Preterm infants with peri/intraventricular hemorrhage have poorer habituation responses to external stimuli / Neonatos prematuros com hemorragia peri-intraventricular apresentam respostas de habituação piores a estímulos externos

ABSTRACT Objective: To evaluate the association between intra-ventricular hemorrhage and habituation responses to external stimuli in preterm infants at 36-38 weeks post-conceptual age. Methods: Cross-sectional study of infants with gestational age <32 weeks. Intra-ventricular hemorrhage was identified by cranial ultrasonography and classified according to Papile et al. (1978). The luminous (flashlight), sound (rattle, bell), and tactile stimuli were presented, and the responses were scored according to Lester and Tronik (2004). Habituation response scores were compared between groups by Student's t-test. The association between IVH and habituation scores was evaluated by linear regression adjusted for GA, clinical severity score, post-conceptual age at habituation assessment, sepsis, and bronchopulmonary dysplasia. Results: Sixty-five infants were studied, 20 with intra-ventricular hemorrhage (16 grades I/II; four grades III/IV) and 45 without intra-ventricular hemorrhage. Infants with intra-ventricular hemorrhage had lower gestational age (28.2 ± 2.2 vs. 29.7 ± 1.7 weeks) and birth weight (990 ± 305 vs. 1275 ± 360 g). Infants with intra-ventricular hemorrhage at 36-38 weeks post-conceptual age had lower habituation scores to light (4.21 ± 2.23 vs. 6.09 ± 2.44), rattle (3.84 ± 2.12 vs. 6.18 ± 2.27), and bell (3.58 ± 1.74 vs. 5.20 ± 2.47) after controlling for confounders. No differences were found for tactile stimulus. Conclusion: Infants with gestational age <32 weeks and intra-ventricular hemorrhage had poorer habituation responses to external stimuli than those without intra-ventricular hemorrhage at 36-38 weeks post-conceptual age.

RESUMO Objetivo: Avaliar a associação entre hemorragia intraventricular e as respostas de habituação a estímulos externos em neonatos prematuros com idade pós-conceptual de 36-38 semanas. Métodos: Estudo transversal com neonatos com idade gestacional < 32 semanas. A hemorragia intraventricular foi identificada por ultrassonografia craniana e classificada de acordo com Papile et al. (1978). Os estímulos luminosos (lanterna), sonoros (chocalho, sino) e táteis foram apresentados e as respostas foram pontuadas de acordo com Lester & Tronik (2004). Os escores das respostas de habituação foram comparadas entre os grupos pelo teste t de Student. A associação entre a hemorragia intraventricular e os escores de habituação foi avaliada por regressão linear ajustada para a idade gestacional, escore de gravidade clínica, idade pós-conceptual na avaliação da habituação, sepse e displasia broncopulmonar. Resultados: 65 neonatos foram estudados, 20 com hemorragia intraventricular (16 graus I/II;4 graus III/IV) e 45 sem hemorragia intraventricular. Os neonatos com hemorragia intraventricular apresentaram menor idade gestacional (28,2 ± 2,2 vs. 29,7 ± 1,7 semanas) e peso ao nascer (990 ± 305 vs. 1275 ± 360 g). Os neonatos com hemorragia intraventricular na idade pós-conceptual de 36-38 semanas apresentaram escores de habituação menores a luz (4,21 ± 2,23 vs. 6,09 ± 2,44), chocalho (3,84 ± 2,12 vs. 6,18 ± 2,27) e campainha (3,58 ± 1,74 vs. 5,20 ± 2,47) após controle para variáveis de confusão. Nenhuma diferença foi encontrada para os estímulos táteis. Conclusão: Neonatos com idade gestacional < 32 semanas e hemorragia intraventricular apresentaram respostas de habituação piores a estímulos externos que os sem hemorragia intraventricular, na idade pós-conceptual de 36-38 semanas.

Subprodutos do metabolismo da hemoglobina se associam com resposta inflamatória em pacientes com acidente vascular cerebral hemorrágico / Hemoglobin metabolism by-products are associated with an inflammatory response in patients with hemorrhagic stroke

RESUMO Objetivo: Avaliar o relacionamento entre os níveis cerebrais de ferro e heme e a resposta inflamatória sistêmica e no sistema nervoso central, assim como o papel dos sistemas de defesa contra a toxicidade do ferro e do heme, no sistema nervoso central. Métodos: Avaliamos uma coorte prospectiva de pacientes com quadro de hemorragia intracraniana e subaracnóidea. Realizamos ensaios em amostras de plasma e líquido cefalorraquidiano quanto à presença de ferro, heme, hemopexina, haptoglobina, enolase, S100-β e citocinas nos primeiros 3 dias após um acidente vascular cerebral hemorrágico. Analisamos também as alterações dinâmicas em todos os componentes de ambos os líquidos e seu relacionamento com as taxas de mortalidade precoce. Resultados: As concentrações de hemopexina e haptoglobina foram quase desprezíveis no cérebro após hemorragia intracraniana e subaracnóidea. As concentrações de ferro e heme no líquido cefalorraquidiano se correlacionaram com resposta pró-inflamatória no sistema nervoso central, e os perfis inflamatórios no líquido cefalorraquidiano no terceiro dia após acidente vascular cerebral hemorrágico se correlacionaram com as taxas de mortalidade precoce. Identificamos que os níveis de interleucina 4 no líquido cefalorraquidiano durante as primeiras 24 horas após acidente vascular cerebral hemorrágico foram mais altos nos sobreviventes do que nos que não sobreviveram. Conclusão: Os níveis de ferro e heme se associaram com resposta pró-inflamatória no sistema nervoso central após acidente vascular cerebral hemorrágico, e o cérebro humano não tem proteção contra hemoglobina e heme. Os perfis inflamatórios dos pacientes se associaram com prognósticos piores, e as respostas inflamatórias locais pareceram ter um papel protetor.

ABSTRACT Objective: To evaluate the relationships of brain iron and heme with the inflammatory response of the systemic and central nervous systems and to investigate the role of defensive systems against the toxicity of iron and heme in the central nervous system. Methods: We assessed a prospective cohort of patients presenting with intracerebral and subarachnoid hemorrhage. We assayed plasma and cerebrospinal fluid samples for the presence of iron, heme, hemopexin, haptoglobin, enolase, S100-β and cytokines for the first three days following hemorrhagic stroke. We also analyzed the dynamic changes in these components within both fluids and their relationship with early mortality rates. Results: Hemopexin and haptoglobin concentrations were nearly negligible in the brain after intracerebral and subarachnoid hemorrhage. Cerebrospinal fluid iron and heme concentrations correlated with a pro-inflammatory response in the central nervous system, and plasmatic and cerebrospinal fluid inflammatory profiles on the third day after hemorrhagic stroke were related to early mortality rates. Interleukin 4 levels within the cerebrospinal fluid during the first 24 hours after hemorrhagic stroke were found to be higher in survivors than in non-survivors. Conclusion: Iron and heme are associated with a pro-inflammatory response in the central nervous system following hemorrhagic stroke, and protections against hemoglobin and heme are lacking within the human brain. Patient inflammatory profiles were associated with a poorer prognosis, and local anti-inflammatory responses appeared to have a protective role.

The Incidence of Stroke by Socioeconomic Status, Age, Sex, and Stroke Subtype: A Nationwide Study in Korea / 예방의학회지

OBJECTIVES: To date, studies have not comprehensively demonstrated the relationship between stroke incidence and socioeconomic status. This study investigated stroke incidence by household income level in conjunction with age, sex, and stroke subtype in Korea. METHODS: Contributions by the head of household were used as the basis for income levels. Household income levels for 21 766 036 people were classified into 6 groups. The stroke incidences were calculated by household income level, both overall within income categories and further by age group, sex, and stroke subtype. To present the inequalities among the six ranked groups in a single value, the slope index of inequality and relative index of inequality were calculated. RESULTS: In 2005, 57 690 people were first-time stroke patients. The incidences of total stroke for males and females increased as the income level decreased. The incidences of stroke increased as the income level decreased in those 74 years old and under, whereas there was no difference by income levels in those 75 and over. Intracerebral hemorrhage for the males represented the highest inequality among stroke subtypes. Incidences of subarachnoid hemorrhage did not differ by income levels. CONCLUSIONS: The incidence of stroke increases as the income level decreases, but it differs according to sex, age, and stroke subtype. The difference in the relative incidence is large for male intracerebral hemorrhage, whereas the difference in the absolute incidence is large for male ischemic stroke.

Hematoma subdural agudo espontâneo e hemorragia intracerebral em paciente com microangiopatia trombótica gestacional / Spontaneous acute subdural hematoma and intracerebral hemorrhage in a patient with thrombotic microangiopathy during pregnancy

Pré-eclâmpsia, síndrome HELLP (hemólise, elevação de enzimas hepáticas e plaquetopenia) e fígado gorduroso agudo da gestação são as principais causas de microangiopatia trombótica e disfunção hepática grave durante a gestação, representando um spectrum do mesmo processo patológico. Relatou-se aqui o caso de uma gestante com 35 semanas internada em unidade de terapia intensiva no pós-operatório imediato de cesariana por morte fetal, com náuseas, vômitos e icterícia. Diagnosticaram-se pré-eclâmpsia pós-parto e fígado gorduroso agudo da gestação. Houve evolução tardia com hematoma subdural agudo e hemorragia intracerebral, sendo realizado tratamento neurocirúrgico. A paciente foi a óbito por anemia hemolítica refratária, com sangramento espontâneo em múltiplos órgãos. Pré-eclâmpsia, síndrome HELLP e fígado gorduroso agudo da gestação são processos patológicos que podem se sobrepor e se associar a complicações potencialmente fatais, como a hemorragia intracraniana aqui descrita. Sua detecção e diagnóstico precoces são fundamentais para a instituição de manejo adequado e sucesso do tratamento.

Preeclampsia, HELLP syndrome (hemolysis, elevated liver enzymes, and low-platelet count), and acute fatty liver of pregnancy are the main causes of thrombotic microangiopathy and evere liver dysfunction during pregnancy and represent different manifestations of the same pathological continuum. The case of a 35-week pregnant woman who was admitted to an intensive care unit immediately after a Cesarean section due to fetal death and the presence of nausea, vomiting, and jaundice is reported. Postpartum preeclampsia and acute fatty liver of pregnancy were diagnosed. The patient developed an acute subdural hematoma and an intracerebral hemorrhage, which were subjected to neurosurgical treatment. The patient died from refractory hemolytic anemia and spontaneous bleeding of multiple organs. Preeclampsia HELLP syndrome, and acute fatty liver of pregnancy might overlap and be associated with potentially fatal complications, including intracranial hemorrhage, as in the present case. Early detection and diagnosis are crucial to ensure management and treatment success.

Supine sleep and positional sleep apnea after acute ischemic stroke and intracerebral hemorrhage

OBJECTIVE: Obstructive sleep apnea is frequent during the acute phase of stroke, and it is associated with poorer outcomes. A well-established relationship between supine sleep and obstructive sleep apnea severity exists in non-stroke patients. This study investigated the frequency of supine sleep and positional obstructive sleep apnea in patients with ischemic or hemorrhagic stroke. METHODS: Patients who suffered their first acute stroke, either ischemic or hemorrhagic, were subjected to a full polysomnography, including the continuous monitoring of sleep positions, during the first night after symptom onset. Obstructive sleep apnea severity was measured using the apnea-hypopnea index, and the NIHSS measured stroke severity. RESULTS: We prospectively studied 66 stroke patients. The mean age was 57.6±11.5 years, and the mean body mass index was 26.5±4.9. Obstructive sleep apnea (apnea-hypopnea index >5) was present in 78.8% of patients, and the mean apnea-hypopnea index was 29.7±26.6. The majority of subjects (66.7%) spent the entire sleep time in a supine position, and positional obstructive sleep apnea was clearly present in the other 23.1% of cases. A positive correlation was observed between the NIHSS and sleep time in the supine position (r s = 0.5; p<0.001). CONCLUSIONS: Prolonged supine positioning during sleep was highly frequent after stroke, and it was related to stroke severity. Positional sleep apnea was observed in one quarter of stroke patients, which was likely underestimated during the acute phase of stroke. The adequate positioning of patients during sleep during the acute phase of stroke may decrease obstructive respiratory events, regardless of the stroke subtype.

Hemorragia intracerebral espontánea / Spontaneous intracerebral hemorrhage

Se conoce que la hemorragia intraparenquimatosa es una afección frecuentemente grave y se asocia a elevada mortalidad. Se afirma que menos del 30 por ciento de los enfermos sobreviven 5 años después del ictus inicial y pocos recuperan su total independencia funcional. Se realizó una revisión sobre los factores de riesgo, la fisiopatología y los problemas frecuentes implicados en el tratamiento médico. Se halló que, según los resultados del estudio prospectivo STICH, la cirugía no ha demostrado beneficios superiores al tratamiento médico.

It is known that intraparenchymatous hemorrhage is a frequently severe affection and that it is associated with an elevated mortality. It is asserted that less than 30 percent of the sick survive 5 years after the initial stroke and a few recovered their total functional independence. A review was made on the risk factors, the physiopathology and the common problems involved in the medical treatment. According to the results of the STICH prospective study, surgery has not showed better benefits than the medical treatment.

Pericardite constritiva em paciente com passado de múltiplas trocas de valva mitral, complicada com insuficiência tricúspide grave e hemorragia cerebral por angiopatia amilóide / Constrictive pericarditis in the patient with a history of numerous mitral valve replacements, complicated by serious tricuspid regurgitation and cerebral hemorrhage for amyloid angiopathy

Paciente do sexo feminino, portadora de cardiopatia reumática, com passado de cirurgias de troca valvar mitral que desenvolveu insuficiência tricúspide grave e pericardite constritive, fez hemorragia cerebral grave por angiopatia amilóide, tendo evoluído para óbito

Motor dysfunction on the nonhemiplegic side in patients with intracerebral haemorrhage.

This study was undertaken to evaluate the motor dysfunction on the nonhemiplegic side in patients with acute intracerebral haemorrhage (ICH) and correlate these with radiological and motor evoked potentials findings. 28 patients (23 males, 5 females), with CT proven ICH within 10 days of ictus were subjected to clinical evaluation and central motor conduction studies (CMCT) of upper limbs. The patient's age ranged between 28 and 84 years. Motor signs on the nonhemiplegic side were present in 17 patients in the form of increased tone (10), hyperreflexia (13) and extensor plantar response (10). Sixteen of these patients had severe weakness on the hemiplegic side. Most of the patients had putaminal haemorrhage (13) and thalamic and lobar haemorrhage was seen in 2 patients each. The motor dysfunction on the nonhemiplegic side correlated with midline shift but not with the size of haematoma. CMCT findings correlated with motor signs on the nonhemiplegic side in 6 patients. In the patients without any signs on the nonhemiplegic side, CMCT was normal. Out of 17 patients with motor dysfunction on the nonhemiplegic side 9 revealed improvement in CMCT at 1 month followup. The patients with CMCT abnormalities on the nonhemiplegic side either died (2) or had poor outcome (9). Motor dysfunction on the nonhemiplegic side may be due to tentorial herniation and suggests a poor outcome.

Neurological evaluation of neonates with intraventricular and periventricular hemorrhage

We studied the clinical aspcets of 100 consecutive premature newborns with and without intraventricular and periventricular hemorrhage (IPVH). The diagnosis of IPVH was obtained by ultrasonic scans of the skull during the first week of life and at the age of one month. Forty eight percent of newborns with IPVH had abnormal results, and there was a significant correlation with the neurological evaluation in 85 per cent of the infants. The probability of normality for a child with no associated brain abnormalities was 72 per cent, whereas for a child of the same gestational age with associated brain abnormalities was 48.7 per cent

Hemorragia intracraneana en el neonato pretérmino

La hemorragia intracraneana en el neonato pretérmino es una patología común, que genera altos índices de morbimortalidad en este grupo de edad. Se hace una revisión de la fisiopatología de la enfermedad, la anatomía ecográfica cerebral normal, los hallazgos patológicos iniciales y las complicaciones más frecuentes

Hipocalcemia en prematuros / Hypocalcemia in premature infants

Se estudiaron prospectivamente 56 recién nacidos prematuros que ingresaron al Departamento de Cuidados Intensivos Neonatales del I.N.P. durante un año. Se encontró hipocalcemia en 24 casos (0.43 por ciento). La patología más frecuentemente asociada a hipocalcemia, al momento de la hospitalización, fue dificultad respiratoria, 20 de 24 paciantes (0.8 por ciento); asfixia, 14 a 24 (0.6 por ciento) septicemía, 10 de 24 (0.4 por ciento) y hemorragia intracraneana, 8 de 24 (0.3 por ciento). La asociación hipocalcemia/sexo femenino fue de 13 a 24 (0.5 por ciento) y ayuno/hipocalcemia 17 de 24 (0.7, cifras altamante significativas con p<0.05 y p<0.01, respectivamente. El temblor fino y la hipotensión fueron más frecuentes en hipocalcémicos que en normocalcémicos. Los niños que recibieron furosemide requirieron aporte terapéutico de calcio por más tiempo que los que no lo recibieron (p<0.001)

Hemicoréia-hemibalismo associado a hemorragia em gânglios da base em diabete mélito descompensado: relato de dois casos / Hemichorea-hemibalism associated to basal ganglia hemorrhage in uncontrolled diabetes mellitus: report of two cases

Os autores apresentam dois casos de hemicoréia-hemibalismo de início súbito em pacientes portadoras de diabete mélito desconpensado, cujas tomografias computadorizadas de crânio revelaram hemorragia difusa nos gânglios da base contralaterais aos movimentos anormais. A descriçao de caso em paciente jovem e portadora de diabete mélito insulino-dependente é inédita. Os autores discutem os mecanismos fisiopatológicos que tentam explicar a relaçao entre a hiperglicemia nao-cetótica e o quadro de hemicoréia-hemibalismo associado a lesao estrutural ao nível de núcleos da base.

Pontine tegmentum hematoma: a case report with the "one-and-a-half" syndrome without pyramidal tract deficit

O autor relata o caso de um paciente de sexo masculino de 54 anos com hematoma pontino que se manifestou por síndrome "one-and-a-half" e ataxia cerebelar mas sem sinais de acometimento do trato piramidal. A ausência de acometimento do trato piramidal é decorrente possivelmente de uma variaçäo da anatomia vascular do segmento pontino do tronco cerebral. Os achados clínicos do caso e os mecanismos fisiopatológicos da síndrome "one-and-a-half" säo discutidos

Complicaciones cerebrovasculares del embarazo / The cerebrovascular complications of pregnancy

A pesar de su baja frecuencia las complicaciones cerebrovasculares del embarazo constituyen una de las principales causas de mortalidad no asociadas a complicaciones obstétricas. Existen pocos reportes en relación al tema, sin embargo, se calcula que el riesgo de Enfermedad Vascular Cereberal (EVC) se incrementa hasta en 13 veces durante este periodo, dejando en la mayoría de las veces secuelas incapacitantes en un individuo jóven, y potencialmente productivo como lo es la embarazada. En este trabajo se revisan las complicaciones más frecuentes durante el embarazo en orden de frecuencia; isquemia cerebral y sus mecanismos durante este período, la trombosis venosa áseptica que puede presentarse durante el tercer trimestre del embarazo o con mayor frecuencia durante el puerperio y finalmente hemorragia cerebral

Hemorragia intracerebral (encefálica) espontánea / Spontaneous intracerebral (encephalic) hemorrhage

Se presenta el estudio de una serie de 100 casos de hemorragia intracerebral (HIC) espontánea, precedido de una exposición acerca de la fisiopatología, de la clínica de la afección. Se destaca la dificultad de una precisión diagnóstica topográfica, y aún nosológica, por la clínica; enfatizandose entonces la importancia de la correlación con la TAC, desde donde se desprenderán deducciones terapéuticas y pronósticas. Se señala la tendencia actual hacia un tratamiento conservador, recomendándose la acción quirúrgica para indicaciones precisas con el único interés de salvar la vida y no la función. Serían por lo tanto, los hematomas grandes, sobre todo los lobares y del cerebelo, en pacientes relativamente jóvenes, los pasibles de sanción evacuadora; y que en la agravación del nivel de vigilancia dentro de límites razonables, cayesen en ese rango, luego del ensayo de un tratamiento médico correcto, oportuno e intenso. se realza la influencia de las medidas de reanimación hoy disponibles, independientemente de si se realiza o no la cirugía, y que implica un descenso de la mortalidad, muy elevada en otra época (10 por ciento en esta serie). El pronóstico se centraría en la gravedad clínica de inicio, en el tamaño del hematoma, y su efecto de masa; jerarquizándose como elememtos tomográficos: la ocupación de las cisternas de la base encefálica, y la hidrocefalia controlateral. