Management of Traumatic Brain Injury at a Medium Complexity Hospital in a Remote Area of Amazonas, 2017-2019.

OBJECTIVE: To describe the traumatic brain injury (TBI) care in the city of Coari, Amazonas, from 2017-2019. METHODS: Ecological study based on the analysis of the data obtained by the Epidemiology Service of the Regional Hospital of Coari regarding TBI attendances in the emergency room from January 2017 to October 2019. According to the Glasgow Coma Scale, TBI was classified as mild, moderate, or severe. Other variables analyzed were sex, age, main causes of TBI, hospitalizations at the admission unit, and transfers to another health center and means of transport used. RESULTS: One hundred ten admissions were registered: 24 mild TBI, 51 moderate, and 35 severe; higher prevalence among men (70%); and age between 20 and 29 years (29%). The main causes were motorcycle accidents (42.7%), falls (29%), and physical aggression (21%). Some 69% of the patients admitted required to be transferred to another health center, with aerial intensive care unit (ICU) as the most significant means of transport (48.7%). Thirty patients hospitalized at the admission unit progressed with hospital discharge and 4 died. CONCLUSIONS: The profile of patients affected by TBI in the city of Coari was characterized by male victims of motorcycle accidents with age between 20 and 29 years. The high transfer rates indicates the need for a better neurotrauma assistance. Further investigations and studies associated with regional specificities are essential to recommend changes on the scope of public health and therefore decrease the incidence of TBI.

Mismatch between midline shift and hematoma thickness as a prognostic factor of mortality in patients sustaining acute subdural hematoma.

BACKGROUND: Acute subdural hematoma (ASDH) is a traumatic lesion commonly found secondary to traumatic brain injury. Radiological findings on CT, such as hematoma thickness (HT) and structures midline shift (MLS), have an important prognostic role in this disease. The relationship between HT and MLS has been rarely studied in the literature. Thus, this study aimed to assess the prognostic accuracy of the difference between MLS and HT for acute outcomes in patients with ASDH in a low-income to middle-income country. METHODS: This was a post-hoc analysis of a prospective cohort study conducted in a university-associated tertiary-level hospital in Brazil. The TRIPOD (Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis) statement guidelines were followed. The difference values between MLS and HT (Zumkeller index, ZI) were divided into three categories (<0.00, 0.01-3, and >3). Logistic regression analyses were performed to reveal the OR of categorized ZI in predicting primary outcome measures. A Cox regression was also performed and the results were presented through HR. The discriminative ability of three multivariate models including clinical and radiological variables (ZI, Rotterdam score, and Helsinki score) was demonstrated. RESULTS: A total of 114 patients were included. Logistic regression demonstrated an OR value equal to 8.12 for the ZI >3 category (OR 8.12, 95% CI 1.16 to 40.01; p=0.01), which proved to be an independent predictor of mortality in the adjusted model for surgical intervention, age, and Glasgow Coma Scale (GCS) score. Cox regression analysis demonstrated that this category was associated with 14-day survival (HR 2.92, 95% CI 1.38 to 6.16; p=0.005). A multivariate analysis performed for three models including age and GCS with categorized ZI or Helsinki or Rotterdam score demonstrated area under the receiver operating characteristic curve values of 0.745, 0.767, and 0.808, respectively. CONCLUSIONS: The present study highlights the potential usefulness of the difference between MLS and HT as a prognostic variable in patients with ASDH. LEVEL OF EVIDENCE: Level III, epidemiological study.

Lhermitte-Duclos Disease and Cowden Syndrome: A Case Report and Literature Review

Lhermitte-Duclos disease (LDD), also known as dysplastic gangliocytoma of the cerebellum, is a rare, usually benign, slow-growing tumor, that commonly affects patients aged 30 to 50 years-old. The manifestations of dysplastic cerebellar gangliocytoma are nonspecific and are related both to the mass effect produced by its growth and to the location of the lesion. Cerebellar symptoms such as ataxia are often present. In 40% of cases, the tumor is associated with Cowden syndrome, which is part of a group ofgenetic disorders called polypoid hamartoma complex. In this case report, the patient presented expansive lesion in the posterior fossa, compatible with LDD, associated with macrocephaly. These findings are consideredmajor criteria for Cowden syndrome. When together, they confirm the diagnoses. To our knowledge, this is the first report of the association of LDD and Cowden syndrome in Brazil.

Chronic subdural hematoma with sudden clinical uncal herniation and coma: case report

Context: Chronic subdural hematomas are frequent diseases in neurosurgery units. Decreased level of consciousness is observed in 28 to 100 percent of cases, nevertheless in rare cases are seen comatous patients. We describe a case of a patient with clinical uncal herniation elapsed by a chronic subdural hematoma. Case report: Patient with previous diagnosis of breast cancer, presented sudden occurrence of a headache followed by decreasing level of consiousness the day before reaching our service. The patient was taken than to another Hospital at 1:00 AM in Glasgow Coma Scale (GCS) 13, with isochonic pupils. At 7:00 AM the GCS went to 7 and the pupils became anisochonic L > R and than transferred to our Unit and immediatly submitted to a computed tomohraphy scanning of the head that showed a chronic subdural hematoma with midline shift. The patient promptly was taken to surgical room and treated with a single burr hole with drainage of hypertensive chronic subdural hematoma. The level of consiousness increased few hours after surgery, being in GCS 15 just 6 hours after, without motor deficits. Conclusion: In spite of commonly progressive evolution chronic subdural hematomas can present with herniation, becoming itself a neurosurgical emergency.