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BACKGROUND AND PURPOSE: Early brain injury is a major determinant of clinical outcome in poor-grade (World Federation of Neurosurgical Societies [WFNS] IV-V) aneurysmal SAH and is radiologically defined by global cerebral edema. Little is known, though, about the effect of global intracranial hemorrhage volume on early brain injury development and clinical outcome. MATERIALS AND METHODS: Data from the multicentric prospective Poor-Grade Aneurysmal Subarachnoid Hemorrhage (POGASH) Registry of consecutive patients with poor-grade aneurysmal SAH admitted from January 1, 2015, to August 31, 2022, was retrospectively evaluated. Poor grade was defined according to the worst-pretreatment WFNS grade. Global intracranial hemorrhage volume as well as the volumes of intracerebral hemorrhage, intraventricular hemorrhage, and SAH were calculated by means of analytic software in a semiautomated setting. Outcomes included severe global cerebral edema (defined by Subarachnoid Hemorrhage Early Brain Edema Score grades 3-4), in-hospital mortality (mRS 6), and functional independence (mRS 0-2) at follow-up. RESULTS: Among 400 patients (median global intracranial hemorrhage volume of 91 mL; interquartile range, 59-128), severe global cerebral edema was detected in 218/400 (54.5%) patients. One hundred twenty-three (30.8%) patients died during the acute phase of hospitalization. One hundred fifty-five (38.8%) patients achieved mRS 0-2 at a median of 13 (interquartile range, 3-26) months of follow-up. Multivariable analyses showed global intracranial hemorrhage volume as independently associated with severe global cerebral edema (adjusted OR, 1.009; 95% CI, 1.004-1.014; P < .001), mortality (adjusted OR, 1.006; 95% CI, 1.001-1.01; P = .018) and worse clinical outcome (adjusted OR, 0.992; 95% CI, 0.98-0.996; P < .010). The effect of global intracranial hemorrhage volume on clinical-radiologic outcomes changed significantly according to different age groups (younger than 50, 50-70, older than 70 year of age). Volumes of intracerebral hemorrhage, intraventricular hemorrhage, and SAH affected the 3 predefined outcomes differently. Intracerebral hemorrhage volume independently predicted global cerebral edema and long-term outcome, intraventricular hemorrhage volume predicted mortality and long-term outcome, and SAH volume predicted long-term clinical outcome. CONCLUSIONS: Global intracranial hemorrhage volume plays a pivotal role in global cerebral edema development and emerged as an independent predictor of both mortality and long-term clinical outcome. Aging emerged as a reducing predictor in the relationship between global intracranial hemorrhage volume and global cerebral edema.
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Edema Encefálico , Lesões Encefálicas , Hemorragia Subaracnóidea , Humanos , Resultado do Tratamento , Edema Encefálico/diagnóstico por imagem , Edema Encefálico/etiologia , Estudos Retrospectivos , Estudos Prospectivos , Hemorragia Subaracnóidea/diagnóstico por imagem , Hemorragia Subaracnóidea/cirurgia , Hemorragia CerebralRESUMO
Brain injury and cerebral vasospasm during the 14 days after the subarachnoid hemorrhage (SAH) are considered the leading causes of poor outcomes. The primary injury induces a cascade of events, including increased intracranial pressure, cerebral vasospasm and ischemia, glutamate excitotoxicity, and neuronal cell death. The objective of this study was to monitor the time course of glutamate, and associated enzymes, such as glutamate-oxaloacetate transaminase (GOT1), glutamate-pyruvate transaminase (GPT) in cerebrospinal fluid (CSF) and serum, shortly after SAH, and to assess their prognostic value. A total of 74 participants participated in this study: 45 participants with SAH and 29 controls. Serum and CSF were sampled up to 14 days after SAH. SAH participants' clinical and neurological status were assessed at hospitalization, at discharge from the hospital, and 3 months after SAH. Furthermore, a logistic regression analysis was carried out to evaluate the ability of GOT1 and glutamate levels to predict neurological outcomes. Our results demonstrated consistently elevated serum and CSF glutamate levels after SAH. Furthermore, serum glutamate level was significantly higher in patients with cerebral ischemia and poor neurological outcome. CSF GOT1 was significantly higher in patients with uncontrolled intracranial hypertension and cerebral ischemia post-SAH, and independently predicted poor neurological outcomes.
