Actualización en el manejo de la hipertensión intracraneal tras un traumatismo craneoencefálico / Update in management of intracraneial hypertensión after traumatic brain injury

El traumatismo craneoencefálico es una entidad heterogénea y dinámica cuya característica común, cualquiera que sea su etiología, es la disminución de la perfusión cerebral en las horas siguientes al impacto. Dado que las lesiones cerebrales por hipoxia,pueden producirse en momentos variables tras el traumatismo, la monitorización de la hipoxia, la disfunción metabólica, la hipertensión intracraneal y la actividad comicial deben detectarse de forma precoz para evitar secuelas. La neuromonitorización va a permitir detectar esas posibles anomalías que pueda comprometer el adecuado aporte de oxígeno y sustrato metabólico a las células cerebrales. A pesar de que, en los últimos años, se han incrementado las herramientas de medición de oximetría cerebral, en nuestro país su uso sigue siendo todavía muy limitado y la monitorización se basa, fundamentalmente, en la observación de la presión intracraneal y la presión de perfusión cerebral, insuficiente para garantizar una adecuada oxigenación cerebral. El objetivo de esta revisión pretende integrar la fisiopatología del traumatismo craneoencefálico con las distintas técnicas de neuromonitorización, proporcionando así un manejo actualizado y más individualizado que mejore el pronóstico del enfermo neurocrítico. (AU)

Trauma brain injury is a heterogeneous and dynamic entity characterized, whatever its etiology, by a decrease in cerebral perfusion the first hours after the impact. Brain injury due to hypoxia can occur after trauma, so monitoring brain hypoxia, metabolic dysfunction, intracranial hypertension and seizure activity must be detected early to prevent brain sequelae. Neuromonitoring will detect those anomalies that could compromise the adequate oxygen supply and substrates of cerebral metabolism. Despite cerebral oximetry monitoring has increased in recent years, unfortunately very limited in our country, neuromonitoring is often based on intracranial pressure and cerebral perfusion pressure, insufficient to measure cerebral oxygenation. The objective of this review is to integrate the pathophysiology of trauma brain injury with the different neuromonitoring techniques to provide an updated and more individualized management that improves the prognosis of neurocritical patients. (AU)

[Von Willebrand factor, endothelial lesion, and ischemic heart disease]. / Factor de von Willebrand, lesión endotelial y cardiopatía isquémica.

OBJECTIVE: To analyze if the levels of von Willebrand factor (FvW) are higher in patients with ischemic heart disease than in healthy subjects and evaluate the relationship of these levels with clinical recurrence and coronary interventionism. DESIGN: Observational prospective study. PATIENTS: We analyzed the levels of FvW in 75 patients with ischemic heart disease who underwent coronary interventionism (Group I) and compared them with those of 30 healthy subjects with no cardiovascular risk factors and who, theoretically, had no coronary injuries (Group II). MAIN VARIABLES: Levels of FvW before coronary interventionism (sample 0), 24 hours after (sample 1), and at three months of out-patient follow-up (sample 2). A single measurement was made of the FvW levels in Group II. RESULTS: Subjects with ischemic heart disease had higher levels of FvW than healthy subjects (162+/-74% versus 95+/-33%; p=0.0001). FvW levels were significantly increased after coronary interventionism (162.4+/-74.9% in sample 0 versus 213+/-90% in sample 1; p=0.0001). Patients with clinical symptoms at three months have no significant difference regarding those with no symptoms in the FvW levels (125+/-63% versus 133+/-60%; p=0.57). CONCLUSIONS: FvW levels reflect an endothelial alteration in patients with ischemic heart disease. The increase of the levels after coronary interventionism could be due to the endothelial aggression itself of the intervention. It was not possible to demonstrate higher levels of FvW in patients with symptoms in the three month follow-up.

