Normal-pressure hydrocephalus: A critical review / Hidrocefalia de pressão normal: uma revisão crítica

ABSTRACT. Normal-pressure hydrocephalus (NPH) is a potentially reversible syndrome characterized by enlarged cerebral ventricles (ventriculomegaly), cognitive impairment, gait apraxia and urinary incontinence. A critical review of the concept, pathophysiology, diagnosis, and treatment of both idiopathic and secondary NPH was conducted. We searched Medline and PubMed databases from January 2012 to December 2018 using the keywords "normal-pressure hydrocephalus" / "idiopathic normal-pressure hydrocephalus" / "secondary normal-pressure hydrocephalus" / "NPH" / "ventriculoperitoneal shunt". The initial search produced 341 hits. After careful selection, a total of 54 articles were chosen and additional relevant studies were included during the process of writing this article. NPH is an important cause of potentially reversible dementia, frequent falls and recurrent urinary infections in the elderly. The clinical and imaging features of NPH may be incomplete or nonspecific, posing a diagnostic challenge for medical doctors and often requiring expert assessment to minimize unsuccessful surgical treatments. Recent advances resulting from the use of non-invasive MRI methods for quantifying cerebral blood flow, in particular arterial spin-labeling (ASL), and the frequent association of NPH and obstructive sleep apnea (OSA), offer new avenues to understand and treat NPH.

RESUMO. A hidrocefalia de pressão normal (HPN) é uma síndrome potencialmente reversível marcada por ventrículos cerebrais alargados (ventriculomegalia), declínio cognitivo, apraxia da marcha e incontinência urinária. Revisar criticamente o conceito, a fisiopatologia, o diagnóstico e o tratamento da HPN idiopática e secundária. Os autores acessaram as bases de dados Medline e Pubmed entre janeiro de 2012 e dezembro de 2018, utilizando as palavras-chave "normal-pressure hydrocephalus" / "idiopathic normal-pressure hydrocephalus" / "secondary normal-pressure hydrocephalus" / "NPH" / "ventriculoperitoneal shunt". A busca inicial resultou em 341 artigos. Após cuidadosa seleção, 54 estudos foram escolhidos e pesquisas adicionais foram incluídas durante o processo de elaboração do manuscrito. A HPN é uma importante causa de demência potencialmente reversível, quedas frequentes e infecção urinária recorrente em idosos. As características clínicas e de imagem da HPN podem ser incompletas ou inespecíficas, de modo que este se torna um diagnóstico difícil para médicos. Não raro uma avaliação por especialista é necessária, visando minimizar tratamentos cirúrgicos ineficazes. Avanços recentes advindos do uso não invasivo de ressonância magnética para quantificação do fluxo sanguíneo cerebral, em particular arterial spin-labeling (ASL), assim como a usual associação entre HPN e apneia obstrutiva do sono representam novos meios de entender e de tratar a HPN.

Monitoring of drug treatment and psychosocial intervention with SPECT in Alzheimer patients: implications for neurologically appropriate psychosocial interventions. An observational study. The Osaki-Tajiri Project / Monitoramento do tratamento medicamentoso e intervenção psicossocial com SPECT em pacientes com Alzheimer: implicações para intervenções psicossociais neurologicamente apropriadas. um estudo observacional. o Projeto Osaki-Tajiri

ABSTRACT We previously examined cerebral blood flow (CBF) with single-photon emission computed tomography (SPECT) in Alzheimer's disease (AD) with reference to drug treatment (donepezil) and psychosocial intervention. Objective: The aim is to provide "brain-based" evidence for psychosocial interventions using SPECT. Methods: The participants were 27 consecutive outpatients with AD who received the drug and psychosocial intervention, and SPECT three times (baseline, pre-/post-intervention) at 6 month-intervals. The significance level of changes in CBF (Z score) and the extent of significantly changed areas, calculated with the eZIS system, were used as monitoring parameters. The participants were classified into three groups: improve (post-intervention CBF increased), worsening (progressive decline), and no change. Results: Six, 8, and 13 patients were classified as improve, worsening, and no change, respectively. All subjects in the improve group showed improvement in cognitive test scores for the MMSE and/or the CGI scores associated with the brain area with a CBF increase (right parietal lobe), suggesting appropriate psychosocial intervention (visuospatial intervention). Conclusion: These results suggest that monitoring of CBF with the eZIS system may be clinically applicable for monitoring of drug treatment and psychosocial intervention in AD patients.

