The Effects of Head Elevation on Intracranial Pressure, Cerebral Perfusion Pressure, and Cerebral Oxygenation Among Patients with Acute Brain Injury: A Systematic Review and Meta-Analysis.

BACKGROUND: Head elevation is recommended as a tier zero measure to decrease high intracranial pressure (ICP) in neurocritical patients. However, its quantitative effects on cerebral perfusion pressure (CPP), jugular bulb oxygen saturation (SjvO2), brain tissue partial pressure of oxygen (PbtO2), and arteriovenous difference of oxygen (AVDO2) are uncertain. Our objective was to evaluate the effects of head elevation on ICP, CPP, SjvO2, PbtO2, and AVDO2 among patients with acute brain injury. METHODS: We conducted a systematic review and meta-analysis on PubMed, Scopus, and Cochrane Library of studies comparing the effects of different degrees of head elevation on ICP, CPP, SjvO2, PbtO2, and AVDO2. RESULTS: A total of 25 articles were included in the systematic review. Of these, 16 provided quantitative data regarding outcomes of interest and underwent meta-analyses. The mean ICP of patients with acute brain injury was lower in group with 30° of head elevation than in the supine position group (mean difference [MD] - 5.58 mm Hg; 95% confidence interval [CI] - 6.74 to - 4.41 mm Hg; p < 0.00001). The only comparison in which a greater degree of head elevation did not significantly reduce the ICP was 45° vs. 30°. The mean CPP remained similar between 30° of head elevation and supine position (MD - 2.48 mm Hg; 95% CI - 5.69 to 0.73 mm Hg; p = 0.13). Similar findings were observed in all other comparisons. The mean SjvO2 was similar between the 30° of head elevation and supine position groups (MD 0.32%; 95% CI - 1.67% to 2.32%; p = 0.75), as was the mean PbtO2 (MD - 1.50 mm Hg; 95% CI - 4.62 to 1.62 mm Hg; p = 0.36), and the mean AVDO2 (MD 0.06 µmol/L; 95% CI - 0.20 to 0.32 µmol/L; p = 0.65).The mean ICP of patients with traumatic brain injury was also lower with 30° of head elevation when compared to the supine position. There was no difference in the mean values of mean arterial pressure, CPP, SjvO2, and PbtO2 between these groups. CONCLUSIONS: Increasing degrees of head elevation were associated, in general, with a lower ICP, whereas CPP and brain oxygenation parameters remained unchanged. The severe traumatic brain injury subanalysis found similar results.

A Comprehensive Perspective on Intracranial Pressure Monitoring and Individualized Management in Neurocritical Care: Results of a Survey with Global Experts.

BACKGROUND: Numerous trials have addressed intracranial pressure (ICP) management in neurocritical care. However, identifying its harmful thresholds and controlling ICP remain challenging in terms of improving outcomes. Evidence suggests that an individualized approach is necessary for establishing tolerance limits for ICP, incorporating factors such as ICP waveform (ICPW) or pulse morphology along with additional data provided by other invasive (e.g., brain oximetry) and noninvasive monitoring (NIM) methods (e.g., transcranial Doppler, optic nerve sheath diameter ultrasound, and pupillometry). This study aims to assess current ICP monitoring practices among experienced clinicians and explore whether guidelines should incorporate ancillary parameters from NIM and ICPW in future updates. METHODS: We conducted a survey among experienced professionals involved in researching and managing patients with severe injury across low-middle-income countries (LMICs) and high-income countries (HICs). We sought their insights on ICP monitoring, particularly focusing on the impact of NIM and ICPW in various clinical scenarios. RESULTS: From October to December 2023, 109 professionals from the Americas and Europe participated in the survey, evenly distributed between LMIC and HIC. When ICP ranged from 22 to 25 mm Hg, 62.3% of respondents were open to considering additional information, such as ICPW and other monitoring techniques, before adjusting therapy intensity levels. Moreover, 77% of respondents were inclined to reassess patients with ICP in the 18-22 mm Hg range, potentially escalating therapy intensity levels with the support of ICPW and NIM. Differences emerged between LMIC and HIC participants, with more LMIC respondents preferring arterial blood pressure transducer leveling at the heart and endorsing the use of NIM techniques and ICPW as ancillary information. CONCLUSIONS: Experienced clinicians tend to personalize ICP management, emphasizing the importance of considering various monitoring techniques. ICPW and noninvasive techniques, particularly in LMIC settings, warrant further exploration and could potentially enhance individualized patient care. The study suggests updating guidelines to include these additional components for a more personalized approach to ICP management.