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Isquemia Encefálica , Hipertensão Intracraniana , Hemorragia Subaracnóidea , Vasoespasmo Intracraniano , Humanos , Hemorragia Subaracnóidea/etiologia , Ácido Glutâmico , Vasoespasmo Intracraniano/etiologia , Isquemia Encefálica/complicações , Infarto Cerebral/complicações , Hipertensão Intracraniana/complicações , TransaminasesRESUMO
OBJECTIVES: Patients with COVID-19 frequently develop acute respiratory distress syndrome (ARDS) requiring intensive care unit (ICU) admission. Data on long-term survival of these patients are lacking. The authors investigated 1-year survival, quality of life, and functional recovery of patients with COVID-19 ARDS requiring invasive mechanical ventilation. DESIGN: Prospective observational study. SETTING: Tertiary-care university hospital. PARTICIPANTS: All patients with COVID-19 ARDS receiving invasive mechanical ventilation and discharged alive from hospital. INTERVENTIONS: Patients were contacted by phone after 1 year. Functional, cognitive, and psychological outcomes were explored through a questionnaire and assessed using validated scales. Patients were offered the possibility to undergo a follow-up chest computed tomography (CT) scan. MEASUREMENTS AND MAIN RESULTS: The study included all adult (age ≥18 years) patients with COVID-19-related ARDS admitted to an ICU of the authors' institution between February 25, 2020, and April 27, 2020, who received at least 1 day of invasive mechanical ventilation (IMV). Of 116 patients who received IMV, 61 (52.6%) survived to hospital discharge. These survivors were assessed 1 year after discharge and 56 completed a battery of tests of cognition, activities of daily living, and interaction with family members. They had overall good functional recovery, with >80% reporting good recovery and no difficulties in usual activities. A total of 52 (93%) of patients had no dyspnea at rest. Severe anxiety/depression was reported by 5 (8.9%) patients. Comparing 2-month and 1-year data, the authors observed the most significant improvements in the areas of working status and exertional dyspnea. One-year chest CT scans were available for 36 patients; fibrotic-like changes were present in 4 patients. CONCLUSIONS: All patients who survived the acute phase of COVID-19 and were discharged from the hospital were alive at the 1-year follow up, and the vast majority of them had good overall recovery and quality of life.
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COVID-19 , Respiração Artificial , Atividades Cotidianas , Adolescente , Adulto , COVID-19/terapia , Seguimentos , Humanos , Unidades de Terapia Intensiva , Qualidade de Vida , SARS-CoV-2RESUMO
BACKGROUND: Effective treatment for metachromatic leukodystrophy (MLD) remains a substantial unmet medical need. In this study we investigated the safety and efficacy of atidarsagene autotemcel (arsa-cel) in patients with MLD. METHODS: This study is an integrated analysis of results from a prospective, non-randomised, phase 1/2 clinical study and expanded-access frameworks. 29 paediatric patients with pre-symptomatic or early-symptomatic early-onset MLD with biochemical and molecular confirmation of diagnosis were treated with arsa-cel, a gene therapy containing an autologous haematopoietic stem and progenitor cell (HSPC) population transduced ex vivo with a lentiviral vector encoding human arylsulfatase A (ARSA) cDNA, and compared with an untreated natural history (NHx) cohort of 31 patients with early-onset MLD, matched by age and disease subtype. Patients were treated and followed up at Ospedale San Raffaele, Milan, Italy. The coprimary efficacy endpoints were an improvement of more than 10% in total gross motor function measure score at 2 years after treatment in treated patients compared with controls, and change from baseline of total peripheral blood mononuclear cell (PBMC) ARSA activity at 2 years after treatment compared with values before treatment. This phase 1/2 study is registered with ClinicalTrials.gov, NCT01560182. FINDINGS: At the time of analyses, 26 patients treated with arsa-cel were alive with median follow-up of 3·16 years (range 0·64-7·51). Two patients died due to disease progression and one due to a sudden event deemed unlikely to be related to treatment. After busulfan conditioning, all arsa-cel treated patients showed sustained multilineage engraftment of genetically modified HSPCs. ARSA activity in PBMCs was significantly increased above baseline 2 years after treatment by a mean 18·7-fold (95% CI 8·3-42·2; p<0·0001) in patients with the late-infantile variant and 5·7-fold (2·6-12·4; p<0·0001) in patients with the early-juvenile variant. Mean differences in total scores for gross motor function measure between treated patients and age-matched and disease subtype-matched NHx patients 2 years after treatment were significant for both patients with late-infantile MLD (66% [95% CI 48·9-82·3]) and early-juvenile MLD (42% [12·3-71·8]). Most treated patients progressively acquired motor skills within the predicted range of healthy children or had stabilised motor performance (maintaining the ability to walk). Further, most displayed normal cognitive development and prevention or delay of central and peripheral demyelination and brain atrophy throughout follow-up; treatment benefits were particularly apparent in patients treated before symptom onset. The infusion was well tolerated and there was no evidence of abnormal clonal proliferation or replication-competent lentivirus. All patients had at least one grade 3 or higher adverse event; most were related to conditioning or to background disease. The only adverse event related to arsa-cel was the transient development of anti-ARSA antibodies in four patients, which did not affect clinical outcomes. INTERPRETATION: Treatment with arsa-cel resulted in sustained, clinically relevant benefits in children with early-onset MLD by preserving cognitive function and motor development in most patients, and slowing demyelination and brain atrophy. FUNDING: Orchard Therapeutics, Fondazione Telethon, and GlaxoSmithKline.