RESUMO Nós examinamos previamente o fluxo sanguíneo cerebral (FSC) com tomografia computadorizada de emissão de fóton único (SPECT) na doença de Alzheimer (DA) com referência ao tratamento medicamentoso (donepezila) e intervenção psicossocial. Objetivo: Fornecer evidências "baseadas no cérebro" para intervenções psicossociais usando o SPECT. Métodos: Os participantes foram 27 pacientes ambulatoriais consecutivos com DA que receberam a droga e intervenção psicossocial, e SPECT por três vezes (basal, pré/pós-intervenção) em intervalos de seis meses. O nível de significância das mudanças no FSC (escore Z) e a extensão das áreas significativamente alteradas calculadas com o sistema eZIS foram utilizados como parâmetros de monitoramento. Os participantes foram classificados em três grupos: melhora (FSC pós-intervenção aumentada), piora (declínio progressivo) e nenhuma mudança. Resultados: Seis, oito e 13 pacientes foram classificados como melhora, piora e sem alteração, respectivamente. Todos no grupo melhora mostraram aumento dos escores no MEEM e/ou nos escores do CGI associados à área do cérebro com aumento do FSC (lobo parietal direito), sugerindo intervenção psicossocial apropriada (intervenção visoespacial). Conclusão: Estes resultados sugerem que o monitoramento do FSC com o sistema eZIS pode ser clinicamente aplicável para o monitoramento do tratamento medicamentoso e intervenção psicossocial em pacientes com DA.

Patient state index and cerebral blood flow changes during shoulder arthroscopy in beach chair position / Patient State Index e alterações do fluxo sanguíneo cerebral durante artroscopia do ombro em posição de cadeira de praia

Abstract Background and objectives: The aim of the study were to demonstrate the possible hemodynamic changes and cerebral blood flow alterations in patients who were positioned from supine to beach chair position; and to detect if the position change causes any cortical activity alteration as measured by the 4-channeled electroencephalography monitor. Methods: 35 patients were included. Before the induction, mean arterial pressure and patient state index values were recorded (T0). After the intubation, doppler-ultrasonography of the patients’ internal carotid and vertebral arteries were evaluated to acquire cerebral blood flow values from the formula. In supine position, mean arterial pressure, patient state index and cerebral blood flow values were recorded (T1) and the patient was positioned to beach chair position. After 5 min all measurements were repeated (T2). Measurements of patient state index and mean arterial pressure were repeated after 20 (T3), and 40 (T4) min. Results: There was a significant decrease between T0 and T1 in heart rate (80.5 ± 11.6 vs. 75.9 ± 14.4 beats/min), MAP (105.8 ± 21.9 vs. 78.9 ± 18.4 mmHg) and PSI (88.5 ± 8.3 vs. 30.3 ± 9.7) (all p < 0.05). Mean arterial pressure decreased significantly after position change, and remained decreased, compared to T1. The overall analysis of patient state index values (T1-T4) showed no significant change; however, comparing only T1 and T2 resulted in a statically significant decrease in patient state index. There was a significant decrease in cerebral blood flow after beach chair position. Conclusion: Beach chair position was associated with a decrease in cerebral blood flow and patient state index values. Patient state index was affected by the gravitational change of the cerebral blood flow; however, both factors were not directly correlated to each other. Moreover, the decrease in patient state index value was transient and returned to normal values within 20 min.

Resumo Justificativa e objetivos: Demonstrar as possíveis alterações hemodinâmicas e do fluxo sanguíneo cerebral (FSC) em pacientes que foram posicionados de supinação para cadeira de praia (CP) e detectar se a mudança de posição causa alguma alteração na atividade cortical como mensurado pelo monitor de EEG com quatro canais. Métodos: Foram incluídos 35 pacientes. Antes da indução, os valores da PAM e do IEP foram registrados (T0). Após a intubação, ultrassonografias com Doppler da carótida interna e artérias vertebrais dos pacientes foram avaliadas para adquirir os valores do FSC a partir da fórmula. Em supinação, os valores da PAM, IEP e FSC foram registrados (T1) e o paciente foi posicionado em CP. Após cinco minutos, todas as mensurações foram repetidas (T2). As mensurações do IEP e PAM foram repetidas após 20 (T3) e 40 minutos (T4). Resultados: Houve uma diminuição significativa entre T0 e T1 na FC (80,5 ± 11,6 vs. 75,9 ± 14,4 bpm), PAM (105,8 ± 21,9 vs. 78,9 ± 18,4 mmHg) e IEP (88,5 ± 8,3 vs. 30,3 ± 9,7) (p < 0,05 para todos). A PAM diminuiu significativamente após a mudança de posição e permaneceu diminuída em relação a T1. A análise global dos valores do IEP (T1-T4) não mostrou mudança significativa, mas a comparação de apenas T1 e T2 resultou em redução estatisticamente significativa do IEP. Houve redução significativa do FSC após o posicionado em CP. Conclusão: O posicionado em CP foi associado à diminuição do FSC e dos valores do IEP. O IEP foi afetado pela mudança gravitacional do FSC; no entanto, ambos os fatores não estavam diretamente correlacionados. Além disso, a diminuição do valor do IEP foi transitória e voltou aos valores normais dentro de 20 minutos.