Clinical Characteristics and Outcomes of Patients with Aneurysmal Subarachnoid Hemorrhage: A Prospective Multicenter Study in a Middle-Income Country.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (SAH) is associated with high mortality and long-term functional impairment. Data on clinical management and functional outcomes from developing countries are scarce. We aimed to define patient profiles and clinical practices and evaluate long-term outcomes after SAH in a middle-income country. METHODS: This was a prospective study including consecutive adult patients admitted with SAH to two reference centers in Brazil from January 2016 to February 2020. The primary outcome was functional status at 6 months using the modified Rankin Scale. Mixed multivariable analysis was performed to determine the relationship between clinical variables and functional outcomes. RESULTS: From 471patients analyzed, the median time from symptom onset to arrival at a study center was 4 days (interquartile range 0-9). Median age was 55 years (interquartile range 46-62) and 353 (75%) patients were women. A total of 426 patients (90%) were transferred from nonspecialized general hospitals, initial computed tomography revealed thick hemorrhage in 73% of patients (modified Fisher score of 3 or 4), and 136 (29%) had poor clinical grade (World Federation of Neurological Surgeons score of 4 or 5). A total of 312 (66%) patients underwent surgical clipping, and 119 (25%) underwent endovascular coiling. Only 34 patients (7%) underwent withdrawal or withholding of life-sustaining therapy during their hospital stay, and in-hospital mortality was 24%. A total of 187 (40%) patients had an unfavorable long-term functional outcome (modified Rankin Scale score of 4 to 6). Factors associated with unfavorable outcome were age (adjusted odds ratio [OR] 1.05, 95% confidence interval [CI] 1.03-1.08), hypertension (adjusted OR 1.81, 95% CI 1.04-3.16), poor clinical grade (adjusted OR 4.92, 95% CI 2.85-8.48), external ventricular drain (adjusted OR 3.8, 95% CI 2.31-6.24), postoperative deterioration (adjusted OR 2.33, 95% CI 1.32-4.13), cerebral infarction (adjusted OR 3.16, 95% CI 1.81-5.52), rebleeding (adjusted OR 2.95, 95% CI 1.13-7.69), and sepsis (adjusted OR 2.68, 95% CI 1.42-5.05). CONCLUSIONS: Our study demonstrated that SAH management in a middle-income country diverges significantly from published cohorts and current guidelines, despite comparable clinical profiles on presentation and admission to high-volume referral centers. Earlier aneurysm occlusion and increased use of endovascular therapy could potentially reduce modifiable in-hospital complications and improve functional outcomes in Brazil.

Effects of Tranexamic Acid in Patients with Subarachnoid Hemorrhage in Brazil: A Prospective Observational Study with Propensity Score Analysis.