Factor de von Willebrand, lesión endotelial y cardiopatía isquémica / Von Willebrand factor, endothelial lesion, and ischemic heart disease

Objetivo. Analizar si los niveles de factor de von Willebrand (FvW) son más elevados en pacientes con cardiopatía isquémica que en individuos sanos, y evaluar la relación de dichos niveles con la recidiva clínica de angina y el intervencionismo coronario. Diseño. Estudio prospectivo observacional. Pacientes. Analizamos los niveles de FvW en 75 pacientes con cardiopatía isquémica sometidos a intervencionismo coronario (Grupo I), y los comparamos con los de 30 individuos sanos, sin factores de riesgo cardiovascular, y libres teóricamente de lesiones coronarias (Grupo II). Variables principales. Niveles de FvW antes de la realización del intervencionismo coronario (toma 0), a las 24 horas (toma 1) y a los tres meses durante el seguimiento ambulatorio (toma 2). En el Grupo II se efectuó una única determinación de los niveles de FvW. Resultados. Los sujetos con cardiopatía isquémica tuvieron unos niveles más elevados de FvW que los sujetos sanos (162 ± 74% frente a 95 ± 33%; p = 0,0001). Los niveles de FvW aumentaron de manera significativa tras el intervencionismo coronario (162,4 ± 74,9% en la toma 0 frente a 213 ± 90% en la toma 1; p = 0,0001). Los pacientes sintomáticos a los tres meses no presentaron diferencias significativas respecto a los asintomáticos en los niveles de FvW (125 ± 63% frente a 133 ± 60%; p = 0,57). Conclusiones. Los niveles de FvW reflejan una alteración endotelial en pacientes con cardiopatía isquémica. El aumento de los niveles tras el intervencionismo coronario podría ser debido a la propia agresión endotelial del intervencionismo. No se demuestran mayores niveles de FvW en pacientes sintomáticos en el seguimiento a tres meses

Objective. To analyze if the levels of von Willebrand factor (FvW) are higher in patients with ischemic heart disease than in healthy subjects and evaluate the relationship of these levels with clinical recurrence and coronary interventionism. Design. Observational prospective study. Patients. We analyzed the levels of FvW in 75 patients with ischemic heart disease who underwent coronary interventionism (Group I) and compared them with those of 30 healthy subjects with no cardiovascular risk factors and who, theoretically, had no coronary injuries (Group II). Main variables. Levels of FvW before coronary interventionism (sample 0), 24 hours after (sample 1), and at three months of out-patient follow-up (sample 2). A single measurement was made of the FvW levels in Group II. Results. Subjects with ischemic heart disease had higher levels of FvW than healthy subjects (162 ± 74% versus 95 ± 33%; p = 0.0001). FvW levels were significantly increased after coronary interventionism (162.4 ± 74.9% in sample 0 versus 213 ± 90% in sample 1; p = 0.0001). Patients with clinical symptoms at three months have no significant difference regarding those with no symptoms in the FvW levels (125 ± 63% versus 133 ± 60%; p = 0.57). Conclusions. FvW levels reflect an endothelial alteration in patients with ischemic heart disease. The increase of the levels after coronary interventionism could be due to the endothelial aggression itself of the intervention. It was not possible to demonstrate higher levels of FvW in patients with symptoms in the three month follow-up

[Cerebellar hematomas. Description of a cohort and prognosis based on therapeutic attitude]. / Hematomas cerebelosos. Descripción de una cohorte y pronóstico en función de la actitud terapéutica.

OBJECTIVES: Spontaneous cerebellar hematomas (CH) represent 5%-10% of intracranial hemorrhaging. We describe the existing cardiovascular risk factors, clinical presentation of CH and its relationship with mortality and the association between the treatment type (conservative medical or neurosurgical treatment) and the subsequent course of the patients. DESIGN AND SCOPE: Observational study of patients diagnosed of CH admitted over three years in an Intensive Care Unit of a level III Hospital. PATIENTS: Fifty-six consecutive patients diagnosed of CH. VARIABLES OF PRINCIPAL INTEREST: We studied the cardiovascular risk factors, presentation form (with Glasgow Coma Scale- GCS), hematoma size and site, and morbidity-mortality of the patients (with the Glasgow Outcome Scale--GOS). RESULTS: Fisher's exact test, Chi squared, calculation of Spearman's coefficient between certain variables and logistic regression analysis were used. Hematoma size, GCS on admission and presence of hydrocephaly obtained statistical significance. Conservative medical treatment has greater mortality. CONCLUSIONS: Patients with GCS < or = 8 and hematoma size > or = 3 cm benefit from surgical treatment. Initial GCS and vermian site are mortality predictor factors. There is no more morbidity due to surgical treatment.

[Predictors of outcome in blunt chest trauma]. / Marcadores pronósticos en los pacientes con traumatismo torácico cerrado.

INTRODUCTION: Thoracic trauma is often associated with polytrauma. Because mortality is high, the search for prognostic tools is useful. PATIENTS AND METHODS: A total of 108 patients with blunt thoracic trauma, 73 of whom had multiple injuries, were studied in an intensive care unit (ICU). The variables named as potential predictors of outcome were the need for mechanical ventilation, duration of ventilation, and high positive end-expiratory pressure (PEEP); the presence of rib fractures, pulmonary contusion, pleural involvement (hemo- and/or pneumothorax), or lung infection; the need for emergency surgery; mean duration of ICU stay, and age. We also studied whether or not the mortality rate was higher in polytrauma patients. Student t and chi2 tests (95% confidence level) and multiple regression analysis (Hosmer-Lemeshow goodness of fit) were used to analyze the results. RESULTS: The need for mechanical ventilation, radiographic evidence of pulmonary contusion, emergency surgery, and hemodynamic instability were risk factors for increased mortality. Higher risk of mortality was not demonstrated for patients with multiple injuries. For patients in need of mechanical ventilation, high PEEP was a predictor of poor prognosis. CONCLUSIONS: The presence of the aforementioned predictors (mechanical ventilation, high PEEP, pulmonary contusion, emergency surgery, and hemodynamic instability) indicate serious injury to the lung parenchyma, which is the main determinant of outcome for patients with thoracic trauma.

[Haemostatic activation in head injury]. / Activación hemostática en el traumatismo creoencefálico.

A relationship between Central Nervous System and coagulation has been known since the work by Goodnight et al5. When an encephalic injury occurs tissue damage causes the release of thromboplastin-related products, mainly the Tissular Factor. This release produces an activation of the coagulation system specially through its extrinsic path. With this physiopathologic basis we attempt to improve the knowledge of this relation by performing a prospective study at the Intensive Care Unit of our Hospital. The study included 67 patients with cranioencephalic trauma alone, with an average Glasgow coma scale score of 10 and a control group consisting of 40 healthy subjects. Two peripheral vein blood extractions were performed, at admission and 24 hours later. Global coagulation parameters (prothrombin time, activated partial thromboplastin time, platelet count and fibrinogen), hypercoagulability markers (prothrombin fragments F1+2 and thrombin-antithrombin complex (TAT)) and thrombolisis markers (D-dimer) were determined. Our results show that early after head trauma an increase in fragments F1+2, TAT and Ddimer occur. After the first 24 hours a significant decrease in hypercoagulability markers levels is detected. Modification of the global coagulation parameters was also detected. In conclusion, early after a cranioencephalic trauma a simultaneous state of hypercoagulability and thrombolysis occur which may have the purpose of improving the hemostatic balance.

Activación hemostática en el traumatismo craneoencefálico / Haemostatic activation in head injury

Desde los estudios de Goodnight et al'., se conoce la relación entre el sistema nervioso central y el sistema de la coagulación sanguínea. Cuando se produce una lesión a nivel del encéfalo, la destrucción tisular produce la liberación de sustancias tromboplastínicas, principalmente Factor Tisular. Esta liberación produce una activación de la coagulación principalmente por la vía extrínseca. Ante esta base fisiopatológica nos planteamos avanzar en el estudio de esta relación, para lo cual realizamos un estudio prospectivo en el Servicio de Medicina Intensiva del Hospital Clínico Universitario "Lozano Blesa" de Zaragoza. El estudio esta formado por 67 pacientes con traumatismo craneoencefálico aislado, con un Glasgow medio de 10 puntos y un grupo control formado por 40 personas sanas. Realizamos dos extracciones de vena periférica, al ingreso y a las 24 horas de evolución. Determinamos parámetros globales de la coagulación (tiempo de protrombina, tiempo de tromboplastina parcial activado, recuento de plaquetas y fibrinógeno), marcadores de hipercoagulabilidad (fragmentos de la protrombina F1+2 y complejo trombina antitrombina) y marcadores de fibrinolisis (D-dímeros).Nuestros resultados muestran que de forma precoz se produce un aumento en los niveles de fragmentos F1+2, TAT y D-dímeros tras producirse un traumatismo craneoencefálico. Una vez transcurridas las primeras 24 horas de evolución hay un descenso significativo de los marcadores de hipercoagulabilidad. También hemos detectado una alteración en los parámetros globales de la coagulación. Así de forma precoz tras un traumatismo craneoencefálico se produce un estado simultáneo de hipercoagulabilidad y fibrinolisis, que quizá intente conseguir un equilibrio hemostático (AU)

[Therapeutic attitude, evolution and prognosis of the cerebral hemorrhages of patients in dicumarinic treatment, in function of their supra or infratentorial localization]. / Actitud terapéutica, evolución y pronóstico de la hemorragia cerebral, según la localización supra o infratentorial, de pacientes en tratamiento dicumarínico.

INTRODUCTION: The anticoagulants are drugs with possible serious secondary effects, being one of the most serious the appearance of intracraneal hemorrhages, being able to vary the clinical course as they were hemorrhages in the deep supratentorial compartment (ST) or in the infratentorial (IT). OBJECTIVES: Compare the therapeutic attitude, the evolution and the prognostic of the cerebral hemorrhages in patient with warfarin treatment, in function of their localization ST or IT. PATIENTS AND METHODS: Descriptive and retrospective analysis of 42 patients; in 28 of the cases (66,6%) the localization was ST, and in 14 of the patients (33,3%) the localization was IT. We study risk vascular factors, age and the sex of the patients, the volume of the hemorrhage, the initial clinical state of the patients, the therapeutic attitude, the average stay and the mortality. As statistical tools, the t of Student and the c2 test were used, demanding a confidence interval of 95%. RESULTS: The factors of cardiovascular risk of our serie were similar to the existent ones in other studies. The hemorrhages IT are more frequent in women, existing significant differences in the age among sexes in function of the localization. 100% of the hemorrhages IT exceeded the therapeutic INR, in front of 39% of the ST. A bigger half stay is also demonstrated in the ST hemorrhages so much in the surviving as in the exitus. Statistical significance was not reached in the rest of the studied parameters. CONCLUSIONS: The presence of a INR that surpasses the therapeutic is an indicator of hemorrhage risk IT, in patient dicumarinic drawees, and that in this same subgrup, the stays stockings are sensibly inferior, in all the subgrups (medical treatment and surgical treatment). Also the feminine sex has a bigger incidence of processes ST, with a smaller presentation age.

[Analysis of the reliability of 4 ventilators used in critically ill patients]. / Análisis de la fiabilidad de cuatro ventiladores empleados en pacientes críticos.

OBJECTIVES: Mechanical ventilators are often used in critically-ill patients with acute respiratory insufficiency. We aimed to assess the reliability of four commonly used ventilators. METHODS: This experimental study assessed four Bio-Tek VT-2 ventilators set for different levels of impedance and compliance in comparison with a tester. We gathered data on differences between the ventilators and the tester for volumes supplied and end-expiratory pressures. Statistical significance was determined using a Student-t test (95% confidence interval) and a coefficient of variation was calculated to study variation over time in parameters programmed. Error margins were calculated and applied for each ventilator. RESULTS: For situations in which compliance and impedance are similar to those of patients with chronic obstructive pulmonary disease and acute respiratory distress syndrome, there were differences in tidal volumes measured by the ventilators monitors and those actually supplied at the end of the breathing circuits, although the differences are only slightly greater than the error margins. The coefficients of variation were not significant at any of the compliance and impedance levels studied. CONCLUSIONS: In situations of low compliance and/or high impedance, tidal volumes supplied by ventilators and volumes shown on the monitors are different, although the differences are small and hardly exceed the ventilators acceptable error margins. The coefficient of variation indicated that the parameters set remain highly stable over time.

[Diagnose and predict utility of transcranial Doppler in the serious cerebral anoxia]. / Utilidad diagnóstica y pronóstica del Doppler transcraneal en los casos de anoxia cerebral grave.

INTRODUCTION: In the clinical daily practice, exist multiple situations in which could produce phenomenons of serious hypoxia to encephalic level, normally with important repercussions for the patient. OBJECTIVES: Study if after the existence of a situation of serious encephalic hypoxia, any typical pattern in the exploration transcranial Doppler (TCD) exists, and the possible diagnostic and/or prognostic implications could bear. PATIENTS AND METHODS: We presented 10 patients admitted in our Unit of Intensive Care, for clinical situations in which a situation of encephalic hypoxia took place and to which was practiced a TCD like exploration of encephalic flow. We related the discoveries of the DTC, with the clinical situation, the images of the cerebral computed tomography in three of the patients, and the data of the electroencephalogram in the other seven. Like statistical tool, is used the test of square ji, demanding a confidence interval of the 95%. RESULTS: In all the patients, we found a patron TCD, of high speed mean with low Pulsatility Index. Nine patients died, surviving with serious sequels the last patient. CONCLUSIONS: In our series, we could conclude, that the existence of a patron TCD with high speed mean and with low Pulsatility Index, after an episode of brain hypoxia, its associated to a wrong presage, existing a high risk of death of the patient.

[Morbi-mortality of medical and surgical treatments in the intracranial bleeding like complication of therapy with drugs that modifies normal coagulation]. / Morbimortalidad del tratamiento médico conservador y del tratamiento neuroquirúrgico en los casos de hemorragia intracraneal como complicación del empleo de fármacos que modifican la hemostasia.

INTRODUCTION: Antiaggregant and anticoagulant therapy has possible sever secondary effects, being the most serious intracranial bleeding. OBJECTIVES: Compare morbi-mortality between surgical and medical treatments in anticoagulated and/or antiaggregated patients with any kind of intracranial bleeding. Also risk factors and main indications of those treatments are studied. PATIENTS AND METHODS: Descriptive and retrospective study including 105 patients admitted in our Critical Care Unit, with intracranial bleeding, under anticoagulant or antiaggregant treatment. We study the type of bleeding (subarachnoid, epidural, subdural and intraparenchimal bleeding) and the relation between morbi-mortality and treatment applicated using relative risk like analytic tool. RESULTS: Major bleeding risk appears after the six first months from the beginning of the treatment. Thirty-four patients died with a relative risk of 1.55 in the surgical patients from the medical treatment patients. Relative risk between anticoagulated patients and antiaggregated ones was 1.16. Serious consequences happened on eight of the 49 patients under surgical treatment, and on 13 of the 52 patients under medical treatment. CONCLUSIONS: Surgical treatment has more morbi-mortality. Oral anticoagulation has only a little more relative risk than treatment with antiaggregants. Both groups had serious consequences.