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Cerebrosídeo Sulfatase/genética , Transplante de Células-Tronco Hematopoéticas , Lentivirus/genética , Leucodistrofia Metacromática , Idade de Início , Criança , Pré-Escolar , Feminino , Terapia Genética , Vetores Genéticos , Humanos , Itália , Leucodistrofia Metacromática/genética , Leucodistrofia Metacromática/terapia , Masculino , Estudos Prospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Coronavirus disease 2019 acute respiratory distress syndrome (COVID-19 ARDS) is a disease that often requires invasive ventilation. Little is known about COVID-19 ARDS sequelae. We assessed the mid-term lung status of COVID-19 survivors and investigated factors associated with pulmonary sequelae. METHODS: All adult COVID-19 patients admitted to the intensive care unit from 25th February to 27th April 2020 were included. Lung function was evaluated through chest CT scan and pulmonary function tests (PFT). Logistic regression was used to identify predictors of persisting lung alterations. RESULTS: Forty-nine patients (75%) completed lung assessment. Chest CT scan was performed after a median (interquartile range) time of 97 (89-105) days, whilst PFT after 142 (133-160) days. The median age was 58 (52-65) years and most patients were male (90%). The median duration of mechanical ventilation was 11 (6-16) days. Median tidal volume/ideal body weight (TV/IBW) was 6.8 (5.71-7.67) ml/Kg. 59% and 63% of patients showed radiological and functional lung sequelae, respectively. The diffusion capacity of carbon monoxide (DLCO ) was reduced by 59%, with a median per cent of predicted DLCO of 72.1 (57.9-93.9) %. Mean TV/IBW during invasive ventilation emerged as an independent predictor of persistent CT scan abnormalities, whilst the duration of mechanical ventilation was an independent predictor of both CT and PFT abnormalities. The extension of lung involvement at hospital admission (evaluated through Radiographic Assessment of Lung Edema, RALE score) independently predicted the risk of persistent alterations in PFTs. CONCLUSIONS: Both the extent of lung parenchymal involvement and mechanical ventilation protocols predict morphological and functional lung abnormalities months after COVID-19.
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COVID-19 , Síndrome do Desconforto Respiratório , Adulto , Humanos , Unidades de Terapia Intensiva , Pulmão/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Síndrome do Desconforto Respiratório/diagnóstico por imagem , Síndrome do Desconforto Respiratório/etiologia , SARS-CoV-2 , SobreviventesRESUMO
BACKGROUND & AIMS: Sarcopenia, a loss of muscle mass, quality and function, which is particularly evident in respiratory muscles, has been associated with many clinical adverse outcomes. In this study, we aimed at evaluating the role of reduced muscle mass and quality in predicting ventilation weaning, complications, length of intensive care unit (ICU) and of hospital stay and mortality in patients admitted to ICU for SARS-CoV-2-related pneumonia. METHODS: This was an observational study based on a review of medical records of all adult patients admitted to the ICU of a tertiary hospital in Milan and intubated for SARS-CoV-2-related pneumonia during the first wave of the COVID-19 pandemic. Muscle mass and quality measurement were retrieved from routine thoracic CT scans, when sections passing through the first, second or third lumbar vertebra were available. RESULTS: A total of 81 patients were enrolled. Muscle mass was associated with successful extubation (OR 1.02, 95% C.I. 1.00-1.03, p = 0.017), shorter ICU stay (OR 0.97, 95% C.I. 0.95-0.99, p = 0.03) and decreased hospital mortality (HR 0.98, 95% C.I. 0.96-0.99, p = 0.02). Muscle density was associated with successful extubation (OR 1.07, 95% C.I. 1.01-1.14; p = 0.02) and had an inverse association with the number of complications in ICU (Β -0.07, 95% C.I. -0.13 - -0.002, p = 0.03), length of hospitalization (Β -1.36, 95% C.I. -2.21 - -0.51, p = 0.002) and in-hospital mortality (HR 0.88, 95% C.I. 0.78-0.99, p = 0.046). CONCLUSIONS: Leveraging routine CT imaging to measure muscle mass and quality might constitute a simple, inexpensive and powerful tool to predict survival and disease course in patients with COVID-19. Preserving muscle mass during hospitalisation might have an adjuvant role in facilitating remission from COVID-19.
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COVID-19 , Desmame do Respirador , Adulto , Humanos , Desmame do Respirador/métodos , Pandemias , SARS-CoV-2 , Unidades de Terapia Intensiva , Tempo de Internação , Músculos , Respiração Artificial/métodos , Estudos Observacionais como AssuntoRESUMO
PURPOSE: To determine whether Macklin effect (a linear collection of air contiguous to the bronchovascular sheath) on baseline CT imaging is an accurate predictor for subsequent pneumomediastinum (PMD)/pneumothorax (PNX) development in invasively ventilated patients with COVID-19-related acute respiratory distress syndrome (ARDS). MATERIALS AND METHODS: This is an observational, case-control study. From a prospectively acquired database, all consecutive invasively ventilated COVID-19 ARDS patients who underwent at least one baseline chest CT scan during the study time period (February 25th, 2020-December 31st, 2020) were identified; those who had tracheal lesion or already had PMD/PNX at the time of the first available chest imaging were excluded. RESULTS: 37/173 (21.4%) patients enrolled had PMD/PNX; specifically, 20 (11.5%) had PMD, 10 (5.8%) PNX, 7 (4%) both. 33/37 patients with subsequent PMD/PNX had Macklin effect on baseline CT (89.2%, true positives) 8.5 days [range, 1-18] before the first actual radiological evidence of PMD/PNX. Conversely, 6/136 patients without PMD/PNX (4.4%, false positives) demonstrated Macklin effect (p < 0.001). Macklin effect yielded a sensitivity of 89.2% (95% confidence interval [CI]: 74.6-96.9), a specificity of 95.6% (95% CI: 90.6-98.4), a positive predictive value (PV) of 84.5% (95% CI: 71.3-92.3), a negative PV of 97.1% (95% CI: 74.6-96.9) and an accuracy of 94.2% (95% CI: 89.6-97.2) in predicting PMD/PNX (AUC:0.924). CONCLUSIONS: Macklin effect accurately predicts, 8.5 days in advance, PMD/PNX development in COVID-19 ARDS patients.
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COVID-19 , Enfisema Mediastínico , Pneumotórax , Síndrome do Desconforto Respiratório , Estudos de Casos e Controles , Humanos , Enfisema Mediastínico/diagnóstico por imagem , Síndrome do Desconforto Respiratório/diagnóstico por imagem , SARS-CoV-2RESUMO
COVID-19 associated severe respiratory failure frequently requires admission to an intensive care unit, tracheal intubation, and mechanical ventilation. Among the risks of prolonged mechanical ventilation under these conditions, there is the development of tracheoesophageal fistula. We describe a case of a severe COVID-19 associated respiratory failure, who developed a tracheoesophageal fistula. We hypothesized that one of the mechanisms for tracheoesophageal fistula, along with other local and general risk factors, is the local infection due to the location of the virus itself in the tracheobronchial tree. The patient was managed successfully with surgical intervention. This case highlights the increased risk of this potentially life-threatening complication among the COVID-19 patient cohort and suggests a management strategy.
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Objective: The use of angiotensin II in invasively ventilated patients with coronavirus disease 2019 (COVID-19) is controversial. Its effect on organ function is unknown. Design: Prospective observational study. Setting: Intensive care unit (ICU) of a tertiary academic hospital in Milan, Italy. Participants: Adult patients receiving mechanical ventilation due to COVID-19. Interventions: Use angiotensin II either as rescue vasopressor agent or as low dose vasopressor support. Main outcome measures: Patients treated before angiotensin II was available or treated in an adjacent COVID-19 ICU served as controls. For data analysis, we applied Bayesian modelling as appropriate. We assessed the effects of angiotensin II on organ function. Results: We compared 46 patients receiving angiotensin II therapy with 53 controls. Compared with controls, angiotensin II increased the mean arterial pressure (median difference, 9.05 mmHg; 95% CI, 1.87-16.22; P = 0.013) and the PaO2/FiO2 ratio (median difference, 23.17; 95% CI, 3.46-42.88; P = 0.021), and decreased the odds ratio (OR) of liver dysfunction (OR, 0.32; 95% CI, 0.09-0.94). However, angiotensin II had no effect on lactate, urinary output, serum creatinine, C-reactive protein, platelet count, or thromboembolic complications. In patients with abnormal baseline serum creatinine, Bayesian modelling showed that angiotensin II carried a 95.7% probability of reducing the use of renal replacement therapy (RRT). Conclusions: In ventilated patients with COVID-19, angiotensin II therapy increased blood pressure and PaO2/FiO2 ratios, decreased the OR of liver dysfunction, and appeared to decrease the risk of RRT use in patients with abnormal baseline serum creatinine. However, all of these findings are hypothesis-generating only. Trial registration:ClinicalTrials.gov NCT04318366.
