RESUMO
Statins may improve outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH) but randomized controlled trials, including all patients with aSAH whatever their clinical severity, were negative. We studied whether pravastatin improved neurologic outcome in patients with early good neurological status, whose prognosis is related to secondary lesions as delayed cerebral ischemia (DCI). We conducted a single-center study of cases and historical controls in a neurocritical care unit. We included consecutive patients with aSAH from 2011 to 2016 with early good neurological status defined by a WFNS score ≤ 3 on the third day. Patients treated before 2014 with oral pravastatin (40 mg/day for 14 days) as a standard of care were matched using propensity score to patients treated after 2014 without pravastatin. Good neurologic outcome was defined by a Glasgow Outcome Scale ≥ 4 at neurocritical care unit discharge. We included 270 patients (135 patients with pravastatin), mostly treated with coiling (94.1%). Demographic, initial and subacute features were the same in the 2 groups. More patients experienced good outcome in the pravastatin group than in the control group (94.8% vs 74.2%; OR 7.16 95% CI [3.07 - 16.72], p < 0.001). There was no difference in the occurrence of DCI in the 2 groups. In our study, outcome on neurocritical care discharge was better in patients with early good neurological status treated with pravastatin. Another randomized controlled trial should be conducted on this subtype of population.
Assuntos
Isquemia Encefálica , Hemorragia Subaracnóidea , Isquemia Encefálica/complicações , Isquemia Encefálica/tratamento farmacológico , Isquemia Encefálica/epidemiologia , Estudos de Casos e Controles , Infarto Cerebral/complicações , Humanos , Pravastatina/uso terapêutico , Prognóstico , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea/tratamento farmacológico , Resultado do TratamentoRESUMO
Aneurysmal subarachnoid hemorrhage (SAH) is a rare event affecting relatively young patients therefore leading to a high social impact. The management of SAH follows a biphasic course with early brain injuries in the first 72 hours followed by a phase at risk of secondary deterioration due to delayed cerebral ischemia (DCI) in 20 to 30% patients. Cerebral infarction from DCI is the most preventable cause of mortality and morbidity after SAH. DCI prevention, early detection and treatment is therefore advocated. Formerly limited to the occurrence of vasospasm, DCI is now associated with multiple pathophysiological processes involving for instance the macrocirculation, the microcirculation, neurovascular units, and inflammation. Therefore, the therapeutic targets and management strategies are also evolving and are not only focused on proximal vasospasm. In this review, we describe the current knowledge of DCI pathophysiology. We then discuss the diagnosis strategies that may guide physicians at the bedside with a multimodal approach in the unconscious patient. We will present the prevention strategies that have proven efficient as well as future targets and present the therapeutic approach that is currently being developed when a DCI occurs.
Assuntos
Isquemia Encefálica , Hemorragia Subaracnóidea , Vasoespasmo Intracraniano , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/etiologia , Isquemia Encefálica/terapia , Infarto Cerebral , Humanos , Microcirculação , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea/diagnóstico , Hemorragia Subaracnóidea/terapia , Vasoespasmo Intracraniano/diagnóstico , Vasoespasmo Intracraniano/epidemiologia , Vasoespasmo Intracraniano/etiologiaRESUMO
OBJECTIVE: Delayed cerebral ischemia (DCI) is the most important and preventable morbidity cause after subarachnoid hemorrhage (SAH). Therefore, DCI early detection is a major challenge. Yet, neurological examination can be unreliable in poor grade SAH patients. EEG provides information from most superficial cortical area, with ischemia-related changes. This study aims at defining an alpha-theta/delta (AT/D) ratio decrease thresholds to detect DCI. METHODS: We used EEG with a montage matching vascular territories (right and left anterior central and posterior) and compared them to follow-up brain imaging. RESULTS: 15 SAH patients (Fischerâ¯≥â¯3, World Federation of Neurological Surgeons scale ≥4, 9 DCI) were monitored during 6.4 [4-8] days (minâ¯=â¯2d, maxâ¯=â¯13d). AT/D changes could follow three different patterns: (1) prolonged or (2) transient decrease and (3) no decrease or progressive increase. A regional 30% decrease outlasting 3.7â¯h reached 100% sensitivity and 88.9% specificity to detect DCI. Only 22.6% were in a zone of uncertain diagnosis (3.7-8.04â¯h). These prolonged decreases, with a loss of transient changes, started in cortical areas evolving toward DCI, and preceded intracranial changes when available. CONCLUSION: Although this study has a small sample size, prolonged AT/D decrease seems to be a reliable biomarker of DCI. SIGNIFICANCE: cEEG changes are likely to precede cerebral infarction and could be useful at the bedside to detect DCI before irreversible damage.