BACKGROUND: Rebleeding from a ruptured aneurysm increases the risk of unfavorable outcomes after subarachnoid hemorrhage (SAH) and is prevented by early aneurysm occlusion. The role of antifibrinolytics before aneurysm obliteration remains controversial. We investigated the effects of tranexamic acid on long-term functional outcomes of patients with aneurysmal SAH (aSAH). METHODS: This was a single-center, prospective, observational study conducted in a high-volume tertiary hospital in a middle-income country from December 2016 to February 2020. We included all consecutive patients with aSAH who either received or did not receive tranexamic acid (TXA) treatment. Multivariate logistic regression analysis using propensity score was used to evaluate the association of TXA use with long-term functional outcomes, measured by the modified Rankin Scale (mRS) at 6 months. RESULTS: A total of 230 patients with aSAH were analyzed. The median (interquartile range) age was 55 (46-63) years, 72% were women, 75% presented with good clinical grade (World Federation of Neurological Surgeons grade 1-3), and 83% had a Fisher scale of 3 or 4. Around 80% of patients were admitted up to 72 h from ictus. The aneurysm occlusion method was surgical clipping in 80% of the patients. A total of 129 patients (56%) received TXA. In multivariable logistic regression using inverse probability treatment weighting, the long-term rate of unfavorable outcomes (modified Rankin scale 4-6) was the same in the TXA and non-TXA groups (61 [48%] in TXA group vs. 33 [33%] in non-TXA group; odds ratio [OR] 1.39, 95% confidence interval [CI] 0.67-2.92; p = 0.377). The TXA group had higher in-hospital mortality (33 vs. 11% in non-TXA group; OR 4.13, 95% CI 1.55-12.53, p = 0.007). There were no differences between the groups concerning intensive care unit length of stay (16 ± 11.22 days in TXA group vs. 14 ± 9.24 days in non-TXA group; p = 0.2) or hospital (23 ± 13.35 days in TXA group vs. 22 ± 13.36 days in non-TXA group; p = 0.9). There was no difference in the rates of rebleeding (7.8% in TXA group vs. 8.9% in non-TXA group; p = 0.31) or delayed cerebral ischemia (27% in TXA group vs. 19% in non-TXA group; p = 0.14). For the propensity-matched analysis, 128 individuals were selected (64 in TXA group and 64 in non-TXA group), and the rates of unfavorable outcomes at 6 months were also similar between groups (45% in TXA group and 36% in non-TXA group; OR 1.22, 95% CI 0.51-2.89; p = 0.655). CONCLUSIONS: Our findings in a cohort with delayed aneurysm treatment reinforce previous data that TXA use before aneurysm occlusion does not improve functional outcomes in aSAH.

Long-Term Outcome After Decompressive Craniectomy in a Developing Country.

BACKGROUND: Decompressive craniectomy (DC) may reduce mortality but might increase the number of survivors in a vegetative state. In this study, we assessed the long-term functional outcome of patients undergoing DC in a middle-income country. METHODS: This was a prospective observational study of patients undergoing DC at a single tertiary hospital in southern Brazil between January 2015 and December 2018. RESULTS: Of the 125 patients who were included in this study, 57.6% (72/125) had a traumatic brain injury (TBI), 21.6% (27/125) had a stroke, 19.2% (24/125) had a cerebral hemorrhage (intracerebral or subarachnoid hemorrhage), and 0.8% (1/125) had a cerebral abscess. The mean age was 45.18 ± 19.6 years, and 71% of the patients were men. The mean initial Glasgow Coma Scale (GCS) score was 7.8 ± 3.6. The in-hospital mortality rate was 44.8% (56/125). Of the survivors, 50.7% (35/69) had a favorable outcome 6 months after DC. After multivariate analysis, a lower initial GCS score (7.5 ± 3.6 versus 8.8 ± 3.5, P = 0.007) and older age (49.7 ± 18.9 versus 33.3 ± 16.2 years, P = 0.0001) were associated with an unfavorable outcome. CONCLUSION: Six months after DC, almost half of the patients who survive have a favorable outcome.

Effects of Cranioplasty After Decompressive Craniectomy on Neurological Function and Cerebral Hemodynamics in Traumatic Versus Nontraumatic Brain Injury.

After decompressive craniectomy (DC), cranioplasty (CP) can help to normalize vascular and cerebrospinal fluid circulation besides improving the patient's neurological status. The aim of this study was to investigate the effects of CP on cerebral hemodynamics and on cognitive and functional outcomes in patients with and without a traumatic brain injury (TBI). Over a period of 3 years, 51 patients were included in the study: 37 TBI patients and 14 non-TBI patients. The TBI group was younger (28.86 ± 9.71 versus 45.64 ± 9.55 years, P = 0.0001), with a greater proportion of men than the non-TBI group (31 versus 6, P = 0.011). Both groups had improved cognitive outcomes (as assessed by the Mini-Mental State Examination) and functional outcomes (as assessed by the Barthel Index and Modified Rankin Scale) 90 days after CP. In the TBI group, the mean velocity of blood flow in the middle cerebral artery ipsilateral to the cranial defect increased between the time point before CP and 90 days after CP (34.24 ± 11.02 versus 42.14 ± 10.19 cm/s, P = 0.0001). In conclusion, CP improved the neurological status in TBI and non-TBI patients, but an increment in cerebral blood flow velocity after CP occurred only in TBI patients.

A Comparative Study of the Effects of Early Versus Late Cranioplasty on Cognitive Function.