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The use of lumbar drain (LD) in the aneurysmal subarachnoid hemorrhage (aSAH) has been described to reduce cerebral vasospasm and delayed cerebral ischemia (DCI), with a lack of studies referring to high grade population. The purpose of our study is to assess safety and feasibility of LD in the poor grade aSAH population subjected to endovascular aneurysm occlusion. Twenty-four consecutive poor grade aSAH patients, defined as grade IV and V according to World Federation of Neurological Surgeons (WFNS) classification, subjected to endovascular aneurysm occlusion, were retrospectively reviewed. Details of CSF drainage via LD and related complications were analyzed. Ventriculo-lumbar pressure gradient (VLPG) lower than 6â¯mmHg was considered in order to start LD use. Good outcome was defined as modified Rankin Scale (mRS) 0-2. LD was started within 72â¯h since aSAH in 17 cases (70.8%), and in 7 cases (29.2%) it was delayed due to contraindications. The mean LD length was of 13.8â¯days. The median VLPG during drainage was 2â¯mmHg (IQR: 0-4). No cases of brain or spinal hemorrhage, permanent neurological worsening due to brain herniation were noted. Three cases (12.5%) of CSF infection and a related death (4.2%) were reported. The use of LD, in association with external ventricular drain (EVD), seems to be safe and feasible in the poor grade aSAH population. VLPG monitoring seems to play a key role in avoiding potentially severe complications.
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Líquido Cefalorraquidiano , Aneurisma Intracraniano/complicações , Hemorragia Subaracnóidea/terapia , Adulto , Idoso , Drenagem/métodos , Feminino , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Hemorragia Subaracnóidea/líquido cefalorraquidiano , Hemorragia Subaracnóidea/etiologiaRESUMO
STUDY OBJECTIVE: To assess the safety of mechanical ventilation and effectiveness of extrinsic positive end-expiratory pressure (PEEP) (PEEPe) in improving peripheral oxygen saturation (SpO2) during direct microlaryngeal laser surgery; to assess the incidence, amount, and nature (dynamic hyperinflation or airflow obstruction) of ensuing intrinsic PEEP (PEEPi); and to find a surrogate PEEPi indicator. DESIGN: Quasiexperimental. SETTING: S. Raffaele Hospital (Milano), November 2009 to December 2010. PATIENTS: Fifty-two adults scheduled for direct microlaryngeal laser surgery. Exclusion criterion is pregnancy. INTERVENTIONS: Twenty-one percent O2 mechanical ventilation through 4.5- to 5.5-mm internal diameter endotracheal tubes; in 29 patients, after measurement of PEEPi, an identical amount of PEEPe was added; and PEEPi. MEASUREMENTS: SpO2, peak (Pawpeak) and plateau (Pawplateau) airway pressure, and end-expiratory carbon dioxide were measured every 5 minutes. Respiratory compliance (Crs) was computed. PEEPi was measured (end-expiratory occlusion method). MAIN RESULTS: PEEPi ≥5 cm H2O occurred in 14 patients (27%) after intubation, in 16 (30%) at the beginning, and in 14 (27.3%) at the end of surgery. Thirty-one patients (59.4%) exhibited PEEPi ≥5 cm H2O on at least 1 time point. PEEPi at the beginning of surgery was positively correlated with Pawplateau, Crs, tidal volume, and body mass index. Body mass index was the only predictor for the occurrence of PEEPi ≥5 cm H2O. At the beginning of surgery, the Pawplateau receiver operating characteristic curve predicting PEEPi ≥5 cm H2O had area under the receiver operating characteristic curve of 0.85; best cutoff value of 15.5 cm H2O (sensitivity, 88.9%; specificity, 75%; correctly classified cases, 86.1%). When PEEPe was applied, in 23 cases (82.1%), total PEEP equaled PEEPe+ PEEPi; in 3 (10.7%), it was lower; and in 2 (7.1%), it was higher. Application of PEEPe increased SpO2 (P< .05) and Crs (P< .05). CONCLUSIONS: During ventilation through small endotracheal tubes, PEEPi (mostly due to dynamic hyperinflation) is common. Hemodynamic complications, barotrauma, and O2 desaturation (reversible with PEEPe) are rare. Pawplateau provided by ventilators is useful in suspecting and monitoring the occurrence of PEEPi and allows detection of lung overdistension as PEEPe is applied.
