الملخص
SUMMARY: Cerebral ischemia has not only a high mortality rate, which is the second leading cause of death worldwide, but is also responsible for severe disabilities in working age individuals, generating enormous public expending for treatment and rehabilitation of the affected individuals. The role of microRNAs in the pathophysiology of cerebral ischemia has been highlighted in current investigations. In addition, recent studies have also highlighted physical exercise as a possible protective factor both in the prevention and in the effects of cerebral ischemia, placing it as an important study resource. Thus, we investigated the role of physical exercise in experimental cerebral ischemia associated with the expression of microRNA-27b. 16 animals were used, divided into four experimental groups: Control, Physical Exercise, Cerebral Ischemia and Cerebral Ischemia associated with Physical Exercise. The real-time PCR methodology was used to analyze the expression of microRNA-27b. Although there were no statistically significant differences in the expression of microRNA-27b between the groups studied, the increased expression of microRNA-27b in the Physical Exercise group indicates its neuroprotective role in the pathophysiology of cerebral ischemia.
RESUMEN: La isquemia cerebral no solo tiene una alta tasa de mortalidad y es la segunda causa principal de muerte en todo el mundo, sino también es la causa de enfermedades invalidantes en personas en edad laboral, lo que genera un gasto público enorme para el tratamiento y la rehabilitación de las personas afectadas. El papel de los microARN en la fisiopatología de la isquemia cerebral se ha destacado en las investigaciones actuales. Además, estudios recientes también han destacado el ejercicio físico como un posible factor protector tanto en la prevención como en los efectos de la isquemia cerebral, situándolo como un importante recurso de estudio. Por lo tanto, investigamos el papel del ejercicio físico en la isquemia cerebral experimental asociada con la expresión del microARN-27b. Se utilizaron 16 animales, divididos en cuatro grupos experimentales: Control, Ejercicio Físico, Isquemia Cerebral e Isquemia Cerebral asociada al Ejercicio Físico. Se utili- zó la metodología de PCR en tiempo real para analizar la expresión de microARN-27b. Aunque no se observaron diferencias estadísticamente significativas en la expresión de microARN-27b entre los grupos estudiados, la mayor expresión de microARN-27b en el grupo de Ejercicio Físico indica su papel neuroprotector en la fisiopatología de la isquemia cerebral.
الموضوعات
Animals , Rats , Exercise , Brain Ischemia/physiopathology , Brain Ischemia/metabolism , MicroRNAs/metabolism , Brain Ischemia/genetics , Disease Models, Animal , Real-Time Polymerase Chain Reactionالملخص
ABSTRACT Aneurysmal subarachnoid hemorrhage is a condition with a considerable incidence variation worldwide. In Brazil, the exact epidemiology of aneurysmal SAH is unknown. The most common presenting symptom is headache, usually described as the worst headache ever felt. Head computed tomography, when performed within six hours of the ictus, has a sensitivity of nearly 100%. It is important to classify the hemorrhage based on clinical and imaging features as a way to standardize communication. Classification also has prognostic value. In order to prevent rebleeding, there still is controversy regarding the ideal blood pressure levels and the use of antifibrinolytic therapy. The importance of definitely securing the aneurysm by endovascular coiling or surgical clipping cannot be overemphasized. Hydrocephalus, seizures, and intracranial pressure should also be managed. Delayed cerebral ischemia is a severe complication that should be prevented and treated aggressively. Systemic complications including cardiac and pulmonary issues, sodium abnormalities, fever, and thromboembolism frequently happen and may have na impact upon prognosis, requiring proper management.
RESUMO Hemorragia subaracnoidea aneurismática (aHSA) é uma condição com grande variação de incidência mundialmente. No Brasil, não dispomos de números epidemiológicos exatos. A apresentação clínica mais comum da HSA é a cefaleia, usualmente descrita como a pior da vida. A tomografia de crânio, quando feita nas primeiras 6 horas do ictus, tem uma sensibilidade próxima a 100%. É importante classificar a hemorragia utilizando escalas clínicas e radiológicas, como forma de padronizar a comunicação, e também predizer prognóstico. Para prevenção de ressangramento, ainda há controvérsias quanto aos níveis pressóricos ideais e uso de antifibrinolíticos. O tratamento definitivo do aneurisma, por sua vez, é fundamental, seja por meio endovascular ou cirúrgico. Hidrocefalia, crises epilépticas e a pressão intracraniana devem ser manejadas de forma apropriada. Isquemia cerebral tardia é uma complicação grave que deve ser prevenida e tratada agressivamente. Complicações sistêmicas, incluindo cardíacas, pulmonares, anormalidades de sódio, febre e tromboembolismo ocorrem frequentemente e podem ter impacto no prognóstico, necessitando de manejo adequado.
الموضوعات
Humans , Subarachnoid Hemorrhage/complications , Subarachnoid Hemorrhage/physiopathology , Seizures/etiology , Seizures/physiopathology , Seizures/therapy , Subarachnoid Hemorrhage/therapy , Brain Ischemia/etiology , Brain Ischemia/physiopathology , Brain Ischemia/therapy , Risk Factors , Hydrocephalus/etiology , Hydrocephalus/physiopathology , Hydrocephalus/therapyالملخص
ABSTRACT A swallowing disorder is present in more than 50% of patients with acute stroke. Objective To identify clinical prognostic indicators of the swallowing function in a population with acute ischemic stroke and to determine prioritization indicators for swallowing rehabilitation. Methods Participants were adults admitted to the emergency room who were diagnosed with acute ischemic stroke. Data gathering involved a swallowing assessment to determine the functional level of swallowing (American Speech-Language-Hearing Association National Outcome Measurement System - ASHA NOMS) and the verification of demographic and clinical variables. Results The study sample included 295 patients. For analysis purposes, patients were grouped as follows: ASHA NOMS levels 1 and 2 - ASHA1 (n = 51); levels 3, 4 and 5 - ASHA2 (n = 96); levels 6 and 7 - ASHA3 (n = 148). Statistical analyses indicated that patients who presented a poorer swallowing function (ASHA1) were older (age ≥ 70 years); had anterior circulation infarct; had lower scores on the Glasgow Coma Scale (GCS ≤ 14 points); took longer to initiate swallowing rehabilitation; had longer hospital stays; made more use of alternative feeding methods; needed more sessions of swallowing rehabilitation to remove alternate feeding methods; took longer to return to oral feeding and had poorer outcomes (fewer individuals discharged from swallowing rehabilitation sessions and increased mortality). Conclusion Patients with acute ischemic stroke, admitted to the emergency room, aged ≥ 70 years, score on the GCS ≤ 14, anterior circulation infarct and dementia should be prioritized for swallowing assessment and rehabilitation.