Cranioplasty (CP) after decompressive craniectomy (DC) is associated with neurological improvement. We evaluated neurological recovery in patients who underwent late CP (more than 6 months after DC) in comparison with early CP. This prospective study of 51 patients investigated neurological function using the Addenbrooke's Cognitive Examination Revised (ACE-R), Mini-Mental State Examination (MMSE), Barthel Index (BI), and Modified Rankin Scale (mRS) prior to and after CP. Most patients with traumatic brain injury (74%) were young (mean age 33.4 ± 12.2 years) and male (33/51; 66%). There were general improvements in the patients' cognition and functional status, especially in the late-CP group. The ACE-R score increased from the time point before CP to 3 days after CP (51 ± 28.94 versus 53.1 ± 30.39, P = 0.016) and 90 days after CP (51 ± 28.94 versus 58.10 ± 30.43, P = 0.0001). In the late-CP group, increments also occurred from the time point before CP to 90 days after CP in terms of the MMSE score (18.54 ± 1.51 versus 20.34 ± 1.50, P = 0.003), BI score (79.84 ± 4.66 versus 85.62 ± 4.10, P = 0.028), and mRS score (2.07 ± 0.22 versus 1.74 ± 0.20, P = 0.015). CP is able to improve neurological outcomes even more than 6 months after DC.

Early Transcranial Doppler Evaluation of Cerebral Autoregulation Independently Predicts Functional Outcome After Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Cerebral autoregulation (CA) impairment after aneurysmal subarachnoid hemorrhage (SAH) has been associated with delayed cerebral ischemia and an unfavorable outcome. We investigated whether the early transient hyperemic response test (THRT), a transcranial Doppler (TCD)-based CA evaluation method, can predict functional outcome 6 months after aneurysmal SAH. METHODS: This is a prospective observational study of all aneurysmal SAH patients consecutively admitted to a single center between January 2016 and February 2017. CA was evaluated within 72 h of hemorrhage by THRT, which describes the changes in cerebral blood flow velocity after a brief compression of the ipsilateral common carotid artery. CA was considered to be preserved when an increase ≥ 9% of baseline systolic velocity was present. According to the modified Rankin Scale (mRS: 4-6), the primary outcome was unfavorable 6 months after hemorrhage. Secondary outcomes included cerebral infarction, vasospasm on TCD, and an unfavorable outcome at hospital discharge. RESULTS: Forty patients were included (mean age = 54 ± 12 years, 70% females). CA was impaired in 19 patients (47.5%) and preserved in 21 (52.5%). Impaired CA patients were older (59 ± 13 vs. 50 ± 9, p = 0.012), showed worse neurological conditions (Hunt&Hess 4 or 5-47.4% vs. 9.5%, p = 0.012), and clinical initial condition (APACHE II physiological score-12 [5.57-13] vs. 3.5 [3-5], p = 0.001). Fourteen patients in the impaired CA group and one patient in the preserved CA group progressed to an unfavorable outcome (73.7% vs. 4.7%, p = 0.0001). The impaired CA group more frequently developed cerebral infarction than the preserved CA group (36.8% vs. 0%, p = 0.003, respectively). After multivariate analysis, impaired CA (OR 5.15 95% CI 1.43-51.99, p = 0.033) and the APACHE II physiological score (OR 1.67, 95% CI 1.01-2.76, p = 0.046) were independently associated with an unfavorable outcome. CONCLUSIONS: Early CA impairment detected by TCD and admission APACHE II physiological score independently predicted an unfavorable outcome after SAH.

TRansfusion strategies in Acute brain INjured patients (TRAIN): a prospective multicenter randomized interventional trial protocol.

BACKGROUND: Although blood transfusions can be lifesaving in severe hemorrhage, they can also have potential complications. As anemia has also been associated with poor outcomes in critically ill patients, determining an optimal transfusion trigger is a real challenge for clinicians. This is even more important in patients with acute brain injury who were not specifically evaluated in previous large randomized clinical trials. Neurological patients may be particularly sensitive to anemic brain hypoxia because of the exhausted cerebrovascular reserve, which adjusts cerebral blood flow to tissue oxygen demand. METHODS: We described herein the methodology of a prospective, multicenter, randomized, pragmatic trial comparing two different strategies for red blood cell transfusion in patients with acute brain injury: a "liberal" strategy in which the aim is to maintain hemoglobin (Hb) concentrations greater than 9 g/dL and a "restrictive" approach in which the aim is to maintain Hb concentrations greater than 7 g/dL. The target population is patients suffering from traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), or intracerebral hemorrhage (ICH). The primary outcome is the unfavorable neurological outcome, evaluated using the extended Glasgow Outcome Scale (eGOS) of 1-5 at 180 days after the initial injury. Secondary outcomes include, among others, 28-day survival, intensive care unit (ICU) and hospital lengths of stay, the occurrence of extra-cerebral organ dysfunction/failure, and the development of any infection or thromboembolic events. The estimated sample size is 794 patients to demonstrate a reduction in the primary outcome from 50 to 39% between groups (397 patients in each arm). The study was initiated in 2016 in several ICUs and will be completed in December 2022. DISCUSSION: This trial will assess the impact of a liberal versus conservative strategy of blood transfusion in a large cohort of critically ill patients with a primary acute brain injury. The results of this trial will help to improve blood product and transfusion use in this specific patient population and will provide additional data in some subgroups of patients at high risk of brain ischemia, such as those with intracranial hypertension or cerebral vasospasm. TRIAL REGISTRATION: ClinicalTrials.gov NCT02968654.

POCUS, how can we include the brain? An overview.

Point-of-care ultrasound (POCUS) is an essential tool to assess and manage different pathologies in the intensive care unit, and many protocols have been proposed for its application in critical care literature. However, the brain has been overlooked in these protocols.Brain ultrasonography (BU) is easily available, and it allows a goal-directed approach thanks to its repeatability and immediate interpretation and provides a quick management and real time assessment of patients' conditions. Based on recent studies, the increasing interest from intensivists, and the undeniable benefits of ultrasound, the main goal of this overview is to describe the main evidence and progresses in the incorporation of BU into the POCUS approach in the daily practice, and thus becoming POCUS-BU. This integration would allow a noninvasive global assessment to entail an integrated analysis of the critical care patients.

Ten Good Reasons to Practice Neuroultrasound in Critical Care Setting.

In the beginning, cerebral ultrasound (US) was not considered feasible because the intact skull was a seemingly impenetrable obstacle. For this reason, obtaining a clear image resolution had been a challenge since the first use of neuroultrasound (NUS) for the assessment of small deep brain structures. However, the improvements in transducer technologies and advances in signal processing have refined the image resolution, and the role of NUS has evolved as an imaging modality for the brain parenchyma within multiple pathologies. This article summarizes ten crucial applications of cerebral ultrasonography for the evaluation and management of neurocritical patients, whose transfer from and to intensive care units poses a real problem to medical care staff. This also encompasses ease of use, low cost, wide acceptance by patients, no radiation risk, and relative independence from movement artifacts. Bedsides, availability and reliability raised the interest of critical care intensivists in using it with increasing frequency. In this mini-review, the usefulness and the advantages of US in the neurocritical care setting are discussed regarding ten aspects to encourage the intensivist physician to practice this important tool.

The impact of cranioplasty on the patients' quality of life.

OBJECTIVE: To evaluate the quality of life in patients with moderate or large cranial bone defects before and after late cranioplasty. METHODS: Authors performed a prospective clinical trial including all consecutive patients that filled inclusion criteria during a period of 1 year. All patients answered the quality of life SF-36 questionnaire in 5 different times. Besides authors gathered information about the primary trauma and demographic characteristics. RESULTS: A total of 70 consecutive patients were admitted to the hospital during the study period, and 62 were included in the project. Cranioplasty statistically improved patients' quality of life in all 8 domains after a 24 months follow-up. CONCLUSION: Cranioplasty has a significant impact over the quality of life in brain trauma victims who survived the primary trauma and harbor a large cranial bone defect.

Traumatic Dissection of Arterial Cervical Vessels: Report of Two Cases and Literature Review

Even though traumatic dissection of cervical arterial vessels is themajor cause of stroke among adults, it is still an underdiagnosed disease in neurosurgical emergencies, since most patients do not have or present subtle clinical signs in the acute phase. The authors report two interesting cases of cervical artery dissection with different traumatic mechanisms and present a broad literature review about this subject.

Efeitos da estimulaçäo vibro-acústica na velocidade do sangue da artéria cerebral média e na freqüência cardíaca fetal: 1. entre a 35ª e 41ª semana de gestaçäo / The effect of vibratory acoustic stimulation on fetal middle cerebral artery impendance and instantaneous fetal heart rate: 1. a transversal study on fetuses with 35 to 41 weeks of gestacional age

Objetivos: estudar, em fetos hígidos, quais säo as respostas da freqüência cardíaca fetal basal a da resistência na artéria cerebral média à estimulaçäo vibro-acústica padronizada. Métodos: em estado comportamental de hipo ou de inatividade fetal (apnéia e ausência de movimentos corpóreos), mediu-se o índice de pulsatilidade (IP) da artéria cerebral média (ACM), bem como calculou-se a freqüência cardíaca fetal basal (FCFB) pela análise da onda espectral, antes e após a aplicaçäo de estímulo vibro-acústico (EVA) por 3 segundos. Foram empregados ecógrafos de alta resoluçäo, com Doppler pulsado e mapeamento a cores. A fonte sonora emitia som com 400 a 40.000 Hz, sob forma de varredura, com pressäo sonora de 65 a 110 dB. Resultados: a média da FCFB pré-estímulo foi 139 bpm, com desvio padräo de 3,14 bpm. A média da FCFB pós-estímulo foi 153 bpm, com desvio padräo de 7,23 bpm (p<0.0001). A média do IP da ACM pré-estímulo foi 1,84, com desvio padräo de 0,07. A média do IP da ACM foi 1,56, com desvio padräo de 0,04 (p<0.00001). Em todos os casos houve resposta do concepto, caracterizada pela evidência de movimento corpóreo vigoroso, aumento da FCFB e reduçäo do IP na ACM. Em nenhum caso houve necessidade de repetir o estímulo vibro-acústico. Conclusões: a aplicaçäo de estímulo vibro-acústico, com as características aqui descritas, em conceptos hígidos e de termo, por período de 3 segundos, determina incremento na FCFB e nos movimentos corpóreos, bem como reduçäo na impedância da ACM. Em que pese haver tendência em se inferir que a EVA determina aumento no fluxo de sangue ao cérebro fetal, os dados aqui evidenciados näo permitem interpretações clínicas

Tratamento endoscópico da coledocolitíase: experiência em 262 casos / Endoscopic treatment of bile duct stones: experience with 262 cases

Os autores apresentam sua experiência coletada prospectivamente em 262 casos (184 mulheres e 78 homens, média etária: 55,6 anos) de coledocolitíase tratados endoscopicamente. Quando analisado na base de intençäo de tratanento houve sucesso na retirada de cálculos em 231 (88,2 por cento) casos. Em apenas 14 deles a näo canulaçäo da papila foi a causa do insucesso (5,3 por cento) Houve 15 complicaçöes (5,7 por cento) e 5 mortes (1,9 por cento), uma delas relacionada ao procedimento (0,4 por cento). Em 23 (8,7 por cento) pacientes foi utilizada a técnica do pré-corte, com sucesso na retirada dos cálculos em 15 casos (65,2 por cento) Sete (30,4 por cento) desses 23 pacientes apresentaram algumas complicaçöes, ante 3,3 porcento (8 de 239) dos casos submetidos papilotomia standard (p<0,0001) Em suma, a papilotomia endoscópica 0 um procedimento seguro e eficaz para o tratamento da coledocolitiases e a técnica do pré-corte aumenta significativamente os riscos de complicaçäo desse procedimtno, devendo ser restrita a profissionais com profissionais com proficiência em endoscopia biliar e a casos em que a intervençäo terapeutica na via biliar é necessária

Tratamento endoscópico da coledocolitíase na era da colecistectomia laparoscópica: análise prospectiva de 328 casos / Endoscopic tratment of common bile duct stones in the era of laparoscopic cholecystectomy: prospective analysis of 328 cases

Os autores apresentam experiência coletada prospectivamente em 328 casos (231 fem.; 97 masc., média etária 57,5 anos) de coledocolitíase encaminhados para tratamento endoscópico. Quando analisados na base de intenção de tratamento, houve sucesso na retirada dos cálculos em 291 (88,7 por cento) casos...