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Anestesia Geral , Respiração por Pressão Positiva Intrínseca/epidemiologia , Respiração Artificial/instrumentação , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Fatores de RiscoRESUMO
BACKGROUND: Acupuncture anesthesia was created in the 1950's in China and continues to be used there today during most major surgeries. It is widely used in China for such complex operations as brain, heart, and abdominal surgery. It is popular in China because it is economical, practical, and beneficial to the patients. With acupuncture anesthesia there is less bleeding during surgery and there is also quicker post-operative recovery. OBJECTIVE: This randomized prospective study aims at comparing the effect of two acupoints (Yongquan, KI1 and Renzhong, DU26) with sham acupuncture and no acupuncture on the time to recovery of consciousness after general anesthesia by means of the Bispectral Index monitor (BIS). DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS: This is a prospective randomized controlled study. We randomly assigned 50 patients to 5 groups during recovery from surgical anesthesia. Four groups had acupuncture on KI1 (group A), DU26 (groups B), both KI1 and DU26 (group C), and sham points (group D), and one had no acupuncture (group E). MAIN OUTCOME MEASURES: Bispectral Index (BIS), time to spontaneous eye opening, time to tracheal extubation, and time to following commands were measured as the main outcome measures. RESULTS: Time to spontaneous eye opening differed among groups (P=0.002), as well as time to tracheal extubation (P<0.000 1) and time to following commands (P=0.000 6). BIS values differed significantly among groups both 5 and 10 min after the end of anesthesia (P<0.000 1 and P=0.000 4, respectively). BIS values of groups D and E were lower than those of the other groups and those of group C were higher. The same pattern was observed also 15 and 30 min after the end of anesthesia, although the difference among groups was not significant at these time points (P=0.164 and P=0.104, respectively). CONCLUSION: Acupuncture on DU26 and KI1 accelerates recovery of consciousness after general anesthesia. Moreover, a possible synergistic effect of DU26 and KI1 is suggested. This issue may play a role in the optimization of operating room management and raise interest about the usefulness of acupuncture on unconsciousness states of different nature.
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Terapia por Acupuntura/métodos , Período de Recuperação da Anestesia , Anestesia Geral/métodos , Recuperação Demorada da Anestesia/prevenção & controle , Adulto , Idoso , Estado de Consciência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica/métodos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/métodos , Resultado do TratamentoRESUMO
Cushing response, which acts to preserve cerebral blood flow by inducing arterial hypertension, could induce neurogenic heart damage through hyperactivation of autonomic nervous system. Most of clinical reports describe neurogenic heart damage as a self-limiting condition clinically characterized by electrocardiographic abnormalities in the setting of an acute neurologic insult. Here we describe a case of life-threatening cardiac dysfunction immediately after a massive intracerebral hemorrhage in a healthy 7-year-old child. The low probability of ischemic heart disease, the poor increase of cardiac necrosis markers, the localization of regional wall motion abnormalities that are not typical for coronary artery disease, and reversibility after brain surgical decompression are consistent all with neurogenic heart damage. Acute decrease of brain oxygen delivery caused by cardiac dysfunction worsens secondary brain injury in the setting of an acute neurologic insult. Thus, Cushing response, which is a physiological mechanism of cerebral protection, could become a double-edged sword when massive sympathetic activation makes the myocardium stunned.