Assuntos
Isquemia Encefálica/diagnóstico , Eletroencefalografia/métodos , Hemorragia Subaracnóidea/complicações , Isquemia Encefálica/etiologia , Isquemia Encefálica/fisiopatologia , Diagnóstico Precoce , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sensibilidade e Especificidade , Hemorragia Subaracnóidea/fisiopatologiaAssuntos
Doenças das Artérias Carótidas/etiologia , Trombose Intracraniana/complicações , Embolia Pulmonar/etiologia , Acidente Vascular Cerebral/etiologia , Doenças das Artérias Carótidas/diagnóstico por imagem , Artéria Carótida Interna/diagnóstico por imagem , Artéria Carótida Interna/patologia , Feminino , Humanos , Trombose Intracraniana/diagnóstico por imagem , Pessoa de Meia-Idade , Embolia Pulmonar/diagnóstico por imagem , Acidente Vascular Cerebral/diagnóstico por imagem , Tomografia Computadorizada por Raios XRESUMO
The introduction of direct oral anticoagulants (DOA) in the early stage of cerebral infarction after thrombolysis may reduce the recurrence rate but raises safety concern. We sought to study the feasibility and safety of the introduction of rivaroxaban or dabigatran in this context. Thirty-four consecutive patients admitted for ischemic stroke related to non-valvular atrial fibrillation in whom DOA were given within the first two weeks following intravenous rt-PA were studied. A clinical and radiological monitoring protocol was established to ensure the safety of the prescription. None of the patients experienced symptomatic hemorrhagic transformation or a symptomatic recurrent ischemic event after early rivaroxaban or dabigatran introduction.
Assuntos
Antitrombinas/uso terapêutico , Isquemia Encefálica/tratamento farmacológico , Dabigatrana/uso terapêutico , Inibidores do Fator Xa/uso terapêutico , Fibrinolíticos/uso terapêutico , Hemorragias Intracranianas/induzido quimicamente , Rivaroxabana/uso terapêutico , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Antitrombinas/administração & dosagem , Antitrombinas/efeitos adversos , Fibrilação Atrial/sangue , Fibrilação Atrial/complicações , Dabigatrana/administração & dosagem , Dabigatrana/efeitos adversos , Esquema de Medicação , Inibidores do Fator Xa/administração & dosagem , Inibidores do Fator Xa/efeitos adversos , Feminino , Fibrinolíticos/administração & dosagem , Humanos , Hemorragias Intracranianas/diagnóstico por imagem , Tempo de Internação , Masculino , Projetos Piloto , Radiografia , Proteínas Recombinantes/administração & dosagem , Proteínas Recombinantes/uso terapêutico , Recidiva , Estudos Retrospectivos , Rivaroxabana/administração & dosagem , Rivaroxabana/efeitos adversos , Índice de Gravidade de Doença , Trombofilia/tratamento farmacológico , Trombofilia/etiologia , Ativador de Plasminogênio Tecidual/administração & dosagemAssuntos
Transtornos de Deglutição/etiologia , Síndrome Medular Lateral/complicações , Idoso de 80 Anos ou mais , Transtornos de Deglutição/diagnóstico , Diagnóstico Diferencial , Humanos , Síndrome Medular Lateral/diagnóstico , Síndrome Medular Lateral/patologia , Masculino , Bulbo/irrigação sanguínea , Bulbo/patologiaRESUMO
Muscular dystrophies are genetic muscular disease with disability. Heart failure is a classical complication mainly in Duchenne muscular dystrophy (DMD). We report 2 cases of severe acute heart failure revealed by abdominal discomfort in a patient with DMD and in a patient with gamma-sarcoglycanopathy.