Patient state index and cerebral blood flow changes during shoulder arthroscopy in beach chair position.

BACKGROUND AND OBJECTIVES: The aim of the study were to demonstrate the possible hemodynamic changes and cerebral blood flow alterations in patients who were positioned from supine to beach chair position; and to detect if the position change causes any cortical activity alteration as measured by the 4-channeled electroencephalography monitor. METHODS: 35 patients were included. Before the induction, mean arterial pressure and patient state index values were recorded (T0). After the intubation, doppler-ultrasonography of the patients' internal carotid and vertebral arteries were evaluated to acquire cerebral blood flow values from the formula. In supine position, mean arterial pressure, patient state index and cerebral blood flow values were recorded (T1) and the patient was positioned to beach chair position. After 5min all measurements were repeated (T2). Measurements of patient state index and mean arterial pressure were repeated after 20 (T3), and 40 (T4)min. RESULTS: There was a significant decrease between T0 and T1 in heart rate (80.5±11.6 vs. 75.9±14.4beats/min), MAP (105.8±21.9 vs. 78.9±18.4mmHg) and PSI (88.5±8.3 vs. 30.3±9.7) (all p<0.05). Mean arterial pressure decreased significantly after position change, and remained decreased, compared to T1. The overall analysis of patient state index values (T1-T4) showed no significant change; however, comparing only T1 and T2 resulted in a statically significant decrease in patient state index. There was a significant decrease in cerebral blood flow after beach chair position. CONCLUSION: Beach chair position was associated with a decrease in cerebral blood flow and patient state index values. Patient state index was affected by the gravitational change of the cerebral blood flow; however, both factors were not directly correlated to each other. Moreover, the decrease in patient state index value was transient and returned to normal values within 20min.

[Patient state index and cerebral blood flow changes during shoulder arthroscopy in beach chair position]. / Patient State Index e alterações do fluxo sanguíneo cerebral durante artroscopia do ombro em posição de cadeira de praia.

BACKGROUND AND OBJECTIVES: The aim of the study were to demonstrate the possible hemodynamic changes and cerebral blood flow alterations in patients who were positioned from supine to beach chair position; and to detect if the position change causes any cortical activity alteration as measured by the 4-channeled electroencephalography monitor. METHODS: 35 patients were included. Before the induction, mean arterial pressure and patient state index values were recorded (T0). After the intubation, doppler-ultrasonography of the patients' internal carotid and vertebral arteries were evaluated to acquire cerebral blood flow values from the formula. In supine position, mean arterial pressure, patient state index and cerebral blood flow values were recorded (T1) and the patient was positioned to beach chair position. After 5min all measurements were repeated (T2). Measurements of patient state index and mean arterial pressure were repeated after 20 (T3), and 40 (T4)min. RESULTS: There was a significant decrease between T0 and T1 in heart rate (80.5±11.6 vs. 75.9±14.4beats/min), MAP (105.8±21.9 vs. 78.9±18.4mmHg) and PSI (88.5±8.3 vs. 30.3±9.7) (all p<0.05). Mean arterial pressure decreased significantly after position change, and remained decreased, compared to T1. The overall analysis of patient state index values (T1-T4) showed no significant change; however, comparing only T1 and T2 resulted in a statically significant decrease in patient state index. There was a significant decrease in cerebral blood flow after beach chair position. CONCLUSION: Beach chair position was associated with a decrease in cerebral blood flow and patient state index values. Patient state index was affected by the gravitational change of the cerebral blood flow; however, both factors were not directly correlated to each other. Moreover, the decrease in patient state index value was transient and returned to normal values within 20min.