RESUMO Alterações da deglutição são observadas em mais de 50% dos pacientes com acidente vascular cerebral isquêmico (AVCI) agudo. Objetivo Identificar os indicadores de prognóstico clínico da funcionalidade da deglutição na população com AVCI em fase aguda, visando o estabelecimento de indicadores de priorização de atendimento fonoaudiológico. Métodos Participaram do estudo adultos admitidos em Pronto Socorro (PS) com AVCI. As etapas de coleta de dados envolveram avaliação fonoaudiológica para determinação do nível funcional da deglutição (American Speech-Language-Hearing Association National Outcome Measurement System - ASHA NOMS) e a coleta de variáveis demográficas e clínicas. Resultados A amostra do estudo incluiu 295 pacientes agrupados de acordo com os níveis ASHA NOMS: níveis 1 e 2 - ASHA1 (n = 51); níveis 3, 4 e 5 - ASHA2 (n = 96); níveis 6 e 7 - ASHA3 (n = 148). As análises indicaram os seguintes resultados significantes: pacientes com pior funcionalidade da deglutição (ASHA1) apresentaram média de idade superior a 70 anos, maior comprometimento da circulação cerebral anterior pós-AVCI, pior pontuação na Escala de Coma de Glasgow (ECG ≤ 14 pontos), demoraram mais tempo para iniciar o atendimento fonoaudiológico, permaneceram mais tempo internados no hospital, fizeram mais uso de via alternativa de alimentação, necessitaram de mais sessões fonoaudiológicas para retirada da via alternativa de alimentação, demoraram mais tempo para retornar para alimentação por via oral e apresentaram pior desfecho (um número menor de indivíduos recebeu alta fonoaudiológica e apresentaram mortalidade aumentada). Conclusão Pacientes com AVCI agudo, admitidos em PS, que apresentem idade ≥ 70 anos, pontuação na ECG ≤ 14, com comprometimento do sistema circulatório cerebral anterior e demência, devem ser priorizados no atendimento fonoaudiológico.
الموضوعات
Humans , Male , Female , Middle Aged , Aged , Deglutition Disorders/diagnosis , Brain Ischemia/physiopathology , Stroke/physiopathology , Prognosis , Deglutition Disorders/etiology , Deglutition Disorders/rehabilitation , Comorbidity , Glasgow Coma Scale , Cross-Sectional Studiesالملخص
Physical exercise is a known preventive and therapeutic alternative for several cerebrovascular diseases. Therefore, the objective of the present study was to evaluate the motor performance and histomorphometry of the biceps brachii, soleus, and tibialis anterior muscles of rats submitted to a treadmill training program prior to the induction of cerebral ischemia via occlusion of the middle cerebral artery (OMCA). A total of 24 Wistar rats were distributed into four groups: Sham-Sed: sedentary control animals (n=6), who underwent sham surgery (in which OMCA did not occur); Sham+Ex: control animals exercised before the sham surgery (n=6); I-Sed: sedentary animals with cerebral ischemia (n=6); and I+Ex: animals exercised before the induction of ischemia (n=6). The physical exercise consisted of treadmill training for five weeks, 30 min/day (5 days/week), at a speed of 14 m/min. The results showed that the type-I fibers presented greater fiber area in the exercised ischemic group (I+Ex: 2347.96±202.77 µm2) compared to the other groups (Sham-Sed: 1676.46±132.21 µm2; Sham+Ex: 1647.63±191.09 µm2; I+Ex: 1566.93±185.09 µm2; P=0.0002). Our findings suggested that the angiogenesis process may have influenced muscle recovery and reduced muscle atrophy of type-I fibers in the animals that exercised before cerebral ischemia.
الموضوعات
Animals , Male , Rats , Physical Conditioning, Animal/physiology , Muscular Atrophy/prevention & control , Brain Ischemia/complications , Muscle, Skeletal/physiopathology , Infarction, Middle Cerebral Artery , Muscular Atrophy/etiology , Muscular Atrophy/pathology , Brain Ischemia/physiopathology , Rats, Wistar , Disease Models, Animalالملخص
Abstract Background: Long-term monitoring has been advocated to enhance the detection of atrial fibrillation (AF) in patients with stroke. Objective: To evaluate the performance of a new ambulatory monitoring system with mobile data transmission (PoIP) compared with 24-hour Holter. We also aimed to evaluate the incidence of arrhythmias in patients with and without stroke or transient ischemic attack. Methods: Consecutive patients with and without stroke or TIA, without AF, were matched by propensity score. Participants underwent 24-hour Holter and 7-day PoIP monitoring. Results: We selected 52 of 84 patients (26 with stroke or TIA and 26 controls). Connection and recording times were 156.5 ± 22.5 and 148.8 ± 20.8 hours, with a signal loss of 6,8% and 11,4%, respectively. Connection time was longer in ambulatory (164.3 ± 15.8 h) than in hospitalized patients (148.8 ± 25.6 h) (p = 0.02), while recording time did not differ between them (153.7 ± 16.9 and 143.0 ± 23.3 h). AF episodes were detected in 1 patient with stroke by Holter, and in 7 individuals (1 control and 6 strokes) by PoIP. There was no difference in the incidence of arrhythmias between the groups. Conclusions: Holter and PoIP performed equally well in the first 24 hours. Data transmission loss (4.5%) occurred by a mismatch between signal transmission (2.5G) and signal reception (3G) protocols in cell phone towers (3G). The incidence of arrhythmias was not different between stroke/TIA and control groups.