Assuntos
Insuficiência Cardíaca/etiologia , Distrofia Muscular de Duchenne/complicações , Sarcoglicanopatias/complicações , Dor Abdominal/etiologia , Doença Aguda , Adulto , Insuficiência Cardíaca/diagnóstico , Humanos , MasculinoAssuntos
Procedimentos Endovasculares/efeitos adversos , Malformações Arteriovenosas Intracranianas/terapia , Hemorragias Intracranianas/etiologia , Mielite Transversa/etiologia , Neuromielite Óptica/etiologia , Adulto , Aquaporina 4/imunologia , Autoanticorpos/análise , Autopsia , Evolução Fatal , Humanos , Malformações Arteriovenosas Intracranianas/diagnóstico , Hemorragias Intracranianas/diagnóstico , Hemorragias Intracranianas/cirurgia , Masculino , Mielite Transversa/diagnóstico , Mielite Transversa/imunologia , Mielite Transversa/terapia , Neuromielite Óptica/diagnóstico , Neuromielite Óptica/imunologia , Neuromielite Óptica/terapia , Procedimentos Neurocirúrgicos/efeitos adversos , Reoperação , Ruptura EspontâneaRESUMO
INTRODUCTION: Paraneoplastic movement disorders are rare. Reported cases frequently describe association with anti-CV2/CRMP5 antibodies. CASE REPORT: We report a case of an 80-year-old man who developed sensorial neuronopathy, following by movement disorders mimicking chorea and obsessive-compulsive and behavioral disorders. These manifestations were first considered to be associated with a prostatic adenocarcinoma but PET and surgical biopsy revealed a mediastinal small cell lung carcinoma classically associated with anti-CV2/CRMP5 antibodies. CONCLUSION: This case demonstrates that in a context of paraneoplastic neurological syndrome, search for a classically associated cancer is necessary in order to institute adapted treatment early, even if another tumor is obvious.
Assuntos
Autoanticorpos/imunologia , Transtornos Mentais/complicações , Proteínas do Tecido Nervoso/imunologia , Polineuropatia Paraneoplásica/complicações , Idoso de 80 Anos ou mais , Coreia/complicações , Coreia/diagnóstico por imagem , Dislipidemias/complicações , Eletrodiagnóstico , Fluordesoxiglucose F18 , Humanos , Hidrolases , Imageamento por Ressonância Magnética , Masculino , Neoplasias do Mediastino/complicações , Neoplasias do Mediastino/patologia , Transtornos Mentais/etiologia , Proteínas Associadas aos Microtúbulos , Infarto do Miocárdio/complicações , Transtorno Obsessivo-Compulsivo/etiologia , Transtorno Obsessivo-Compulsivo/psicologia , Polineuropatia Paraneoplásica/diagnóstico por imagem , Polineuropatia Paraneoplásica/etiologia , Tomografia por Emissão de Pósitrons , Compostos Radiofarmacêuticos , Carcinoma de Pequenas Células do Pulmão/complicações , Carcinoma de Pequenas Células do Pulmão/patologia , Tomografia Computadorizada por Raios XRESUMO
Neurosarcoidosis is a rare disease that can involve all the nervous system with variable clinical onset and prognosis. The initial therapeutic approach is mainly based on corticosteroids and immunosuppressive agents. Treatment of refractory forms of neurosarcoidosis is not well established and emerging immunomodulating drugs like infliximab have been recently tested. The clinical report of a new case of neurosarcoidosis responding to infliximab is followed by a review of the new therapeutic agents available for the treatment of refractory neurosarcoidosis.