Is there any influence of breastfeeding on the cerebral blood flow? A review of 256 healthy newborns

OBJECTIVE: To investigate whether breastfeeding influence the cerebral blood-flow velocity. MATERIALS AND METHODS: The present study included 256 healthy term neonates, all of them with appropriate weight for gestational age, 50.8% being female. Pulsatility index, resistance index and mean velocity were measured during breastfeeding or resting in the anterior cerebral artery, in the left middle cerebral artery, and in the right middle cerebral artery of the neonates between their first 10 and 48 hours of life. The data were analyzed by means of a paired t-test, Brieger's f-test for analysis of variance and linear regression, with p < 0.01 being accepted as statistically significant. RESULTS: Mean resistance index decreased as the mean velocity increased significantly during breastfeeding. Pulsatility index values decreased as much as the resistance index, but in the right middle cerebral artery it was not statistically significant. CONCLUSION: Breastfeeding influences the cerebral blood flow velocities.

Cerebral hemodynamics: concepts of clinical importance / Hemodinâmica encefálica: conceitos de importância clínica

Cerebral hemodynamics and metabolism are frequently impaired in a wide range of neurological diseases, including traumatic brain injury and stroke, with several pathophysiological mechanisms of injury. The resultant uncoupling of cerebral blood flow and metabolism can trigger secondary brain lesions, particularly in early phases, consequently worsening the patient's outcome. Cerebral blood flow regulation is influenced by blood gas content, blood viscosity, body temperature, cardiac output, altitude, cerebrovascular autoregulation, and neurovascular coupling, mediated by chemical agents such as nitric oxide (NO), carbon monoxide (CO), eicosanoid products, oxygen-derived free radicals, endothelins, K+, H+, and adenosine. A better understanding of these factors is valuable for the management of neurocritical care patients. The assessment of both cerebral hemodynamics and metabolism in the acute phase of neurocritical care conditions may contribute to a more effective planning of therapeutic strategies for reducing secondary brain lesions. In this review, the authors have discussed concepts of cerebral hemodynamics, considering aspects of clinical importance.

Alterações hemodinâmicas e metabólicas do encéfalo ocorrem frequentemente em diversas doenças neurológicas, principalmente em condições de traumatismo cranioencefálico e acidente vascular encefálico, com vários mecanismos patofisiológicos lesionais. O desacoplamento resultante do fluxo sanguíneo e do metabolismo encefálico pode resultar em lesões encefálicas secundárias, principalmente nas primeiras fases, e, consequentemente, no agravamento do desfecho neurológico dos pacientes. Diversos fatores influenciam o fluxo sanguíneo encefálico, entre eles, a concentração sanguínea de gases, viscosidade sanguínea, temperatura corpórea, débito cardíaco, altitude, autorregulação cerebrovascular e acoplamento neurovascular, que é mediado por óxido nítrico (ON), monóxido de carbono (CO), eicosanoides, radicais livres derivados do oxigênio, endotelinas, potássio, íons hidrogênio e adenosinas. Melhor compreensão destes fatores é fundamental para o manejo clínico dos pacientes neurológicos críticos. A avaliação hemodinâmica e metabólica do encéfalo nas lesões encefálicas agudas pode contribuir para o planejamento de estratégias de redução das lesões encefálicas secundárias. Nesta revisão, os autores discutiram princípios da hemodinâmica encefálica, considerando os aspectos de importância clínica.

Epilepsia e neuroproteção: o papel do agonista adenosinérgico A1(RPia) na modulação da crise induzida por pilocarpina / Epilepsy and neuroprotection: employment of the RPia during status epilepticus induced by pilocarpine

OBJETIVO: O objetivo desse estudo foi caracterizar a neuroproteção do RPia em ratos submetidos ao status epilepticus (SE) induzido pela pilocarpina (Pilo). MÉTODOS: Avaliou-se o balanço entre utilização local da glicose cerebral (ULGC) e fluxo sanguíneo cerebral local (FSCL) após 4 horas de SE, e a marcação por Fluoro Jade-B (FJB), 24 horas e 90 dias após SE. Quatro grupos foram avaliados: Salina, Pilo, RPia+Salina e RPia+Pilo. RESULTADOS E CONCLUSÃO: Aumentos significantes na ULGC foram observados na maioria das regiões avaliadas nos grupos Pilo e RPia+Pilo quando comparados ao controle. Entretanto, redução significante na ULGC ocorreu na substância negra pars reticulata e giro denteado do grupo RPia+Pilo versus Pilo. Houve aumento significante do FSCL em todas as áreas estudadas, comparando-se os grupos Pilo e RPia+Pilo com o controle. Foi observado um aumento significante do FSCL durante SE em CA2, CA3, giro denteado, córtex entorrinal, corpo mamilar, núcleos talâmicos, núcleo rubro, zona incerta, núcleo oral da ponte e córtex visual, no grupo pré-tratado com RPia comparado ao tratado somente com Pilo. Grande número de células marcadas com FJB foi observado no grupo Pilo e o pré-tratamento com RPia reduziu essa marcação na formação hipocampal, córtex piriforme, amígdala basolateral e substância negra pars compacta.

OBJECTIVE: The aim of this study was to characterize the neuroprotection of the RPia in rats subjected to status epilepticus (SE) induced by pilocarpine (Pilo). METHODS: We evaluated the mismatch between local cerebral glucose utilisation (LCGU) and local cerebral blood flow (LCBF) 4 hours after SE induction. Neuronal loss was evaluated by Fluoro Jade-B (FJB) 24 hours and 90 days after SE. Four groups were studied: Saline, Pilo, RPia+Saline and RPia+Pilo. RESULTS AND CONCLUSIONS: Significant increases in the LCGU were observed in the almost all brain regions of Pilo and RPia+Pilo groups compared to control. However, significant reduction in the LCGU occurred in the substantia nigra pars reticulata and hippocampal formation of RPia+Pilo group versus Pilo. There was significant increase of the LCBF in all the studied areas, comparing the Pilo and RPia+Pilo groups with the control. The increases of LCBF was more intense in rats from RPia+Pilo compared to Pilo, and located mainly in CA2, CA3, dentate gyrus, entorhinal cortex, thalamic nuclei, mammillary body, red nucleus, zone incerta, pontine nucleus and visual cortex. A great number FJB stained cells was observed in the Pilo group and RPia pretreatment reduced the staining in the hippocampal formation, piriform cortex, basolateral amygdala and substantia nigra pars compacta.

Transcranial doppler in sickle cell anaemia: evaluation of brain blood flow parameters in children of Aracaju, Northeast - Brazil / Doppler transcraniano em portadores de anemia falciforme: estudo dos parâmetros de fluxo sangüíneo cerebral em crianças de Aracaju, Sergipe

BACKGROUND: Environmental factors interfere on sickle cell anaemia (SCA). Transcanial Doppler (TCD) is important to evaluate cerebrovascular disease. OBJECTIVE: To evaluate brain haemodynamic profile of children with SCA in Sergipe. METHODS: Cross sectional study (group1: SCA patients aged 3-18; group2: age and sex matched healthy individuals). Baseline brain flow was evaluated. RESULTS: Group1=34 patients; group 2=81 controls. SCA patients had mean velocity (MV)=125.69 cm/s±23.40; pulsatility index (PI)=0.66±0.10; middle cerebral artery ratio (MCAr)=14.53±15.23; right anterior cerebral artery/right middle cerebral artery=0.77±0.20; left anterior cerebral artery/left middle cerebral artery=0.78±0.20. Controls had MV=79.44±15.54; PI=0.82±0.11; MCAr=13.19±13.77; right anterior cerebral artery/right middle cerebral artery=0.80±0.16; left anterior cerebral artery/left middle cerebral artery=0.84±0.18. MV and PI differences were statistically significant between groups. MV was related to age but not to gender. CONCLUSION: MV evaluation using TCD was similar to international standards and possible to be used in our setting.

INTRODUÇÃO: Aspectos ambientais interferem na apresentação da anemia falciforme (AF). Doppler transcraniano (DTC) é útil na avaliação do risco para doença cerebrovascular em pacientes com AF. OBJETIVO: Avaliar o perfil hemodinâmico cerebral de crianças com AF em Sergipe. MÉTODO: Estudo transversal (grupo1: portadores de AF 3-18 anos; grupo2: indivíduos saudáveis, pareados por idade e gênero). Foram avaliadas medidas de fluxo sangüíneo cerebral basal. RESULTADOS: Grupo1 (n=34): velocidade média (Vm)=125,69 cm/s ±23,40; índice de pulsatilidade (Ip)=0,66±0,10; relação entre artéria cerebral média (ACMs)=14,53±15,23; artéria cerebral anterior (ACA)/ACM direita=0,77±0,20; ACA/ACM esquerda=0,78±0,20. Grupo 2 (n=81): Vm=79,44 cm/s ±15,54; Ip=0,82±0,11, relação entre ACMs=13,19±13,77, ACA/ACM direita=0,80±0,16; ACA/ACM esquerda=0,84± 0,18. Vm foi maior e Ip menor no grupo1. Vm se correlacionou com idade mas não com gênero. CONCLUSÃO: O perfil hemodinâmico cerebral de crianças com AF em Sergipe assemelha-se às referências internacionais. Não se observou interferência de fatores ambientais sobre os resultados.