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Hemorragia Cerebral/complicações , Hemorragia Cerebral/fisiopatologia , Sistema de Condução Cardíaco/fisiopatologia , Hipertensão/etiologia , Hipertensão/fisiopatologia , Miocárdio Atordoado/etiologia , Miocárdio Atordoado/fisiopatologia , Sistema Nervoso Autônomo/fisiopatologia , Gasometria , Hemorragia Cerebral/diagnóstico , Hemorragia Cerebral/cirurgia , Criança , Diagnóstico Diferencial , Eletrocardiografia , Humanos , Hipertensão/diagnóstico , Masculino , Miocárdio Atordoado/diagnóstico , Miocárdio Atordoado/terapia , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: There are some intracranial insults which are associated with cardiac abnormalities. Studies of these abnormalities have never been carried out in elective intracranial neurosurgery for the removal of brain tumors. Our prospective study aims at quantifying serum cardiac troponin T (cTnT) and N-terminal pro-brain natriuretic peptide (NT-proBNP) before and after elective intracranial neurosurgery for tumor resection in patients with no history of cardiac abnormality. METHODS: Pre- and postoperative serum cTnT and NT-proBNP were measured in 108 patients submitted to elective major intracranial surgery for the removal of neoplastic lesions. We tested potentially predictive models for these biomarker serum levels. RESULTS: cTnT was undetectable both before and after surgery. Median (IQR) basal NT-proBNP was 35 (18-69) pg/mL and 110 (51-191) pg/mL after surgery. In a multiple linear regression model, basal NT-proBNP was predicted by age, gender, BMI, and the presence of "mass effect" (midline shift or effaced perimesencephalic cisterns on preoperative CT scan) (whole model P < 0.0001; R (2) = 0.3502; and Adjusted R (2) = 0.3247). Postoperative NT-proBNP increase was predicted by baseline NT-proBNP level (whole model P < 0.0001; R (2) = 0.5106; and Adjusted R (2) = 0.5052). CONCLUSION: An intracranial mass effect is associated with higher NT-proBNP serum levels in patients with a brain neoplasm. Following elective intracranial surgery for brain tumor resection NT-proBNP values increase.
Assuntos
Neoplasias Encefálicas/cirurgia , Glioma/cirurgia , Peptídeo Natriurético Encefálico/sangue , Procedimentos Neurocirúrgicos/efeitos adversos , Fragmentos de Peptídeos/sangue , Complicações Pós-Operatórias/sangue , Troponina T/sangue , Adulto , Anestesia por Inalação/estatística & dados numéricos , Anestesia Intravenosa/estatística & dados numéricos , Biomarcadores/sangue , Neoplasias Encefálicas/epidemiologia , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Feminino , Glioma/epidemiologia , Humanos , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Procedimentos Neurocirúrgicos/estatística & dados numéricos , Período Perioperatório , Complicações Pós-Operatórias/epidemiologia , Valor Preditivo dos Testes , Estudos Prospectivos , Fatores de RiscoRESUMO
BACKGROUND: To assess the prognostic value of corpus callosum lesions (CCL) and brain stem lesions (BSL) in diffuse axonal injury (DAI) patients. METHODS: From December 1989 to December 2008, 102 consecutive patients with pure DAI were admitted to our neurosurgical intensive care unit. Age, gender, Acute Physiology and Chronic Health Evaluation score, Glasgow Coma Score (GCS), pupillary light reactivity on admission, brain magnetic resonance imaging (MRI) 24 hours to 72 hours after trauma and sepsis, shock, adult respiratory distress syndrome, renal failure, neurosurgery, high intracranial pressure during the 6 months posttrauma were studied with multiple logistic regression, and Cox's proportional hazards, respectively, considering the Glasgow Outcome Scale and the time to recovery of consciousness as outcome variables. RESULTS: Four variables predicted unfavorable Glasgow Outcome Scale (likelihood ratio p<0.0001; Area Under the Receiver Operator Curve (AUROC)=0.92; Naglekerke's R=0.64; Goodness-of-Fit p=0.8679): age (5-year odds ratio [OR], 1.44; 95% CI, 1.14-1.82; p=0.002), bilateral absence of light reflexes (OR, 11.11; 95% CI, 2.19-57.67; p=0.004), multiplicity of CCL (OR, 29.23; 95% CI, 7.06-121.01; p<0.001), and multiplicity of BSL (OR, 9.43; 95% CI, 2.44-36.42; p=0.001). Four variables affected time to recovery of consciousness: age (hazard ratio, 0.98; 95% CI, 0.97-0.99; p=0.009), bilateral absence of light reflexes (hazard ratio, 0.51; 95% CI, 0.27-0.97; p=0.041), multiplicity of CCL (hazard ratio, 0.40; 95% CI, 0.25-0.66; p<0.001), and total GCS on admission (hazard ratio, 1.45; 95% CI, 1.23-1.71; p<0.001). CONCLUSIONS: In DAI patients, bad outcome is predicted by age, bilateral absence of pupillary light reflexes, multiplicity of CCL, and BSL on MRI. Time to recovery of consciousness is predicted by age, bilateral absence of light reflexes, multiplicity of CCL on MRI, and GCS on admission.
Assuntos
Lesões Encefálicas/diagnóstico , Adulto , Fatores Etários , Encéfalo/diagnóstico por imagem , Encéfalo/patologia , Lesões Encefálicas/diagnóstico por imagem , Lesões Encefálicas/patologia , Tronco Encefálico/diagnóstico por imagem , Tronco Encefálico/lesões , Tronco Encefálico/patologia , Intervalos de Confiança , Corpo Caloso/diagnóstico por imagem , Corpo Caloso/lesões , Corpo Caloso/patologia , Feminino , Escala de Coma de Glasgow , Humanos , Estimativa de Kaplan-Meier , Modelos Logísticos , Imageamento por Ressonância Magnética , Masculino , Razão de Chances , Prognóstico , Modelos de Riscos Proporcionais , Curva ROC , Tomografia Computadorizada por Raios XRESUMO
We retrospectively reviewed a prospectively collected database of our diffuse axonal injury (DAI) patients to evaluate the accuracy of the evidence of interpeduncular cistern (IPC) blood on computed tomography (CT) scan when diagnosing brainstem lesions (BSL) early after trauma. From December 1989 to December 2008 we prospectively maintained a clinical and radiological database of head injured patients admitted to our neurosurgical intensive care unit (ICU) that met the following criteria: coma (Glasgow Coma Scale [GCS] score < 9) following the traumatic event; neurological derangement not ascribable to hypoxia, hypotension, or long-acting drugs able to alter state of consciousness; absence of lesions accounting for the severity of coma either on the admission CT scan or on subsequent CT scans; and no contraindications to magnetic resonance imaging (MRI; e.g., indwelling metallic implants). Patients with MRI evidence of BSL exhibited a significantly higher incidence of IPC blood on CT scan than patients without such evidence (77.92% versus 20.00%; p < 0.0001). However, these same patients showed a similar incidence of lesions not associated with IPC blood (68.83% versus 56%; p = 0.2459). The evidence of IPC blood on CT scan as an indicator of BSL had a sensitivity of 0.78 (95% CI: 0.70, 0.86), and a specificity of 0.80 (95% CI: 0.72, 0.88), with a 3.90 likelihood ratio for a positive CT scan, and a 0.28 likelihood ratio for a negative CT scan. Our data suggest that the finding of IPC blood on CT scan early after trauma in patients with otherwise unexplained coma is a good marker for possible brainstem lesions.
Assuntos
Lesões Encefálicas/diagnóstico por imagem , Tronco Encefálico/lesões , Hemorragia Subaracnoídea Traumática/diagnóstico por imagem , Espaço Subaracnóideo/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Adolescente , Adulto , Idoso , Biomarcadores , Lesões Encefálicas/complicações , Lesões Encefálicas/patologia , Lesões Encefálicas/fisiopatologia , Tronco Encefálico/irrigação sanguínea , Tronco Encefálico/patologia , Criança , Pré-Escolar , Lesão Axonal Difusa/diagnóstico por imagem , Lesão Axonal Difusa/fisiopatologia , Feminino , Escala de Coma de Glasgow , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Fibras Nervosas Mielinizadas/diagnóstico por imagem , Fibras Nervosas Mielinizadas/patologia , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Estudos Retrospectivos , Hemorragia Subaracnoídea Traumática/patologia , Hemorragia Subaracnoídea Traumática/fisiopatologia , Espaço Subaracnóideo/patologia , Espaço Subaracnóideo/fisiopatologia , Tegmento Mesencefálico/irrigação sanguínea , Tegmento Mesencefálico/diagnóstico por imagem , Tegmento Mesencefálico/patologia , Adulto JovemRESUMO
Magnetic resonance imaging (MRI) requires patient immobility and children generally need to be sedated. The ideal sedative agent for functional MRI (fMRI) should only minimally hamper the neurophysiologic effect of the administered sensorial stimulation. This study compares the effect of propofol and midazolam on the fMRI auditory activation pattern in children. Fourteen children in the 3 to 7 year age group without neurologic or auditory deficits were randomly assigned to receive propofol or midazolam for sedation during auditory fMRI. Two patients in the midazolam group were excluded due to positive baseline MRIs. The children were stimulated using a passive listening task. The fMRI signal was modeled using various functions (hemodynamic response function, temporal derivative, and dispersion derivative) to check for the differing temporal characteristics of the signal between the groups. Patients in the propofol group showed activation only in the primary auditory cortex and exhibited a pattern more similar to that of nonsedated adults. Patients in the midazolam group exhibited a more complex pattern, presenting activation areas other than the primary auditory cortex; a delay in the functional response and higher duration variability were also observed. Our sample sizes are too small to derive a conclusive inference. Our preliminary study encourages the hypothesis that propofol is preferable to midazolam to maintain sedation in 3 to 7-year-old children during auditory fMRI because it facilitates the elicitation of a more focused auditory cortical activation pattern with less temporal and spatial dispersion.