Resumo Fundamentos: Monitorização prolongada permite maior detecção de fibrilação atrial (FA) em pacientes com acidente vascular cerebral (AVC) isquêmico criptogênico. Não há consenso sobre a duração ideal da monitorização ou o valor prognóstico da FA de curta duração. Objetivos: Avaliar o desempenho de um novo sistema de monitorização ambulatorial (PoIP) com transmissão por telefonia celular, comparado ao Holter 24 horas, e a ocorrência de arritmias comparando pacientes com e sem AVC ou ataque isquêmico transitório (AIT). Métodos: Pacientes consecutivos com e sem AVC/AIT, sem FA, foram pareados pelo escore de propensão. Foi utilizado Holter 24 horas e o PoIP por 7 dias. Resultados: Selecionamos 52 de 84 pacientes (26 com AVC/AIT agudo e 26 controles). O tempo de conexão foi de 156,5 ± 22,5 horas e o de gravação no servidor foi de 148,8 ± 20,8 horas, com perdas de 6,8 e 11,4%, respectivamente. Houve maior tempo de conexão nos pacientes ambulatoriais (164,3 ± 15,8 h) que nos hospitalizados (148,8 ± 25,6h) (p = 0,02) com tempo de gravação semelhante (153,7 ± 16,9 e 143 ± 23,3 h). Detectamos FA pelo Holter em 1 paciente com AVC e pela monitorização prolongada em 7 (1 controle e 6 AVC). Não houve diferença na incidência de outras arritmias entre os grupos. Conclusões: Holter e PoIP tiveram desempenho equivalente nas primeiras 24 horas. O menor tempo de monitorização nos pacientes hospitalizados ocorreu por sinal de baixa intensidade. Perda de dados (4,5%) ocorreu por discrepância entre protocolos de transmissão (2,5G) e recepção pelas antenas (3G). A incidência de arritmias não diferiu entre os grupos AVC/AIT e controle.
الموضوعات
Humans , Male , Female , Aged , Atrial Fibrillation/diagnosis , Brain Ischemia/complications , Prognosis , Atrial Fibrillation/etiology , Atrial Fibrillation/physiopathology , Case-Control Studies , Brain Ischemia/physiopathology , Electrocardiography, Ambulatory , Cell Phoneالملخص
Objective: To investigate the relationship between the maximum blood pressure fluctuation within 24 hours after admission and the prognosis at discharge. Methods: The patients with ischemic stroke admitted in Department of Neurology of the First Affiliated Hospital of Harbin Medical University within 24 hours after onset were consecutively selected from April 2016 to March 2017. The patients were grouped according to the diagnostic criteria of hypertension. Ambulatory blood pressure of the patients within 24 hours after admission were measured with bedside monitors and baseline data were collected. The patients were scored by NIHSS at discharge. The relationships between the maximum values of systolic blood pressure (SBP) or diastolic blood pressure (DBP) and the prognosis at discharge were analyzed. Results: A total of 521 patients with acute ischemic stroke were enrolled. They were divided into normal blood pressure group (82 cases) and hypertension group(439 cases). In normal blood pressure group, the maximum values of SBP and DBP were all in normal distribution (P>0.05). The maximum value of SBP fluctuation was set at 146.6 mmHg. After adjustment for potential confounders, the OR for poor prognosis at discharge in patients with SBP fluctuation ≥146.6 mmHg was 2.669 (95%CI: 0.594-11.992) compared with those with SBP fluctuation <146.6 mmHg. The maximum value of DBP fluctuation was set at 90.0 mmHg, and the adjusted OR for poor prognosis at discharge in patients with DBP fluctuation ≥90.0 mmHg was 0.416 (95%CI: 0.087-1.992) compared with those with DBP fluctuation <90.0 mmHg. In hypertension group, the maximum values of SBP and DBP were not in normal distribution (P<0.05). The maximum value of SBP fluctuation was set at median 171.0 mmHg. After adjustment for the confounders, the greater the maximum of SBP, the greater the risk of poor prognosis at discharge was, the OR was 1.636 (95%CI: 1.014-2.641). The maximum value of DBP fluctuation was set at median 98.0 mmHg. After adjustment for the confounders, the greater the maximum of DBP, the greater the risk of poor prognosis at discharge was, the OR was 1.645 (95%CI: 1.003-2.697). Conclusion: In acute ischemic stroke patients with normal blood pressure at admission, the maximum values of SBP and DBP within 24 hours after admission had no relationship with prognosis at discharge. In acute ischemic stroke patients with hypertension at admission, the maximum values of SBP and DBP within 24 hours after admission were associated with poor prognosis at discharge.
الموضوعات
Adult , Humans , Blood Pressure/physiology , Blood Pressure Monitoring, Ambulatory , Brain Ischemia/physiopathology , Hospitals , Hypertension/physiopathology , Outcome Assessment, Health Care , Patient Admission , Patient Discharge , Prognosis , Risk , Stroke/physiopathology , Time-to-Treatmentالملخص
OBJECTIVES: Acute post-stroke patients present cardiovascular autonomic dysfunction, which manifests as lower heart rate variability and impaired baroreflex sensitivity. However, few studies performed to date have evaluated cardiovascular autonomic function in chronic post-stroke patients. The aim of this study was to evaluate cardiovascular autonomic modulation in chronic post-ischemic stroke patients. METHODS: The seventeen enrolled subjects were divided into a stroke group (SG, n=10, 5±1 years after stroke) and a control group (CG, n=7). Non-invasive curves for blood pressure were continuously recorded (Finometer®) for 15 minutes while the subject was in a supine position. Heart rate variability and blood pressure variability were analyzed in the time and frequency domains. RESULTS: No differences were observed in systolic and diastolic pressure and heart rate between post-stroke patients and healthy individuals. The SG group had lower indexes for heart rate variability in the time domain (standard deviation of normal to normal R-R intervals, SDNN; variance of normal to normal R-R intervals, VarNN; and root mean square differences of successive R-R intervals, RMSSD) and a lower high-frequency band for heart rate variability than was observed in the CG. Systolic blood pressure variability and the low-frequency band for systolic pressure were higher in post-stroke patients, while the alpha index was lower in the SG than in the CG. CONCLUSION: After ischemic stroke, affected patients present chronically reduced heart rate variability, impaired cardiac vagal modulation, increased systolic blood pressure variability and higher sympathetic vascular modulation along with impaired baroreflex sensitivity, which can increase the risk of cardiovascular events, despite adequate blood pressure control.
