Tratamento das hemorragias intracranianas espontâneas: o dilema continua / Treatment of Spontaneous Intracranial Hemorrhages: the Dilemma Continues

Introdução As doenças cerebrovasculares (DCV) são a principal causa de morte no Brasil, sendo um grande problema de saúde pública em todo o mundo. Métodos Revisão da literatura utilizando o banco de dados do MEDLINE. Buscados os termos "intracerebral" e "hemorrhage" presentes no título e no resumo publicados em qualquer data. Resultados As hemorragias intracranianas (HIC) acometem, principalmente, os lobos cerebrais, gânglios da base, tálamo, tronco cerebral (predominantemente a ponte) e cerebelo como resultado da ruptura de vasos cerebrais afetados pelos efeitos degenerativos da hipertensão arterial sistêmica (HAS) ou da angiopatia amiloide. O diagnóstico pode ser feito através da tomografia computadorizada de crânio (TCC), sendo auxiliado pela ressonância nuclear magnética (RNM) do encéfalo e a angiografia dos quatro vasos cerebrais na investigação etiológica. Tratamento: dividido em clínico e cirúrgico. Atualmente, não há consenso sobre a seleção do tipo de tratamento para pacientes com HIC, e esta decisão deve levar em consideração idade do paciente, estado neurológico, tamanho e profundidade do hematoma, presença de hidrocefalia e de efeito compressivo. Os estudos atuais mostram uma tendência de superioridade dos procedimentos cirúrgicos minimamente invasivos, commenor risco de lesão encefálica secundária decorrente do acesso cirúrgico ao hematoma. Conclusão A escolha da melhor estratégia para o tratamento das HIC permanece um desafio e ainda deve ser feita de forma individualizada.

Introduction Cerebrovascular Diseases are the major cause of death in Brazil and a public health issue in the world. Methods Review of the literature using the MEDLINE's data bank. We have searched the keywords "intracerebral" and "hemorrhages" in the title and abstract. Results Intracranial hemorrhages (ICH) affect, mainly, the cerebral lobes, basal ganglia, thalamus, brain stem and the cerebellum as a result of the rupture of diseased cerebral vessels by the effects of hypertension or amyloid angiopathy. Diagnosis can be done with the use of a non-contrast computed tomography (CT), magnetic resonance imaging (MRI) and cerebral angiogram (useful in investigation of the etiology). Treatment can be divided in clinical and surgical. This decision still should be taken considering individual features, such as patient's age and neurological status, hematoma's size and deep, time between ictus and the procedure, presence of hydrocephalus and compressive effects. The studies has shown a preference for the minimally invasive procedures, since the secondary brain lesions caused by the surgery tend to be less. Conclusion The choice of what would be the best strategy to treat the ICH is still a challenge and this decision should be taken individually.

The influence of the day of the week of hospital admission on the prognosis of stroke patients / O dia da semana de admissão hospitalar influenciando o prognóstico de pacientes com acidente vascular cerebral / Influencia del día de la semana de admisión hospitalaria en el pronóstico de pacientes con accidente vascular cerebral

This study aimed to evaluate the weekday and weekend distribution of stroke case hospital admissions and their respective prognosis based on a sample from the Estudo de Mortalidade e Morbidade do Acidente Vascular Cerebral (EMMA), a cohort of stroke patients admitted to a community hospital in the city of São Paulo, Brazil. We ascertained all consecutive cases of first-time strokes between April 2006 and December 2008 and performed a subsequent one-year follow-up. No association was found between frequency of hospital admissions due to ischemic and hemorrhagic strokes and the specific day of the week on which the admission occurred. However, ten-day and twelve-month case-fatality was higher in hemorrhagic stroke patients admitted at the weekend. We also found that intracerebral hemorrhage patients admitted on weekends had a worse survival rate (50%) compared with those admitted during weekdays (25.6%, P log-rank = 0.03). We found a multivariate hazard ratio of 2.49 (95%CI: 1.10-5.81, P trend = 0.03) for risk of death at the weekend compared to weekdays for intracerebral hemorrhage cases. No difference in survival was observed with respect to the overall sample of stroke or ischemic stroke patients.

