presence does not confirm or exclude the existence of oropharyngeal dysphagia due to neurological and neuromuscular causes. Therefore, health professionals must not rely on this reflex. Clinicians must go beyond a simple reflex revision, even in neurological patients where it is supposed to be absent.

Síndrome de Balint y trombosis de senos venosos cerebrales: reporte de caso / Balint syndrome and cerebral venous sinus thrombosis: Case report

Introducción: El síndrome de Balint es un trastorno neurológico infrecuente, de etiología diversa, cuya presentación incluye la triada clásica de: simultagnosia, ataxia óptica y apraxia oculomotora, síntomas secundarios asociados a lesiones parieto-occipitales, con pronóstico variable según la etiología que se encuentre. A continuación, se reporta un caso secundario a una trombosis de senos venosos. Presentación del caso: Mujer de 66 años que ingresa a urgencias por cefalea aguda asociada a síntomas neurológicos progresivos con compromiso visual. Presentó tensión arterial elevada, simultagnosia, ataxia óptica y apraxia oculomotora. Los estudios imagenológicos reportaron hemorragia subaracnoidea por trombosis de seno sigmoideo izquierdo, por lo que se inició anticoagulación, antihipertensivo, con adecuada evolución del cuadro clínico. Discusión: A pesar de que el síndrome de Balint es un trastorno poco común, de etiología diversa, con escasos reportes a escala global, el caso comentado concordó con las características descritas en la literatura. El abordaje de la paciente en su atención inicial permitió la sospecha diagnóstica oportuna y la indicación de ayudas diagnósticas imagenológicas pertinentes. Tales ayudas soportaron un manejo temprano y la adecuada evolución y resolución del cuadro, en el contexto de la asociación del síndrome a una trombosis de senos venosos cerebrales (una etiología infrecuente). Conclusión: Mediante una historia clínica completa y minuciosa, junto a un adecuado examen neurológico, es posible hacer un acercamiento diagnóstico temprano que permita generar la sospecha del síndrome de Balint y la solicitud temprana de imágenes diagnósticas que orienten en el estudio de su etiología y manejo oportuno, con mejores desenlaces en el paciente.

Introduction: Balint Syndrome is a rare neurological disorder with multiple etiologies. The physical signs include a classic triad (simultagnosia, optic ataxia, and oculomotor apraxia). These symptoms are associated with parieto-occipital lesions, and the prognosis depends on the etiology. This article reports a case secondary to venous sinus thrombosis. Presentation of the case: A 66-year-old woman presented to the emergency room with acute headache associated with progressive neurological symptoms and visual impairment. She had high blood pressure, simultanagnosia, optic ataxia, and oculomotor apraxia. Imaging studies revealed subarachnoid hemorrhage due to thrombosis of the left sigmoid sinus, for which anticoagulation and antihypertensive therapy were started. The patient had a favorable clinical outcome. Discussion: Although Balint syndrome is a rare disorder of diverse etiology with few clinical cases reported globally, the case discussed here was consistent with the characteristics described in the literature. The patient's initial assessment allowed for timely diagnostic suspicion and appropriate imaging studies, which supported early management and the appropriate evolution and resolution of the condition, given the association of the syndrome with an uncommon cause as cerebral venous sinus thrombosis. Conclusion: A complete and thorough medical history, along with a proper neurological exam, can lead to an early diagnostic approach that raises suspicion of Balint's syndrome and prompts timely imaging studies to guide the investigation of its etiology and management, ultimately leading to better outcomes for the patient.

Reliability of telemedicine evaluation for EDSS functional systems in multiple sclerosis.

Introduction: There was an increase in telemedicine during the COVID-19 pandemic to follow patients with multiple sclerosis (MS). However, there is scarce data if online evaluations can cover important information assessed during in-clinic appointments, especially the Expanded Disability Status Score (EDSS). This study aims to develop a remote evaluation tool for EDSS functional systems and compare the performance with face-to-face evaluations. Methods: This was a single-center study that included all MS patients followed up at outpatient clinics of Hospital São Lucas Pontifícia Universidade Católica do Rio Grande do Sul, between April and August 2022. Initially, patients were routinely in-clinic evaluated by one trained neurologist for EDSS. After, patients were evaluated remotely without any information about the in-clinic EDSS results. We used a standardized interview with an interactive video platform to evaluate EDSS functional systems by telemedicine. Results: Forty-nine participants completed the two steps. Intra-class coefficient was 0.97 (95% CI: 0.95-0.98), concordance for EDSS below 4.0 was 0.87 (95% CI: 0.77-0.93) and ≥4.0 was 0.97 (95% CI: 0.89-0.99). There was perfect agreement in the final EDSS in 71.4% of the online and in-clinic evaluations. In the multivariate analysis, the visual (beta = 0.453; p = 0.003) and pyramidal (beta = 0.403; p = 0.009) systems contributed significantly to the difference in the final EDSS. Conclusion: The telemedicine tool created in this study can detect changes in functional systems with reliable results compared to in-clinic EDSS assessment. Telemedicine evaluations may reduce the number of in-clinic visits and the disease burden for patients with MS.

Feasibility for evaluating motor aspects of Parkinson's disease through video consultations in a resource-limited setting in Southern Brazil / Viabilidade para avaliar os aspectos motores da doença de Parkinson através de consultas por vídeo em um ambiente de recursos limitados no sul do Brasil

Abstract Background Performing motor evaluations using videoconferencing for patients with Parkinson's disease (PD) is safe and feasible. However, the feasibility of these evaluations is not adequately studied in resource-limited settings. Objective To evaluate the feasibility of performing motor evaluations for patients with PD in a resource-limited setting. Methods The examiners rated motor aspects of parkinsonism of 34 patients with PD from the Brazilian public healthcare system through telemedicine with the patient's own means by using the Movement Disorder Society-Sponsored Revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS) rating scale. Quality measures of the video meeting were also obtained. The feasibility of rating the motor aspects was the primary outcome whereas the rating of individual motor aspects, video meeting quality and predictors of a complete evaluation served as secondary outcomes. Results The least assessable parameters were freezing of gait (52.9%), gait (70.6%), leg agility, and rest tremor (both 76.5%). Complete MDS-UPDRS part III was possible in 41.2% of patients and 62 out of 374 motor aspects evaluated (16.6%) were missed. Available physical space for a video evaluation was the worst quality measure. Incomplete evaluations were directly associated with disability (p = 0.048, r = 0.34) and inversely with available physical space (p = 0.003, r = 0.55). Conclusion A significant portion of the MDS-UPDRS part III is unable to be performed during telemedicine-based evaluations in a real-life scenario of a resource-limited setting.

Resumo Antecedentes Realizar avaliações motoras usando videoconferência para pacientes com doença de Parkinson (DP) é seguro e viável. Entretanto, a viabilidade dessas avaliações não é adequadamente estudada em cenários com recursos limitados. Objetivo Identificar a viabilidade de realizar avaliações motoras para pacientes com DP em um ambiente com recursos limitados. Métodos Os examinadores avaliaram os aspectos motores da DP de 34 pacientes do sistema público de saúde brasileiro através da telemedicina com os próprios meios do paciente usando a escala Movement Disorder Society-Sponsored Revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS). Medidas de qualidade da videochamada também foram obtidas. A viabilidade da classificação dos aspectos motores foi o resultado primário, enquanto a classificação dos aspectos motores individuais, a qualidade das videoconferências e os preditores de uma avaliação completa serviram como resultados secundários. Resultados Os parâmetros menos avaliáveis foram congelamento da marcha (52,9%), marcha (70,6%), agilidade dos membros inferiores e tremor de repouso (ambos 76,5%). A parte III completa da MDS-UPDRS foi possível em 41,2% dos pacientes, mas não foi possível avaliar 62 do total de 374 aspectos motores (16,6%). O espaço físico disponível para uma avaliação em vídeo foi a pior medida de qualidade. As avaliações incompletas foram diretamente associadas ao nível de dependência (p = 0,048, r = 0,34) e inversamente ao espaço físico disponível (p = 0,003, r = 0,55). Conclusão Uma porção significativa da parte III da MDS-UPDRS é perdida durante as avaliações baseadas em telemedicina em um cenário da vida real com recursos limitados.

Neurodesarrollo en recién nacidos de muy bajo peso nacidos en Matanzas en el periodo 2016-2018

RESUMEN Fundamento La comparación de los resultados del neurodesarrollo en recién nacidos de muy bajo peso según cohortes de años de nacimiento permite evaluar el impacto de las diferentes intervenciones llevadas a cabo para prevenir y tratar las afecciones más frecuentes en este grupo de pacientes durante el período perinatal y neonatal, así como de las diferentes condiciones y enfermedades que se presentan en estas etapas del desarrollo. Objetivo evaluar el neurodesarrollo a los dos años de edad corregida en una cohorte de recién nacidos de muy bajo peso. Métodos estudio observacional prospectivo, que incluyó a recién nacidos pretérminos con peso al nacer <1500 g egresados vivos del Hospital Docente Ginecobstétrico Provincial de Matanzas, en el período 2016-2018, y que hubieran completado su seguimiento en consulta de neurodesarrollo a los dos años de edad corregida (N=52). Los datos contenidos en las historias clínicas fueron almacenados en una base de datos (SPSS v. 22.0), a partir de la cual se realizó el procesamiento estadístico. Se consideró significativo todo valor p <0,05. Resultados a los dos años de edad corregida, el 90 % de los pacientes eran normales; las alteraciones mayores y menores se encontraron, respectivamente, en 2 y 8 % de los casos. Las convulsiones neonatales clínicas se asociaron significativamente con la ocurrencia de alteraciones del neurodesarrollo. Conclusión La incidencia de alteraciones del neurodesarrollo a los dos años de edad corregida en recién nacidos de muy bajo peso en Matanzas fue menor en el período estudiado, en relación a años anteriores, aunque este hallazgo no resultó estadísticamente significativo.

ABSTRACT Background The comparison of neurodevelopmental results in very low birth weight newborns according to birth year cohorts allows evaluating the impact of the different interventions carried out to prevent and treat the most frequent conditions in this group of patients during the perinatal period and neonatal, as well as the different conditions and diseases that occur in these stages of development. Objective to evaluate neurodevelopment at two years of corrected age in a cohort of very low birth weight newborns. Methods prospective observational study, which included preterm newborns with birth weight <1500 g discharged alive from the Provincial Gynecobstetric Teaching Hospital of Matanzas, in the period 2016-2018, and who had completed their follow-up in a neurodevelopment consultation at two years old corrected age (N=52). The data contained in the medical records were stored in a database (SPSS v. 22.0), from which the statistical processing was performed. Any value p<0.05 was considered significant. Results at two years old of corrected age, 90% of the patients were normal; major and minor alterations were found, respectively, in 2 and 8% of cases. Clinical neonatal seizures were significantly associated with the occurrence of neurodevelopmental abnormalities. Conclusion The incidence of neurodevelopmental disorders at two years old of corrected age in very low birth weight newborns in Matanzas was lower in the period studied, in relation to previous years, although this finding was not statistically significant.

Assessment of Neurological Status in Patients with Cerebrovascular Diseases through the Nursing Outcome Classification: A Methodological Study.

Nurses play an important role in healthcare, and the Nursing Outcomes Classification is a key tool for the standardization of care. This study aims to validate the nursing outcome "Neurological Status" for patients with cerebrovascular diseases. A methodological study was performed in four phases. In Phase 1, the relevance of the indicators was evaluated by seven specialists and the modified kappa coefficient and content validity index were calculated. In Phase 2, conceptual and operational definitions were formulated. In addition, their content was validated with a focus group in Phase 3. In Phase 4, the results were applied in clinical practice and convergence with the National Institute of Health Stroke Scale was verified. The reliability was measured by Cronbach's alpha. Of the 22 initial indicators, 6 were excluded. The focus group suggested changes in the definitions and the exclusion of two indicators. In Phase 4, only 13 indicators were validated due to the impossibility of measuring intracranial pressure. A strong correlation between the two scales and agreement among all the indicators were observed. Following the specialists' review, the nursing outcome was reliable and clinically validated with 13 indicators: consciousness, orientation, language, central motor control, cranial sensory and motor function, spinal sensory and motor function, body temperature, blood pressure, heart rate, eye movement pattern, pupil size, pupil reactivity, and breathing pattern.

Manifestaciones neurológicas de la COVID-19 / Neurological manifestations of COVID-19

Objetivo: Describir la fisiopatología de las manifestaciones neurológicas por infección con COVID-19. Método: Revisión sistemática de 22 articulos relacionados con el objetivo de investigación, procedentes de la base de datos PubMed. Resultados: Dentro de las manifestaciones clínicas del COVID-19 en el SNP, se hallaron en los reportes clínicos, disminución parcial de la capacidad de percibir olores, denominada hiposmia y reducción total de la misma, denominada anosmia, así mismo otros pacientes o en los mismos que reportaron el anterior síntoma, refirieron haber perdido la capacidad para distinguir sabores, así la hipogeusia, y la ageusia también iban de la mano con la hiposmia. Conclusión: Se ha demostrado que el SARS-CoV-2 tiene un tropismo por las células del sistema nervioso, lo cual significaría una afectación al sistema nervioso que demás puede ser afectado por la tormenta de citoquinas, que a su vez pueden desarrollar un daño directo al parénquima neuronal.

Objective: To describe the pathophysiology of neurological manifestations due to infection with COVID-19. Methods: Systematic review of 22 articles related to the research objective, from the PubMed database. Results: Among the clinical manifestations of COVID-19 in the PNS, in the clinical reports, partial reduction of the ability to perceive odors, called hyposmia and total reduction of the same, called anosmia, as well as other patients or in the same patients who reported the previous symptom, reported having lost the ability to distinguish flavors, thus hypogeusia and ageusia also went hand in hand with hyposmia. Conclusion: SARS-CoV-2 has been shown to have a tropism for nervous system cells, which would mean an affectation to the nervous system that can be further affected by the cytokine storm, which in turn can develop direct damage to the neuronal parenchyma.

The general movement checklist: A guide to the assessment of general movements during preterm and term age

Abstract Objectives To develop a checklist describing features of normal and abnormal general movements in order to guide General Movement Assessment novices through the assessment procedure, to provide a quantification of General Movement Assessment; and to demonstrate that normal and abnormal GMs can be distinguished on the basis of a metric checklist score. Methods Three examiners used General Movement Assessment and the newly developed GM checklist to assess 20 videos of 16 infants (seven males) recorded at 31-45 weeks postmenstrual age (writhing general movements). Inter- and intra-scorer agreement was determined for General Movement Assessment (nominal data; Kappa values) and the checklist score (metric scale ranging from 0 to 26; Intraclass Correlation values). The scorers' satisfaction with the usefulness of the checklist was assessed by means of a short questionnaire (score 10 for maximum satisfaction). Results The scorers' satisfaction ranged from 8.44 to 9.14, which indicates high satisfaction. The median checklist score of the nine videos showing normal general movements was significantly higher than that of the eleven videos showing abnormal general movements (26 vs. 11, p < 0.001). The checklist score also differentiated between poor-repertoire (median = 13) and cramped-synchronized general movements (median = 7; p = 0.002). Inter- and intra-scorer agreement on (i) normal vs. abnormal general movements was good to excellent (Kappa = 0.68-1.00); (ii) the distinction between the four general movement categories was considerable to excellent (Kappa = 0.56-0.93); (iii) the checklist was good to excellent (ICC = 0.77-0.96). Conclusion The general movement checklist proved an important tool for the evaluation of normal and abnormal general movements; its score may potentially document individual trajectories and the effect of therapeutic intervention.

Postcardiac Arrest Neuroprognostication Practices: A Survey of Brazilian Physicians.

End-of-life care and decisions on withdrawal of life-sustaining therapies vary across countries, which may affect the feasibility of future multicenter cardiac arrest trials. In Brazil, withdrawal of life-sustaining therapy is reportedly uncommon, allowing the natural history of postcardiac arrest hypoxic-ischemic brain injury to present itself. We aimed to characterize approaches to neuroprognostication of cardiac arrest survivors among physicians in Brazil. DESIGN: Cross-sectional study. SETTING: Between August 2, 2019, and July 31, 2020, we distributed a web-based survey to physicians practicing in Brazil. SUBJECTS: Physicians practicing in Brazil and members of the Brazilian Association of Neurointensive Care, who care for patients resuscitated following cardiac arrest. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: Responses from 185 physicians were obtained. Pupillary reflexes, corneal reflexes, and motor responses were considered critical to prognostication, whereas neuroimaging and electroencephalography were also regarded as important. For patients without targeted temperature management, absent pupillary and corneal reflexes at 24 hours postarrest were considered strongly predictive of poor neurologic outcome by 31.8% and 33.0%, respectively. For targeted temperature management-treated patients, absent pupillary and corneal reflexes at 24-hour postrewarming were considered prognostic by 22.9% and 20.0%, respectively. Physicians felt comfortable making definitive prognostic recommendations at day 6 postarrest or later (34.2%) for nontargeted temperature management-treated patients, and at day 6 postrewarming (20.4%) for targeted temperature management-treated patients. Over 90% believed that improving neuroprognostic accuracy would affect end-of-life decision-making. CONCLUSIONS: There is significant variability in neuroprognostic approaches to postcardiac arrest patients and timing of prognostic studies among Brazilian physicians, with practices frequently deviating from current guidelines, underscoring a need for greater neuroprognostic accuracy. Nearly all physicians believed that improving neuroprognostication will impact end-of-life decision-making. Given the tendency to delay prognostic recommendations while using similar neuroprognostic tools, Brazil offers a unique cohort in which to examine the natural history of hypoxic-ischemic brain injury in future studies.

Neurodevelopmental findings in children 20-30 months of age with postnatal Zika infection at 1-12 months of age, Colombia, September-November 2017.

BACKGROUND: Zika virus (ZIKV) infection during pregnancy can cause infant brain and eye abnormalities and has been associated with adverse neurodevelopmental outcomes in exposed infants. Evidence is limited on ZIKV's effects on children infected postnatally within the first year of life. OBJECTIVE: To determine whether any adverse neurodevelopmental outcomes occurred in early childhood for children infected postnatally with ZIKV during infancy, given the neurotoxicity of ZIKV infection and the rapid brain development that occurs in infancy and early childhood. METHODS: The Colombia Instituto Nacional de Salud (INS) conducted health and developmental screenings between September and November 2017 to evaluate 60 children at ages 20-30 months who had laboratory-confirmed symptomatic postnatal ZIKV infection at ages 1-12 months. We examined the frequency of adverse neurologic, hearing, eye, and developmental outcomes as well as the relationship between age at Zika symptom onset and developmental outcomes. RESULTS: Nine of the 60 (15.0%) children had adverse outcomes on the neurologic, hearing, or eye examination. Six of the 47 (12.8%) children without these adverse findings, and who received a valid developmental screening, had an alert score in the hearing-language domain which signals the need for additional developmental evaluation. CONCLUSION: Neurologic, hearing, eye, and developmental findings suggest reassuring results. Since the full spectrum of neurodevelopmental outcomes in children postnatally infected with ZIKV remains unknown, routine paediatric care is advised to monitor the development of these children to ensure early identification of any adverse neurodevelopmental outcomes.

The general movement checklist: A guide to the assessment of general movements during preterm and term age.

OBJECTIVES: To develop a checklist describing features of normal and abnormal general movements in order to guide General Movement Assessment novices through the assessment procedure, to provide a quantification of General Movement Assessment; and to demonstrate that normal and abnormal GMs can be distinguished on the basis of a metric checklist score. METHODS: Three examiners used General Movement Assessment and the newly developed GM checklist to assess 20 videos of 16 infants (seven males) recorded at 31-45 weeks postmenstrual age (writhing general movements). Inter- and intra-scorer agreement was determined for General Movement Assessment (nominal data; Kappa values) and the checklist score (metric scale ranging from 0 to 26; Intraclass Correlation values). The scorers' satisfaction with the usefulness of the checklist was assessed by means of a short questionnaire (score 10 for maximum satisfaction). RESULTS: The scorers' satisfaction ranged from 8.44 to 9.14, which indicates high satisfaction. The median checklist score of the nine videos showing normal general movements was significantly higher than that of the eleven videos showing abnormal general movements (26 vs. 11, p<0.001). The checklist score also differentiated between poor-repertoire (median=13) and cramped-synchronized general movements (median=7; p=0.002). Inter- and intra-scorer agreement on (i) normal vs. abnormal general movements was good to excellent (Kappa=0.68-1.00); (ii) the distinction between the four general movement categories was considerable to excellent (Kappa=0.56-0.93); (iii) the checklist was good to excellent (ICC=0.77-0.96). CONCLUSION: The general movement checklist proved an important tool for the evaluation of normal and abnormal general movements; its score may potentially document individual trajectories and the effect of therapeutic intervention.

Clinical and molecular correlates of the ASPECTS in the acute phase of stroke / Correlação clínica e molecular com a ASPECTS na fase aguda do acidente vascular cerebral

ABSTRACT Background: The Alberta Stroke Program Early CT Score (ASPECTS) scale was developed for monitoring early ischemic changes on CT, being associated with clinical outcomes. The ASPECTS can also associate with peripheral biomarkers that reflect the pathophysiological response of the brain to the ischemic stroke. Objective: To investigate the association between peripheral biomarkers with the Alberta Stroke Program Early CT Score (ASPECTS) in individuals after ischemic stroke. Methods: Patients over 18 years old with acute ischemic stroke were enrolled in this study. No patient was eligible for thrombolysis. The patients were submitted to non-contrast CT in the first 24 hours of admission, being the Alberta Stroke Program Early CT Score and clinical and molecular evaluations applied on the same day. The National Institutes of Health Stroke Scale (NIHSS), modified Rankin scale and the Mini-Mental State Examination for clinical evaluation were also applied to all subjects. Plasma levels of BDNF, VCAM-1, VEGF, IL-1β, sTNFRs and adiponectin were determined by ELISA. Results: Worse neurological impairment (NIHSS), cognitive (MEEM) and functional (Rankin) performance was observed in the group with changes in the NCTT. Patients with NCTT changes also exhibited higher levels of IL-1β and adiponectin. In the linear multivariate regression, an adjusted R coefficient of 0.515 was found, indicating adiponectin and NIHSS as independent predictors of ASPECTS. Conclusion: Plasma levels of adiponectin are associated with the ASPECTS scores.

RESUMO Introdução: A Alberta Stroke Early Score (ASPECTS) foi desenvolvida para monitorização de alterações isquêmicas precoces na tomografia computadorizada de crânio, estando associada a desfechos clínicos. A ASPECTS também pode se associar aos biomarcadores periféricos que refletem a resposta fisiopatológica do cérebro ao AVC isquêmico. Objetivo: Investigar à associação entre os parâmetros periféricos com a Alberta Stroke Early Score (ASPECTS) em indivíduos após acidente vascular cerebral isquêmico. Métodos: Pacientes acima de 18 anos com AVC isquêmico agudo foram incluídos neste estudo. Nenhum paciente foi elegível para trombólise. Os pacientes foram submetidos à tomografia computadorizada sem contraste nas primeiras 24 horas da admissão, a ASPECTS e as avaliações clínicas e moleculares aplicadas no mesmo dia. O National Institutes of Health Stroke Scale (NIHSS), a escala de Rankin modificada e o Mini Exame do Estado Mental para avaliação clínica também foram aplicados a todos os indivíduos. Os níveis plasmáticos de BDNF, VCAM-1, VEGF, IL-1β, sTNFRs e adiponectina foram determinados por ELISA. Resultados: Pior desempenho neurológico (NIHSS), cognitivo (MEEM) e funcional (Rankin) foram observados no grupo com alterações na ASPECTS. Pacientes com alterações na ASPECTS também exibiram níveis mais altos de IL-1β e adiponectina. Na regressão multivariada linear, foi encontrado um coeficiente R ajustado de 0,515, indicando adiponectina e NIHSS como preditores independentes para a ASPECTS. Conclusão: Os níveis plasmáticos de adiponectina estão associados aos escores da ASPECTS.

Predictive value of the general movements assessment in preterm infants: a meta-analysis / Valor preditivo da general movements assessment na avaliação neurológica de recém-nascidos pré-termo: uma metanálise

ABSTRACT Objective: To discuss the predictive value of the General Movements Assessment for the diagnosis of neurodevelopment disorders in preterm newborns. Data source: We conducted a systematic literature review using the following databases: Scientific Electronic Library Online (SciELO), National Library of Medicine, National Institutes of Health (PubMed), and Excerpta Medica Database (EMBASE). The articles were filtered by language, year of publication, population of interest, use of Prechtl's Method on the Qualitative Assessment of General Movements, and presence of variables related to the predictive value. The Quality Assessment of Diagnostic Accuracy Studies 2 was used to assess the methodology of the included studies. Sensitivity, specificity, Diagnostic Odds Ratio, positive and negative likelihood ratio, and parameter of accuracy were calculated. Data synthesis: Six of 342 articles were included. The evaluation of Writhing Movements is a good indicator for recognizing cerebral palsy, as it has high values for the sensitivity and accuracy parameters. The evaluation of Fidgety Movements has the strongest predictive validity for cerebral palsy, as it has high values in all measures of diagnostic accuracy. The quality assessment shows high risk of bias for patient selection and flow and timing of the evaluation. Therefore, the scale has potential to detect individuals with neurodevelopment disorders. However, the studies presented limitations regarding the selection of subjects and the assessment of neurological outcomes. Conclusions: Despite the high predictive values of the tool to identify neurological disorders, research on the subject is required due to the heterogeneity of the current studies.

RESUMO Objetivo: Analisar o valor preditivo da General Movements Assessment para o diagnóstico de alterações do neurodesenvolvimento em recém-nascidos pré-termo. Fonte de dados: Foi realizada uma revisão sistemática da literatura utilizando as bases de dados: Scientific Electronic Library Online (SciELO), National Library of Medicine, National Institutes of Health (PubMed) e Excerpta Medica Database (EMBASE). Os artigos foram filtrados por idioma, ano de publicação, população de interesse, utilização do Método Prechtl de avaliação e presença das variáveis relacionadas ao valor preditivo da escala. O Quality Assessment of Diagnostic Accuracy Studies 2 foi utilizado para avaliar a metodologia dos artigos. Foi realizado o cálculo de sensibilidade, especificidade, Diagnostic Odds Ratio, razão de verossimilhanças positiva e negativa e parâmetro de acurácia. Síntese dos dados: Foram incluídos seis artigos dentre os 342 encontrados. A escala, quando realizada no período Writhing Movements, possui bom poder discriminativo para o desfecho paralisia cerebral, com valores elevados de sensibilidade e acurácia. Quando realizada no período Fidgety Movements, possui maior valor preditivo para paralisia cerebral, com valores elevados em todas as medidas de acurácia diagnóstica. O risco de viés foi considerado elevado na seleção de pacientes e no fluxo e momento da avaliação. Desse modo, a escala tem potencial para detectar indivíduos que evoluíram com alterações do neurodesenvolvimento, porém, os artigos apresentaram limitações quanto à seleção dos sujeitos e à forma de avaliação do desfecho neurológico. Conclusões: Apesar dos altos valores preditivos descritos para identificação de alterações neurológicas, novas pesquisas são necessárias, devido à heterogeneidade dos estudos e ao método de avaliação a longo prazo do neurodesenvolvimento.

Preterm infants with peri/intraventricular hemorrhage have poorer habituation responses to external stimuli / Neonatos prematuros com hemorragia peri-intraventricular apresentam respostas de habituação piores a estímulos externos

ABSTRACT Objective: To evaluate the association between intra-ventricular hemorrhage and habituation responses to external stimuli in preterm infants at 36-38 weeks post-conceptual age. Methods: Cross-sectional study of infants with gestational age <32 weeks. Intra-ventricular hemorrhage was identified by cranial ultrasonography and classified according to Papile et al. (1978). The luminous (flashlight), sound (rattle, bell), and tactile stimuli were presented, and the responses were scored according to Lester and Tronik (2004). Habituation response scores were compared between groups by Student's t-test. The association between IVH and habituation scores was evaluated by linear regression adjusted for GA, clinical severity score, post-conceptual age at habituation assessment, sepsis, and bronchopulmonary dysplasia. Results: Sixty-five infants were studied, 20 with intra-ventricular hemorrhage (16 grades I/II; four grades III/IV) and 45 without intra-ventricular hemorrhage. Infants with intra-ventricular hemorrhage had lower gestational age (28.2 ± 2.2 vs. 29.7 ± 1.7 weeks) and birth weight (990 ± 305 vs. 1275 ± 360 g). Infants with intra-ventricular hemorrhage at 36-38 weeks post-conceptual age had lower habituation scores to light (4.21 ± 2.23 vs. 6.09 ± 2.44), rattle (3.84 ± 2.12 vs. 6.18 ± 2.27), and bell (3.58 ± 1.74 vs. 5.20 ± 2.47) after controlling for confounders. No differences were found for tactile stimulus. Conclusion: Infants with gestational age <32 weeks and intra-ventricular hemorrhage had poorer habituation responses to external stimuli than those without intra-ventricular hemorrhage at 36-38 weeks post-conceptual age.

RESUMO Objetivo: Avaliar a associação entre hemorragia intraventricular e as respostas de habituação a estímulos externos em neonatos prematuros com idade pós-conceptual de 36-38 semanas. Métodos: Estudo transversal com neonatos com idade gestacional < 32 semanas. A hemorragia intraventricular foi identificada por ultrassonografia craniana e classificada de acordo com Papile et al. (1978). Os estímulos luminosos (lanterna), sonoros (chocalho, sino) e táteis foram apresentados e as respostas foram pontuadas de acordo com Lester & Tronik (2004). Os escores das respostas de habituação foram comparadas entre os grupos pelo teste t de Student. A associação entre a hemorragia intraventricular e os escores de habituação foi avaliada por regressão linear ajustada para a idade gestacional, escore de gravidade clínica, idade pós-conceptual na avaliação da habituação, sepse e displasia broncopulmonar. Resultados: 65 neonatos foram estudados, 20 com hemorragia intraventricular (16 graus I/II;4 graus III/IV) e 45 sem hemorragia intraventricular. Os neonatos com hemorragia intraventricular apresentaram menor idade gestacional (28,2 ± 2,2 vs. 29,7 ± 1,7 semanas) e peso ao nascer (990 ± 305 vs. 1275 ± 360 g). Os neonatos com hemorragia intraventricular na idade pós-conceptual de 36-38 semanas apresentaram escores de habituação menores a luz (4,21 ± 2,23 vs. 6,09 ± 2,44), chocalho (3,84 ± 2,12 vs. 6,18 ± 2,27) e campainha (3,58 ± 1,74 vs. 5,20 ± 2,47) após controle para variáveis de confusão. Nenhuma diferença foi encontrada para os estímulos táteis. Conclusão: Neonatos com idade gestacional < 32 semanas e hemorragia intraventricular apresentaram respostas de habituação piores a estímulos externos que os sem hemorragia intraventricular, na idade pós-conceptual de 36-38 semanas.

Neurological signs described at the Federal University of Rio de Janeiro: connecting the past to the future / Sinais neurológicos descritos na Universidade Federal do Rio de Janeiro: conectando o passado ao futuro

ABSTRACT The Federal University of Rio de Janeiro (UFRJ) is one of the pillars of Brazilian Medicine and, in Neurology, has always shown prominence, with notable professors such as Antônio Austregésilo and Deolindo Couto. Historically, practitioners of the UFRJ Medical School have discovered neurological signs that, although used in medical and academic practice, have never been published. Objective Our aim was to bring these signs to the forefront so that they become properly recognized and studied. Methods We conducted our search by questioning 49 professors and physicians by e-mail about neurological signs that they remembered having had contact with at UFRJ. Results We report on the unpublished pillow sign in progressive supranuclear palsy; the Brazilian sandal sign in functional or malingering patients; the dermographism sign in acute meningitis; the reverse forearm rolling sign in functional palsies; the cycling maneuver in parkinsonian syndromes and the Sá Cavalcanti sign, a Babinski equivalent. We have also recollected the following published signs for their historical relevance: the Austregésilo sign (Antônio Austregésilo), another Babinski equivalent; the digiti quinti rolling sign in subtle palsies (Péricles Maranhão) and the digiti quinti sign in hemiplegic migraine (Maurice Vincent). These signs are easily reproduced and have potential clinical applicability, deserving to be more thoroughly studied. Conclusions Through a qualitative methodology, we have identified six original unpublished neurological signs known by the academic community, establishing the contribution of these individuals to the expansion of neurological semiology.

RESUMO A Universidade Federal do Rio de Janeiro é um dos pilares da Medicina brasileira. Na Neurologia sempre se destacou com notáveis professores, como Antônio Austregésilo e Deolindo Couto. Historicamente, professores da Faculdade de Medicina da UFRJ descreveram sinais neurológicos que, embora utilizados na prática médica e acadêmica, nunca foram publicados. Objetivo Fazer ressurgir sinais clínicos neurológicos nunca antes publicados, para que possam ser devidamente reconhecidos e estudados. Métodos Quarenta e nove professores e médicos foram contactados por e-mail. Dez responderam questionário semi-estruturado acerca de sinais neurológicos conhecidos pelos profissionais, porém nunca publicados. Resultados Foram relatados: 1- Sinal do Travesseiro - na Paralisia Supranuclear Progressiva; 2- Sinal da sandália- nos pacientes funcionais ou simuladores; 3- Sinal do dermografismo- nas meningites agudas da infância; 4- Sinal do rolamento reverso do antebraço- nas paralisias funcionais; 5- Manobra do pedalar- nas síndromes parkinsonianas; 6- Sinal de Sá Cavalcanti- um sucedâneo de Babinski. Revisamos também os seguintes sinais publicados, por sua relevância histórica: o sinal Austregésilo, outro sucedâneo de Babinski; sinal do rolamento do quinto dedo- nas paralisias sutis e o sinal do quinto dedo- na enxaqueca hemiplégia. Conclusão Por meio de metodologia qualitativa, identificamos seis sinais neurológicos inéditos originais. Esses sinais são de fácil reprodutibilidade e têm aplicabilidade clínica potencial, merecendo estudos adicionais.

Risk Factors for Acute Ischemic Stroke Caused by Anterior Large Vessel Occlusion.

Background and Purpose- Accurate prediction of acute ischemic stroke (AIS) caused by anterior large vessel occlusion (LVO) that is amendable to mechanical thrombectomy remains a challenge. We developed and validated a prediction model for anterior circulation LVO stroke using past medical history elements present on admission and neurological examination. Methods- We retrospectively reviewed AIS patients admitted between 2009 and 2017 to 3 hospitals within a large healthcare system in the United States. Patients with occlusions of the internal carotid artery or M1 or M2 segments of the middle cerebral artery were randomly split into 2/3 derivation and 1/3 validation cohorts for development of an anterior circulation LVO prediction model and score that was further curtailed for potential use in the prehospital setting. Results- A total of 1654 AIS were reviewed, including 248 (15%) with proximal anterior circulation LVO AIS. In the derivation cohort, National Institutes of Health Stroke Scale score at the time of cerebrovascular imaging, current smoking status, type 2 diabetes mellitus, extracranial carotid, and intracranial atherosclerotic stenosis was significantly associated with anterior circulation LVO stroke. The prehospital score was curtailed to National Institutes of Health Stroke Scale score, current smoking status, and type 2 diabetes mellitus. The areas under the curve for the prediction model, prehospital score, and National Institutes of Health Stroke Scale score alone were 0.796, 0.757, and 0.725 for the derivation cohort and 0.770, 0.689, and 0.665 for the validation cohort, respectively. The Youden index J was 0.46 for a score of >6 with 84.7% sensitivity and 62.0% specificity for the prediction model. Conclusions- Previously reported LVO stroke prediction scores focus solely on elements of the neurological examination. In addition to stroke severity, smoking, diabetes mellitus, extracranial carotid, and intracranial atherosclerotic stenosis were associated with anterior circulation LVO AIS. Although atherosclerotic stenosis may not be known until imaging is obtained, smoking and diabetes mellitus history can be readily obtained in the field and represent important elements of the prehospital score supplementing National Institutes of Health Stroke Scale score.

Desarrollo motor de una cohorte retrospectiva de niños colombianos de hasta un año de edad corregida, según la escala motora infantil de Alberta / Corrected motor development in a retrospective cohort of Colombian children of up to one year of age according to the Alberta Infant Motor Scale / Desenvolvimento motor de uma coorte retrospectiva de crianças colombianas até um ano de idade corrigida, de acordo com a Alberta Children's Motor Scale

RESUMEN Objetivos La escala motora infantil de Alberta (escala de Alberta en el texto) es utilizada a nivel mundial para evaluar el desarrollo motor en niños menores de 18 meses tanto pretermino como a término. En Colombia la herramienta es utilizada, pero hay poca información sobre los resultados que arroja. El objetivo del estudio fue caracterizar a una cohorte retrospectiva de niños menores de un año según la escala de Alberta para generar información sobre los resultados de la aplicación de esta en población colombiana atendida en un hospital de cuarto nivel. Métodos Estudio descriptivo, retrospectivo, transversal, donde se evaluaron las historias clínicas de 411 niños con edad corregida entre 0 y 12 meses de edad y antecedentes de edad gestacional de menos de 40 semanas, a todos los niños se les aplico la escala de Alberta entre 2010 y 2016 y los puntajes según esta se analizaron estadísticamente en forma descriptiva. Resultados La mayoría de los pacientes fueron clasificados por la escala como "desarrollo normal" como se esperaría por sus antecedentes, los niños de nuestra muestra presentan puntajes inferiores a los de la muestra original de Canadá en todas las edades. Conclusiones La escala se mostró útil en el tamizaje del niño normal, sin embargo, los pacientes presentaron menores puntajes al ser evaluados por la escala que en el estudio original, se genera evidencia sobre la necesidad de validar la escala en Colombia y generar curvas de referencia para esta.(AU)

ABSTRACT Objectives The Alberta Infant Motor Scale is used worldwide to assess motor development in children under 18 months of age, both preterm and full-term. In Colombia, the scale is used, but there is little information on the results it yields. The objective of this study was to characterize a retrospective cohort of children under one year of age according to the Alberta scale to generate information about the results of its application in a Colombian population treated at a highly specialized hospital. Methods Descriptive, retrospective, cross-sectional study, in which the medical records of 411 children with corrected age between 0 and 12 months and a history of gestational age less than 40 weeks were evaluated. The Alberta scale was applied to all children between 2010 and 2016, and scores were analyzed statistically in a descriptive form. Results Most patients were classified by the scale as "normal development" as would be expected based on their medical history. The children in our sample had lower scores than those of the original Canadian sample at all ages. Conclusions The scale was useful for screening normal children; however, the patients had lower scores when they were evaluated by the scale than in the original study, thus making evident the need to validate the scale in Colombia and generate reference curves.(AU)

RESUMO: Objetivos A Escala Motora Infantil de Alberta (escala Alberta no texto) é usada globalmente para avaliar o desenvolvimento motor em crianças menores de 18 meses, pré-termo e termo. Na Colômbia, a ferramenta é usada, mas há pouca informação sobre os resultados mostrados. O objetivo do estudo foi caracterizar uma coorte retrospectiva de crianças menores de um ano, de acordo com a escala de Alberta, para gerar informações sobre os resultados de sua aplicação na população colombiana atendida em um hospital de quarto nível. Métodos Estudo descritivo, retrospectivo, transversal, onde foram avaliados os prontuários de 411 crianças com idade corrigida entre 0 e 12 meses e histórico de idade gestacional inferior a 40 semanas, a escala de Alberta foi aplicada a todas as crianças entre 2010 e 2016 e as pontuações correspondentes foram analisadas estatisticamente de forma descritiva. Resultados A maioria dos pacientes foi classificada pela escala como "desenvolvimento normal", como seria de esperar em sua história; as crianças de nossa amostra tiveram escores mais baixos do que a amostra canadense original em todas as idades. Conclusões A escala foi útil na triagem da criança normal; no entanto, os pacientes tiveram escores mais baixos quando avaliados pela escala do que no estudo original; foram geradas evidências sobre a necessidade de validar a escala na Colômbia e gerar curvas de referência.(AU)

Clinical, Neuroimaging, and Neurophysiological Findings in Children with Microcephaly Related to Congenital Zika Virus Infection.

Zika virus (ZIKV) infection appeared in Brazil in 2015, causing an epidemic outbreak with increased rates of microcephaly and other serious birth disorders. We reviewed 102 cases of children who were diagnosed with microcephaly at birth and who had gestational exposure to ZIKV during the outbreak. We describe the clinical, neuroimaging, and neurophysiological findings. Most mothers (81%) reported symptoms of ZIKV infection, especially cutaneous rash, during the first trimester of pregnancy. The microcephaly was severe in 54.9% of the cases. All infants presented with brain malformations. The most frequent neuroimaging findings were cerebral atrophy (92.1%), ventriculomegaly (92.1%), malformation of cortical development (85.1%), and cortical⁻subcortical calcifications (80.2%). Abnormalities in neurological exams were found in 97.0% of the cases, epileptogenic activity in 56.3%, and arthrogryposis in 10.8% of the infants. The sensorineural screening suggested hearing loss in 17.3% and visual impairment in 14.1% of the infants. This group of infants who presented with microcephaly and whose mothers were exposed to ZIKV early during pregnancy showed clinical and radiological criteria for congenital ZIKV infection. A high frequency of brain abnormalities and signs of early neurological disorders were found, and epileptogenic activity and signs of sensorineural alterations were common. This suggests that microcephaly can be associated with a worst spectrum of neurological manifestations.

Preterm infants with peri/intraventricular hemorrhage have poorer habituation responses to external stimuli.

OBJECTIVE: To evaluate the association between intra-ventricular hemorrhage and habituation responses to external stimuli in preterm infants at 36-38 weeks post-conceptual age. METHODS: Cross-sectional study of infants with gestational age <32 weeks. Intra-ventricular hemorrhage was identified by cranial ultrasonography and classified according to Papile et al. (1978). The luminous (flashlight), sound (rattle, bell), and tactile stimuli were presented, and the responses were scored according to Lester and Tronik (2004). Habituation response scores were compared between groups by Student's t-test. The association between IVH and habituation scores was evaluated by linear regression adjusted for GA, clinical severity score, post-conceptual age at habituation assessment, sepsis, and bronchopulmonary dysplasia. RESULTS: Sixty-five infants were studied, 20 with intra-ventricular hemorrhage (16 grades I/II; four grades III/IV) and 45 without intra-ventricular hemorrhage. Infants with intra-ventricular hemorrhage had lower gestational age (28.2±2.2 vs. 29.7±1.7 weeks) and birth weight (990±305 vs. 1275±360g). Infants with intra-ventricular hemorrhage at 36-38 weeks post-conceptual age had lower habituation scores to light (4.21±2.23 vs. 6.09±2.44), rattle (3.84±2.12 vs. 6.18±2.27), and bell (3.58±1.74 vs. 5.20±2.47) after controlling for confounders. No differences were found for tactile stimulus. CONCLUSION: Infants with gestational age <32 weeks and intra-ventricular hemorrhage had poorer habituation responses to external stimuli than those without intra-ventricular hemorrhage at 36-38 weeks post-conceptual age.

Triagem neurológica de recém-nascidos pré-termo com hemorragias peri e intraventriculares: estudo transversal observacional / Neurological screening of preterm infants with peri- and intra-ventricular hemorrhage: observation transversal study

INTRODUÇÃO: Recém-nascidos pré-termo (RNPT) com menos de 27 semanas de idade gestacional apresentam vulnerabilidade para o desenvolvimento de hemorragias peri e intraventriculares (HPIV), o que pode afetar a mielinização e organização do córtex cerebral, acarretando possíveis prejuízos ao desenvolvimento. OBJETIVO: Avaliar o comportamento neurológico de RNPT acometido por HPIV com e sem sepse segundo a versão resumida do Método Dubowitz, delimitar a presença de itens desviantes da avaliação e comparar com as respostas obtidas pelo grupo controle (sem HPIV). MÉTODOS: Estudo transversal realizado no Hospital Municipal Universitário de São Bernardo do Campo (SP). Os RNPT foram divididos em três grupos, sendo dois estudos (HPIV e HPIV + sepse) e um controle. Os participantes foram avaliados com idade correspondente ao termo. A versão resumida do método, utilizada como triagem para recém-nascidos de risco neurológico é constituída por 12 itens. As análises foram realizadas segundo pontuações desviantes nestes itens e comparadas com as pontuações esperadas para a normalidade. Os dados obtidos foram comparados na pontuação resumida e na pontuação da versão íntegra. RESULTADOS: A frequência de RNPT com pontuações atípicas foram: 40% no grupo HPIV + sepse, 10% no grupo HPIV e 15% no controle. CONCLUSÃO: A HPIV de forma isolada não parece ser um fator significante para presença de itens desviantes no Método Dubowitz resumido. A presença de HPIV em graus mais severos esteve associada à presença de sepse. Os RNPT com HPIV associada à sepse obtiveram pior desempenho neurológico.

INTRODUCTION: Preterm infants with less than 27 weeks of gestacional age present vulnerability for development of periand intraventricular hemorrhage (PIVH). This can affect the myelinization and organization of cerebral cortex, leading to possible developmental impairment. OBJECTIVE: To evaluate the neurological behavior of preterm infants affected by PIVH with and without sepsis according to the Dubowitz Method summary, to delimit the presence of deviant items of the evaluation and to compare with the results of the control group (without PIVH). METHODS: This is a cross-sectional study. The preterm infants were divided in three groups, two study groups (PIVH and PIVH + sepsis), and one control group. The summary version of the Dubowitz Method was used as a neurological screening for the risk in preterm infants. The analysis was performed according to scores with deviation in these items and compared to the expected normal score. Data obtained were compared using the summary score and the full version of the test. RESULTS: The frequency of abnormal scores was: 40% in the group with PIVH + sepsis, 10% in the group only with PIVH, 15% in the control group. CONCLUSION: The PIVH does not seem to be a significant factor for the presence of items with deviation in the summary version of Dubowitz Method. The presence of PIVH in more severe stages was associated with the presence of sepsis. The preterm infants with PIVH with sepsis obtained worse neurological performance in the test.