الموضوعات
Humans , Male , Female , Adult , Middle Aged , Aged , Autonomic Nervous System/physiopathology , Brain Ischemia/physiopathology , Baroreflex/physiology , Heart Rate/physiology , Hypertension/physiopathology , Case-Control Studies , Chronic Disease , Electrocardiographyالملخص
OBJECTIVE: The aim of this study was to assess the relationship between the degree of unilateral spatial neglect during the acute phase of stroke and long-term functional independence. METHODS: This was a prospective study of right ischemic stroke patients in which the independent variable was the degree of spatial neglect and the outcome that was measured was functional independence. The potential confounding factors included sex, age, stroke severity, topography of the lesion, risk factors, glycemia and the treatment received. Unilateral spatial neglect was measured using the line cancellation test, the star cancellation test and the line bisection test within 48 hours of the onset of symptoms. Functional independence was measured using the modified Rankin and Barthel scales at 90 days after discharge. The relationship between unilateral spatial neglect and functional independence was analyzed using multiple logistic regression that was corrected for confounding factors. RESULTS: We studied 60 patients with a median age of 68 (34-89) years, 52% of whom were male and 74% of whom were Caucasian. The risk for moderate to severe disability increased with increasing star cancellation test scores (OR=1.14 [1.03-1.26], p=0.01) corrected for the stroke severity, which was a confounding factor that had a statistically positive association with disability (OR=1.63 [1.13-2.65], p=0.01). The best chance of functional independence decreased with increasing star cancellation test scores (OR=0.86 [0.78-0.96], p=0.006) corrected for the stroke severity, which was a confounding factor that had a statistically negative association with independence (OR=0.66 [0.48-0.92], p=0.017). CONCLUSION: The severity of unilateral spatial neglect in acute stroke worsens the degree of long-term disability and functional independence.
الموضوعات
Perceptual Disorders/etiology , Perceptual Disorders/physiopathology , Brain Ischemia/complications , Brain Ischemia/physiopathology , Stroke/complications , Disability Evaluation , Prognosis , Severity of Illness Index , Logistic Models , Prospective Studies , Risk Factors , Stroke/physiopathology , Neuropsychological Testsالملخص
ABSTRACT Collateral circulation is a physiologic pathway that protects the brain against ischemic injury and can potentially bypass the effect of a blocked artery, thereby influencing ischemic lesion size and growth. Several recent stroke trials have provided information about the role of collaterals in stroke pathophysiology, and collateral perfusion has been recognized to influence arterial recanalization, reperfusion, hemorrhagic transformation, and neurological outcomes after stroke. Our current aim is to summarize the anatomy and physiology of the collateral circulation and to present and discuss a comprehensible review of the related knowledge, particularly the effects of collateral circulation on the time course of ischemic injury and stroke severity, as well as imaging findings and therapeutic implications.
RESUMO A circulação colateral é um circuito fisiológico de proteção contra alterações isquêmicas que, potencialmente, evita os efeitos de uma oclusão arterial e com isso pode influenciar nas dimensões e no crescimento de uma lesão isquêmica. Vários estudos recentes forneceram informações a respeito do papel das colaterais na fisiopatologia do acidente vascular encefálico isquêmico e demonstraram a capacidade da circulação colateral de influenciar as taxas de reperfusão, recanalização, transformação hemorrágica e com isso desfecho clínico dos pacientes. O objetivo desta revisão é sintetizar a anatomia e a fisiologia da circulação colateral encefálica, apresentando e discutindo, o que se conhece atualmente acerca do seu efeito na cronologia e gravidade da lesão isquêmica, além dos achados de imagens e implicações terapêuticas.
الموضوعات
Humans , Brain Ischemia/physiopathology , Cerebrovascular Circulation/physiology , Collateral Circulation/physiology , Stroke/physiopathology , Blood Flow Velocity , Cerebral Angiography , Brain Ischemia/diagnostic imaging , Stroke/diagnostic imagingالملخص
ABSTRACT BACKGROUND AND OBJECTIVES: Fat embolism syndrome may occur in patients suffering from multiple trauma (long bone fractures) or plastic surgery (liposuction), compromising the circulatory, respiratory and/or central nervous systems. This report shows the evolution of severe fat embolism syndrome after liposuction and fat grafting. CASE REPORT: SSS, 42 years old, ASA 1, no risk factors for thrombosis, candidate for abdominal liposuction and breast implant prosthesis. Subjected to balanced general anesthesia with basic monitoring and controlled ventilation. After 45 min of procedure, there was a sudden and gradual decrease of capnometry, severe hypoxemia and hypotension. The patient was immediately monitored for MAP and central catheter, treated with vasopressors, inotropes, and crystalloid infusion, stabilizing her condition. Arterial blood sample showed pH = 7.21; PCO2 = 51 mmHg; PO2 = 52 mmHg; BE = -8; HCO3 = 18 mEq L-1, and lactate = 6.0 mmol L-1. Transthoracic echocardiogram showed PASP = 55 mmHg, hypocontractile VD and LVEF = 60%. Diagnosis of pulmonary embolism. After 24 h of intensive treatment, the patient developed anisocoria and coma (Glasgow coma scale = 3). A brain CT was performed which showed severe cerebral hemispheric ischemia with signs of fat emboli in right middle cerebral artery; transesophageal echocardiography showed a patent foramen ovale. Finally, after 72 h of evolution, the patient progressed to brain death. CONCLUSION: Fat embolism syndrome usually occurs in young people. Treatment is based mainly on the infusion of fluids and vasoactive drugs, mechanical ventilation, and triggering factor correction (early fixation of fractures or suspension of liposuction). The multiorgânico involvement indicates a worse prognosis.