O estudo avaliou a distribuição de casos incidentes de acidente vascular cerebral (AVC) que procuraram hospital de 2ª a 6ª feira ou nos finais de semana no Estudo de Mortalidade e Morbidade do AVC (EMMA). O EMMA é uma coorte de pacientes com AVC em hospital comunitário da cidade de São Paulo, Brasil. Casos consecutivos de primeiro episódio de AVC internados entre abril de 2006 e dezembro de 2008 foram seguidos prospectivamente por um ano. Não houve diferença na frequência das internações por AVC isquêmico ou hemorrágico pelos dias da semana. Entretanto, a letalidade em dez dias e após um ano estava aumentada no AVC hemorrágico. Na análise da sobrevida de um ano, pacientes admitidos nos finais de semana por hemorragia intraparenquimatosa apresentaram menor sobrevida (50%) quando comparados aos admitidos de 2ª a 6ª (22%) (p log-rank = 0.03). Encontrou-se uma razão de risco multivariada de 2,49 (IC95%: 1,10-5,81, p tendência = 0,03) de morrer nos fins de semana em comparação ao período de 2ª a 6ª feira para hemorragia intracerebral. Não houve diferença na sobrevida para amostra total de AVC nem para AVC isquêmico.

El estudio evaluó la distribución de casos incidentes de accidente vascular cerebral (AVC) que fueron al hospital de lunes a viernes o durante los fines de semana en el Estudio de Mortalidad y Morbilidad del AVC (EMMA). El EMMA es una cohorte de pacientes con AVC en un hospital comunitario de la ciudad de São Paulo, Brasil. Casos consecutivos de primer episodio de AVC internados, entre abril de 2006 y diciembre de 2008, fueron seguidos prospectivamente durante un año. No hubo diferencia en la frecuencia de las internaciones por AVC isquémico o hemorrágico durante los días de la semana. Sin embargo, la letalidad en 10 días y tras un año había aumentado en el AVC hemorrágico. En el análisis de supervivencia de un año, pacientes admitidos los fines de semana por hemorragia intraparenquimatosa presentaron menor supervivencia (50%), comparados con los admitidos de Lunes hasta Viernes (22%, p log-rank = 0.03). Se encontró una razón de riesgo multivariada de un 2,49 (IC95%: 1,10-5,81; p tendencia = 0,03) de morir los fines de semana en comparación con los lunes y viernes para la hemorragia intracerebral. No hubo diferencia en la supervivencia para la muestra total de AVC ni para el AVC isquémico.

Demographic profile of head injury cases in Agra region.

Head injury is a serious health problem throughout the world. Increasing vehicles on roads work as catalyst for high incidence of casualties especially of Cranio-cerebral injuries. This is an autopsy based study of head injury cases, conducted in the Department of Forensic Medicine, S.N. Medical College Agra in year 2009-2010 for their demographic and etiological profile. Majority of the victims of head injury are male (76%) and of 3rd – 4th decade of life (54.4%). 66.4% head injury cases due to accident, Road traffic accident is the single largest cause i.e. 59.2%; out of which two wheelers are responsible for one-third (33%) of the casualties. Most common external injury is laceration of the scalp with or without contusion. Fracture of skull bones (97.2% cases; mostly fissured and comminuted fracture of parietal & temporal) and intracranial hemorrhages (96.4%) are seen in almost all the cases. Contre-coup injuries seen in about 2.8% cases, contre-coup haemorrhage observe mostly fronto-temporal area. Majority of the victim died on the spot or in the way to hospital without any medical assistance where the Cause of death mostly haemorrhage and shock.

Risk Factors Related to Hospital Mortality in Kenyan Patients with Traumatic Intracranial Haematomas

Background:The aim of this study was to investigate the factors which influence mortality of patients with traumatic intracranial hematomas (ICH).Methods: Following ethical approval; the records of patients admitted to the Kenyatta National Hospital neurosurgical unit between January 2000 and December 2009 and who were diagnosed with traumatic ICH were retrieved and reviewed.The outcome measured was mortality during admission. Analysis was done using Statistical Package for Social Sciences (SPSS) version 12.Results: During the study period; 608 patients were admitted with a diagnosis of traumatic intracranial haematoma. 89.3were male and 10.7female with a mean age was 35.33 years (+/- 17.420). 59.3of patients with preoperative GCS scores of 8 died; while only 11and 3deaths occurred in the patients with moderate and mild head injury espectively. 70.4of patients with unreactive pupils died as compared to 7.5of patients with bilaterally symmetrical reactive pupils (p=0.002).There was a statistically significant increase in mortality in patients who did not undergo surgical intervention (26.1; p=0.000) as compared to those who were operated (15.7; p=0.000). The mean time from accident to surgery was 3 days.Patients who were operated on more than 4 days after the initial trauma had a mortality of 42.1as compared to 9.3for patients operated on within 24 hours.Conclusion: An increased risk of death was observed in patients who are over 61 years of age;have lower preoperative GCS; the presence of pupillary abnormalities and a long interval between trauma and decompression

Success of heparin use in intraventricular haematoma treatment

Prevent closure of an external intraventricular drainage with the use of heparin. A patient with intraventricular haemorrhage presented with repetitive closure of intraventricular drainage tube. A trial heparin infusion directly into the ventricle was attempted to prevent further closure of the catheter. The heparin used at a dose related of 340 units per 10 ml of intraventricular haematoma was effective in dissolving the clot and maintaining the external drainage patency. Thrombolytic therapy with intraventricular infusion of heparin may be life saving in intraventricular haemorrhage

Positive autopsy: A case report.

The Postmortem examination of bodies brought to mortuary can be conducted by medical officers or by Forensic experts. Usually this job is conducted by medical officers and in doubtful cases dead body is referred to Department of Forensic Medicine to conduct autopsy. Many a times the medical officer fails to see wounds or injuries, they not able to differentiate antemortem injury from Postmortem injury, sometime they are not able to differentiate hanging from strangulation and in cases of multiple injuries, they are not able to draw opinion regarding cause of death, mode of death and manner of death. At most of time these cases remain unnoticed and unobjectionable but in few cases in which relatives of deceased are not satisfied with Postmortem finding and they demand for Re-Postmortem examination by help of Forensic experts. Most of time Second autopsy is not able to draw any opinion regarding cause of death, mode of death and manner of death because of serious alteration and artifact during First autopsy, but one thing which is always highlighted here that First autopsy was not complete. In this paper is discussed a case report in which the medical officer at a district hospital conducted a Postmortem examination on the dead body of a young male, he has preserved viscera for chemical analysis and he was not able to draw opinion regarding cause of death. Later on Re-Postmortem was conducted at the Department of Forensic Medicine and Toxicology, Govt. Medical College and New Civil Hospital Surat, revealed the cause of death as intracranial hemorrhage.

Trends of stroke subtypes mortality in Sao Paulo, Brazil (1996-2003)

O declínio da mortalidade pela doença cerebrovascular no Brasil é conhecido, porém há poucos dados sobre a evolução temporal dos dois principais subtipos, a hemorragia parenquimatosa e o infarto cerebral. As modificações temporais dos subtipos de doença cerebrovascular foram estudadas na cidade de São Paulo entre 1996 e 2003 por gênero e faixa etária decenal entre os 30 e 79 anos. Para os homens detectou-se redução anual para todo os tipos (-3,9%), para hemorragia parenquimatosa (-3,0%), para infarto cerebral (-2,7%) bem como para os casos mal definidos (-7.4%). Para as mulheres somente houve variação significativa para todos os tipos da doença cerebrovascular (-3,3%) e para os casos mal definidos (-12%). Concluindo, as taxas de doença cerebrovascular estão em queda, porém entre as mulheres devido à melhoria do diagnóstico clínico houve migração de casos mal definidos para casos bem definidos. Devido a isso não foi possível detectar declínio nas taxas de mortalidade pelos subtipos de doença cerebrovascular.

Mortalidade por doenças cardiovasculares em mulheres em idade reprodutiva (15 a 49 anos), no estado de säo Paulo, Brasil, 1991 a 1995 / Mortality due to cardiovascular disease in women during the reproductive age (15 to 49 years), in the State of São Paulo, Brazil, from 1991 to 1995

OBJECTIVE: To describe mortality due to cardiovascular diseases in women during the reproductive age (15 to 49 years) in the state of São Paulo, Brazil, from 1991 to 1995. METHODS: A list of all deaths and their underlying causes, coded according to the International Classification of Diseases, 9th revision, multiple causes of death, and estimates of the female population according to age groups were provided by the SEADE Foundation. Specific coefficients for 100 thousand women for each year as well as the medians of these coefficients related to 5 years, and the percentage of death by subgroups were calculated. RESULTS: Cerebrovascular diseases have the highest coefficients (14.24 for 100 thousand females), followed by ischemic heart disease (7.37), other heart diseases (6.39), hypertensive disease (3.03), chronic rheumatic heart disease (1.58), pulmonary vascular diseases (1.29), and active rheumatic fever (0.05). Systemic arterial hypertension, as an associated cause, occurred in 55.3 percent to 57.8 percent of all the deaths due to intracerebral hemorrhage and in 30.4 percent to 30.8 percent due to subarachnoid hemorrhage. CONCLUSION: The significance of cerebrovascular diseases, coronary artery disease, and systemic arterial hypertension as causes of mortality suggests the need to emphasize preventive actions for young women who have the potential to reproduce to avoid possible complications in future pregnancies, and premature mortality