RESUMO JUSTIFICATIVA E OBJETIVOS: A Síndrome da Embolia Gordurosa (SEG) pode acontecer em pacientes vítimas de politrauma (fratura de ossos longos) ou operações plásticas (lipoaspiração), comprometendo circulação, respiração e/ou sistema nervoso central. O presente relato mostra evolução de SEG grave após lipoaspiração e lipoenxertia. RELATO DO CASO: SSS, 42 anos, ASA 1, sem fatores de risco para trombose, candidata a lipoaspiração abdominal e implante de prótese mamária. Submetida à anestesia geral balanceada com monitorização básica e ventilação controlada. Após 45 minutos de procedimento, houve queda súbita e progressiva da capnometria, hipoxemia e hipotensão grave. Imediatamente foi monitorizada com PAM e cateter central, tratada com vasopressores, inotrópicos e infusão de cristaloides, obtendo estabilização do quadro. Amostra sanguínea arterial mostrou pH = 7,21; PCO2 = 51 mmHg; PO2 = 52 mmHg; BE = -8; HCO3 = 18 mEQ/l e lactato = 6,0 mmol/l. Ecocardiograma transtorácico mostrou PSAP = 55 mmHg, VD hipocontrátil e FEVE = 60%. Diagnóstico de embolia pulmonar. Após24 h de tratamento intensivo, a paciente evoluiu com anisocoria e coma com escala de glasgow 3. Realizada TC de encéfalo que evidenciou isquemia cerebral grave, hemisférica, com sinais de êmbolos de gordura em A. cerebral média D; o ecocardiograma transesofágico mostrou forame oval patente. Finalmente, após 72 h de evolução, a paciente evoluiu para morte encefálica. CONCLUSÃO: A SEG ocorre geralmente em jovens. O tratamento baseia-se principalmente na infusão de líquidos e drogas vasoativas, ventilação mecânica e correção do fator desencadeante (fixação precoce de fraturas ou suspensão da lipoaspiração). O comprometimento multiorgânico indica pior prognóstico.
الموضوعات
Humans , Female , Adult , Lipectomy/adverse effects , Brain Ischemia/complications , Adipose Tissue/surgery , Embolism, Fat/complications , Abdomen/surgery , Respiration, Artificial , Syndrome , Severity of Illness Index , Brain Death/physiopathology , Brain Death/diagnostic imaging , Tomography, X-Ray Computed , Brain Ischemia/physiopathology , Brain Ischemia/diagnostic imaging , Fatal Outcome , Echocardiography, Transesophageal , Middle Cerebral Artery/physiopathology , Middle Cerebral Artery/diagnostic imaging , Embolism, Fat/diagnostic imaging , Foramen Ovale, Patent/complications , Foramen Ovale, Patent/physiopathology , Foramen Ovale, Patent/diagnostic imaging , Perioperative Period , Intraoperative Complications/physiopathology , Intraoperative Complications/diagnostic imaging , Anesthesia, Generalالملخص
Una de las causas más importantes de morbilidad y mortalidad es la disfunción neurológica; su alta incidencia ha estimulado una intensa búsqueda de mecanismos para proteger al sistema nervioso central de situaciones que producen hipoxia e isquemia. El mayor reto es interrumpir los eventos bioquímicos que involucra y que llevan a la muerte neuronal. Esto puede conseguirse a través de la neuroprotección que tiene por objeto frenar las cascadas inmunológica y metabólica que aparecen después de un daño neurológico agudo. Cuando esto sucede, se producen eventos fisiopatológicos que incluyen la producción de citocinas, el estrés oxidante y la excitotoxicidad. Respecto a todos esos mecanismos, se han reportado efectos protectores de los endocanabinoides, los cuales parecen ser neuroprotectores en modelos animales de isquemia cerebral, excitotoxicidad, trauma cerebral y en enfermedades neurodegenerativas. Algunos análogos de canabinoides se encuentran actualmente en evaluación (fases clínicas I-III) para el tratamiento de enfermedades agudas que involucran a la muerte neuronal (isquemia y trauma cerebrales). El estudio del sistema canabinoide podría generar agentes neuroprotectores efectivos de amplio espectro de acción para el tratamiento de afecciones neurológicas en un futuro cercano.
One of the most important causes of morbidity and mortality is neurologic dysfunction; its high incidence has led to an intense research of the mechanisms that protect the central nervous system from hypoxia and ischemia. The mayor challenge is to block the biochemical events leading to neuronal death. This may be achieved by neuroprotective mechanisms that avoid the metabolic and immunologic cascades that follow a neurological damage. When it occurs, several pathophysiological events develop including cytokine release, oxidative stress and excitotoxicity. Neuroprotective effects of cannabinoids to all those mechanisms have been reported in animal models of brain ischemia, excitotoxicity, brain trauma and neurodegenerative disorders. Some endocannabinoid analogs are being tested in clinical studies (I-III phase) for acute disorders involving neuronal death (brain trauma and ischemia). The study of the cannabinoid system may allow the discovery of effective neuroprotective drugs for the treatment of neurological disorders.
الموضوعات
Animals , Humans , Cannabinoids/pharmacology , Brain Ischemia/drug therapy , Neurodegenerative Diseases/drug therapy , Brain Ischemia/physiopathology , Cytokines/metabolism , Oxidative Stress/physiology , Neuroprotective Agents/pharmacology , Neurons/pathologyالملخص
Introduction: An ischemic stroke is a clinical condition that affects thousands of people worldwide. As a result of this injury, neuronal death can be observed, and in the natural course of recovery, the individual may develop sepsis. Sepsis is a systemic inflammatory response that can lead the patient to death. To assess the clinical condition of a patient with this condition, the Auditory Brainstem Response (ABR) can be useful, since it is not an invasive procedure, it is a fast technique and it can be done at the bedside. Purpose: To assess auditory brainstem response (ABR) latency values in gerbils subjected to ischemia and sepsis. Methods: ABR values were collected from 72 adult male gerbils, which were divided into six groups: control, sepsis, ischemia, sham, ischemia with sepsis, and sham with sepsis. For the induction of sepsis, lipopolysaccharide (LPS) was applied intraperitoneally in gerbils. The animals were anesthetized with a ketamine/xylazine combination before collection; their ABR were collected before any procedure (base collection), after ischemia, and 24 hours after the application of LPS. The absolute latency of wave IV was evaluated, and the values were compared between groups. Results: There were significant differences in the groups submitted to sepsis in the latency value of wave IV in relation with the other groups. Conclusion: ABR was sensitive to sepsis with the increase in latency of wave IV during the development of the disease in the experimental model used. .
Introdução: O acidente vascular cerebral do tipo isquêmico é um quadro clínico que afeta milhares de pessoas no mundo. Como resultado dessa injúria observamos morte neuronal, e no decorrer natural de recuperação o indivíduo pode desenvolver a sepse. A sepse é uma resposta inflamatória sistêmica que pode levar o indivíduo à morte. Para avaliar as condições clínicas de um paciente com esse quadro, o potencial evocado auditivo de tronco encefálico (PEATE) pode ser útil, uma vez que ele não é um procedimento invasivo, sua técnica é rápida e pode ser feita à beira do leito. Objetivo: Verificar os valores de latência do PEATE em gerbils submetidos à isquemia e sepse. Métodos: Foram coletados os PEATEs de 72 gerbils machos adultos que foram distribuídos em 6 grupos: controle, sepse, isquemia, sham, isquemia com sepse e sham com sepse. Para a indução de sepse, foi aplicado lipopolissacarídeo (LPS) intraperitoneal nos gerbils. Os animais foram anestesiados antes das coletas com ketamina associada à xilazina, seus PEATEs foram coletados antes de qualquer procedimento (coleta base), após isquemia e 24 horas após a aplicação de LPS. Foi avaliada a latência absoluta da onda IV, e os valores foram comparados intergrupos. Resultados: Houve diferença significativa nos grupos submetidos à sepse no valor da latência da onda IV em relação aos demais grupos. Conclusão: O PEATE se mostrou sensível à sepse com aumento de latência da onda IV no desenvolver da doença no modelo experimental utilizado. .
الموضوعات
Animals , Male , Brain Ischemia/physiopathology , Evoked Potentials, Auditory, Brain Stem/physiology , Sepsis/physiopathology , Gerbillinae , Sepsis/diagnosisالملخص
BACKGROUND: Gastroesophageal reflux disease is an increasingly common condition worldwide causing a considerable economic impact. More than half the patients with clinical symptoms of reflux disease display no mucosal erosions on esophagogastroduodenoscopy, making it impossible to confirm the diagnosis without further investigations. AIM: To evaluate the correlation between minimal endoscopic changes on white-light esophagogastroduodenoscopy (carditis, mucosal thickening and invisibility of vessels) and histologic changes observed in distal esophageal biopsies in a sample of patients with symptoms suggestive of reflux disease, and to verify the specificity of these symptoms for non-erosive reflux disease. METHODS: Retrospective, cross-sectional study based on information retrieved from a digital database at a Brazilian hospital for the period March-October, 2012. The sample consisted of previously untreated, non-smoking subjects aged >18 years with symptoms suggestive of reflux disease but no esophageal erosions, submitted to esophagogastroduodenoscopy and distal esophageal biopsy. RESULTS: The final sample included 23 subjects. The most frequently observed change was invisibility of vessels (n=21; 91.3%), followed by mucosal thickening (n=15; 65.2%) and carditis (n=5; 21.7%). The correlation coefficient between each variable and the anatomopathological diagnosis was 0.386 for body mass index, 0.479 for mucosal thickening, -0.116 for invisibility of vessels, 0.306 for carditis and 0.462 for hiatal hernia. CONCLUSION: All patients displayed minimal endoscopic changes on esophagogastroduodenoscopy, but only mucosal thickening revealed a moderately significant correlation with severity of esophagitis, although increased body mass index values and the presence of hiatal hernia were also associated. .
RACIONAL: Doença do refluxo gastroesofágico é condição cada vez mais comum em todo o mundo causando impacto econômico considerável. Mais da metade dos pacientes com sintomas clínicos da doença não apresentam erosões endoscópicas da mucosa, o que torna impossível confirmar o diagnóstico sem outras investigações. OBJETIVO: Avaliar a correlação entre mudanças mínimas endoscópicas em endoscopia digestiva alta de luz branca (cardite, espessamento da mucosa e invisibilidade de vasos) e as alterações histológicas observadas em biópsias distais de uma amostra de pacientes com sintomas sugestivos de doença do refluxo, e para verificar a especificidade desses sintomas para a doença não-erosiva. MÉTODOS: Estudo retrospectivo, transversal, com base em informações obtidas a partir de uma base de dados digital em um hospital brasileiro no período de março/outubro de 2012. A amostra foi composta por indivíduos não tratados previamente, não fumantes, >18 anos, com sintomas sugestivos de doença do refluxo, mas sem erosões esofágicas submetidos à endoscopia digestiva alta e biópsia de esôfago distal. RESULTADOS: A amostra final incluiu 23 indivíduos. A alteração mais frequente foi invisibilidade dos vasos (n=21; 91,3%), seguido por espessamento de mucosa (n=15; 65,2%) e cardite (n=5; 21,7%). O coeficiente de correlação entre cada variável e o diagnóstico anatomopatológico foi 0,386 para o índice de massa corporal, 0,479 para espessamento de mucosa, -0,116 para a invisibilidade de vasos, 0,306 para carditis e 0,462 para hérnia hiatal. CONCLUSÃO: Todos os pacientes apresentaram alterações endoscópicas mínimas, mas apenas espessamento da mucosa revelou correlação moderadamente significativa com a gravidade da esofagite, apesar do aumento dos valores no índice de massa corporal e da presença de hérnia hiatal também estarem associados. .
الموضوعات
Animals , Male , Rats , Brain Ischemia/drug therapy , Isoquinolines/pharmacology , Neutrophils/drug effects , Poly(ADP-ribose) Polymerases/antagonists & inhibitors , Brain Ischemia/physiopathology , DNA Breaks , Disease Models, Animal , Free Radicals/metabolism , Luminescent Measurements , Neutrophils/metabolism , Rats, Wistar , Reperfusion Injury/drug therapy , Reperfusion Injury/physiopathology , Time Factorsالملخص
Objective : To describe a new clinical sign associated with left unilateral neglect syndrome (UNS) in patients with ischemic stroke. Method : Head computed tomography (CT) and National Institute of Health Stroke Scale were obtained in 150 patients with ischemic stroke. Those with right cerebral vascular lesions, left hemiplegia and right leg persistently crossed over the left were submitted to specific tests for UNS. The tests were also applied to 30 patients with right cerebral vascular lesions, left hemiplegia but without crossed legs. Results : From 9 patients with persistent tendency to cross the right leg over the left, UNS was detected in 8. One patient died before the clinical tests were applied. Of the 30 patients without the crossed legs, 20 had normal clinical tests for UNS and 10 had minimal alterations, not sufficient for the diagnosis of UNS. Conclusion : The right leg crossed over the left may represent a new neurological semiotic sign associated with left hemiplegia and left UNS. .
Objetivo : Descrever um novo sinal clínico associado à síndrome de negligência unilateral (SNU) em pacientes com acidente vascular cerebral isquêmico (AVCi). Método : Em 150 pacientes com acidente vascular cerebral isquêmico, foram realizadas tomografias de crânio e aplicada a National Institute of Health Stroke Scale. Aqueles pacientes com lesões vasculares à direita, hemiplegia esquerda e perna direita persistentemente cruzada sobre a esquerda, foram submetidos a testes específicos para SNU. Trinta pacientes também com lesões vasculares à direita, hemiplegia esquerda, porém sem evidências de permanecerem com as pernas cruzadas, foram submetidos aos mesmos testes clínicos. Resultados : Entre 150 pacientes com AVCi, 9 apresentaram lesão vascular cerebral à direita, hemiplegia esquerda e tendência em permanecer com a perna direita cruzada sobre a esquerda. Em 8 deles, testes específicos realizados nos primeiros dias de internação, confirmaram SNU à esquerda. Um paciente morreu antes que os testes pudessem ser aplicados. Dos 30 pacientes que não cruzaram as pernas, os testes foram normais em 20. Dez pacientes apresentaram alterações mínimas, insuficientes para o diagnóstico de SNU. Conclusão : A perna direita cruzada sobre a esquerda pode representar um novo sinal semiológico associado à hemiplegia esquerda e SNU à esquerda. .
الموضوعات
Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Brain Ischemia/physiopathology , Hemiplegia/physiopathology , Leg/physiopathology , Stroke/physiopathology , Brain Ischemia , Disease Progression , Hemiplegia , Neuropsychological Tests , Risk Factors , Syndrome , Stroke , Tomography, X-Ray Computedالملخص
Sublethal ischemic preconditioning (IPC) is a powerful inducer of ischemic brain tolerance. However, its underlying mechanisms are still not well understood. In this study, we chose four different IPC paradigms, namely 5 min (5 min duration), 5×5 min (5 min duration, 2 episodes, 15-min interval), 5×5×5 min (5 min duration, 3 episodes, 15-min intervals), and 15 min (15 min duration), and demonstrated that three episodes of 5 min IPC activated autophagy to the greatest extent 24 h after IPC, as evidenced by Beclin expression and LC3-I/II conversion. Autophagic activation was mediated by the tuberous sclerosis type 1 (TSC1)-mTor signal pathway as IPC increased TSC1 but decreased mTor phosphorylation. Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) and hematoxylin and eosin staining confirmed that IPC protected against cerebral ischemic/reperfusion (I/R) injury. Critically, 3-methyladenine, an inhibitor of autophagy, abolished the neuroprotection of IPC and, by contrast, rapamycin, an autophagy inducer, potentiated it. Cleaved caspase-3 expression, neurological scores, and infarct volume in different groups further confirmed the protection of IPC against I/R injury. Taken together, our data indicate that autophagy activation might underlie the protection of IPC against ischemic injury by inhibiting apoptosis.
الموضوعات
Animals , Male , Rats , Apoptosis/physiology , Autophagy/physiology , Brain Ischemia/physiopathology , Ischemic Preconditioning/methods , Nerve Degeneration/prevention & control , Reperfusion Injury/metabolism , Adenine/analogs & derivatives , Adenine/pharmacology , Brain Ischemia/prevention & control , /metabolism , Cerebrum/injuries , In Situ Nick-End Labeling , Immunosuppressive Agents/pharmacology , Rats, Sprague-Dawley , Sirolimus/pharmacology , Time Factors , TOR Serine-Threonine Kinases/metabolism , Tumor Suppressor Proteins/metabolismالملخص
Procede-se a uma revisão das alterações bioquímicas e hemodinâmicas causadas pela isquemia do tecido nervoso. Trata-se de uma visão introdutória que aborda a fisiopatologia e as repercussões da terapêutica sobre a hemodinâmica encefálica.
This is a review on the biochemical and hemodynamic alterations caused by the isquemia in the neural tissue. This text introduce the pathophysiology and the therapeutic effects of this ischemic alterations.
الموضوعات
Hemodynamics , Intracranial Hypertension , Brain Ischemia/classification , Brain Ischemia/complications , Brain Ischemia/physiopathology , Brain Ischemia/metabolism , Brain Ischemia/therapy , Acidosisالملخص
O objetivo deste texto é o de estruturar e sistematizar novas hipóteses fisiopatológicas sobre as modificações hemodinâmicas do cérebro submetido à isquemia e à reperfusão. São propostas e analisadas hipóteses bioquímicas e hemodinâmicas do fenômeno da hipoperfusão pós-hiperemia.
The aim of this publication is to elaborate and discuss a new pathophysiological hypothesis about the haemodinamic modifications into the brain that occur after the reperfusion. Biochemical and haemodinamic hypothesis are proposed and analyzed, concerning the hipoperfusion following the hiperemia phenomenon.
الموضوعات
Hemodynamics , Hyperemia , Brain Ischemia/physiopathology , Brain Ischemia/metabolism , Reperfusion Injuryالملخص
BACKGROUND: cognitive potential - P300 assessment in individuals with right hemisphere ischemic lesion due to ischemic stroke. AIM: to characterize the cognitive potential - P300 in right-handed individuals with right hemisphere ischemic lesion, and to compare such data to those obtained in normal individuals. METHOD: anamnesis, conventional audiologic assessment and cognitive potential (P300) were carried out in 17 subjects with right hemisphere lesions (research group) and in 25 normal individuals (control group), aged between 20 and 70 years. RESULTS: in the qualitative analysis of the P300 data, there was no statistically significant difference between groups for the normal result. In the quantitative analysis, there was a statistically significant difference between groups in terms of P300 wave latency, with the research group presenting higher latencies. In addition, there was a trend for a statistically significant difference between the right and left ears in the research group - increased P300 wave latency in the right ear. CONCLUSION: right-handed individuals with right hemisphere lesion and normal hearing presented electrophysiological hearing results indicative of central auditory nervous system deficits. Alterations were observed in regions generating this potential (cortical and subcortical areas). Hearing difficulties were not perceived by these individuals, suggesting that this signal can probably be related to an auditory heminegligence. Further studies that evaluate the central auditory pathway of individuals with right hemisphere ischemic lesion are needed in order to better characterize the electrophysiological findings.
TEMA: avaliação do potencial cognitivo P300 em indivíduos com lesão de hemisfério direito provocada por acidente vascular cerebral isquêmico. OBJETIVO: caracterizar os achados do potencial cognitivo P300 em indivíduos destros com lesão isquêmica do hemisfério cerebral direito, bem como comparar seus resultados aos obtidos em indivíduos normais. MÉTODO: foram realizadas anamnese, avaliação audiológica convencional e potencial cognitivo (P300), em 17 indivíduos com lesão do hemisfério direito (grupo pesquisa) e 25 normais (grupo controle), com idades entre 20 e 70 anos. RESULTADOS: na análise dos dados qualitativos do P300, não houve diferença estatisticamente significante entre os grupos para o resultado normal. Para a análise dos dados quantitativos, ocorreu diferença estatisticamente significante entre os grupos com relação à latência da onda P300, sendo que o grupo pesquisa apresentou latência maior. Além disso, houve uma tendência estatisticamente significante entre as orelhas direita e esquerda dentro do grupo pesquisa, mostrando aumento de latência da onda P300 na orelha direita. CONCLUSÃO: Indivíduos destros com lesão de hemisfério direito e limiares auditivos normais, apresentaram resultados eletrofisiológicos da audição indicativos de déficit no sistema nervoso auditivo central. Foram observados comprometimentos nas regiões geradoras deste potencial (áreas subcorticais e corticais). Dificuldades auditivas não foram percebidas pelos indivíduos, sugerindo que, provavelmente tal sinal possa estar relacionado à uma heminegligência auditiva. Tornam-se necessários mais estudos que avaliem a via auditiva central destes indivíduos para uma melhor caracterização dos achados eletrofisiológicos.
الموضوعات
Adult , Aged , Female , Humans , Male , Middle Aged , Young Adult , Brain Ischemia/physiopathology , /physiology , Epidemiologic Methods , Functional Laterality/physiology , Young Adultالملخص
OBJETIVOS: Acidente vascular encefálico isquêmico (AVEi) representa a terceira maior causa de morte e gastos anuais. A literatura demonstra maior ocorrência no período da manhã e em épocas mais frias, podendo ter uma maior prevenção nestes momentos. Portanto, os objetivos foram identificar os fatores de risco, avaliar a influência das variações circadianas e de temperatura na prevalência do AVEi. MÉTODOS: Foram estudados 100 pacientes com o diagnóstico de AVEi. O horário de instalação foi analisado em quatro períodos, sendo obtido do paciente ou dos familiares. A temperatura climática foi obtida do INMET. RESULTADOS: O AVEi foi classificado de acordo com os subtipos estabelecidos pelo projeto TOAST. Dos pacientes, 66 por cento tinham hipertensão arterial como principal fator de risco. Houve um predomínio de casos no período das 6h00 às 11h59 (p< 0.0001) e após variação negativa da temperatura (p < 0,0001). CONCLUSÃO: Encontrou-se uma forte relação entre a prevalência de eventos encefálicos isquêmicos e variação negativa de temperatura e que o horário de maior frequência foi entre 6h00 e 11h59. Não foi possível avaliar as variações de temperatura e circadianas para cada subtipo de AVEi, pois o número de casos estudados não permitiu avaliação estatística significante.
BACKGROUND: Ischemic stroke (IS) ranks third as cause of death and annual costs. Literature shows a greater number of cases in the first hours of the morning and on colder days, allowing for better prevention at these times. The objectives were to identify risk factors, evaluate the influence of circadian and temperature variations on prevalence of IS. METHODS: Onset time was analyzed during four periods and obtained from the patient or family. Weather temperature was obtained from the INMET. The IS were classified according to subtypes established by the TOAST project. RESULTS: Hypertension was the main risk factor in 66 percent of the patients. There was a predominance of cases between 06:00 AM and 11:59 AM (p < 0. 0001) and after a negative variation of temperature (p < 0. 0001). CONCLUSIONS: A strong relationship was found between prevalence of IS and negative variation of temperature. Events were more frequent between 6:00 AM and 11:59 AM. It was not possible to evaluate the variations for each subtype of IS because the number of cases did not allow for significant statistic evaluation.
الموضوعات
Aged , Female , Humans , Male , Brain Ischemia/etiology , Circadian Rhythm/physiology , Temperature , Brain Ischemia/epidemiology , Brain Ischemia/physiopathology , Brazil/epidemiology , Chi-Square Distribution , Cross-Sectional Studies , Hypertension/complications , Risk Factors , Seasonsالملخص
El infarto cerebral agudo representa una emergencia clínica, potencialmente reversible si se trata con trombolisis durante las primeras 3 a 6 horas de evolución. La reversibilidad del cuadro clínico es función, entre otros factores, del grado de profundidad de la hipoperfusión en la región cerebral comprometida. Otros factores que inciden en la reversibilidad del cuadro clínico es el tiempo transcurrido desde el inicio de la sintomatología antes del tratamiento y la recanalización del vaso obstruido. Presentamos dos casos de infarto cerebral embólicos que fueron estudiados con SPECT Cerebral y tratados con trombolisis cerebral durante las primeras 3 horas de evolución. El primer caso se trataba de una cardioembolía en T con oclusión de la carótida interna distal y de las arterias cerebral anterior y media proximales izquierdas y el segundo caso es de una cardioembolía con oclusión de la arteria cerebral media derecha desde su origen. La evolución de ambos casos fue diametralmente diferente y analizamos en este trabajo los resultados de la cuantificación de la hipoperfusión en la zona infartada con objeto de definir factores pronósticos de estos pacientes y la indicación de trombolisis arterial.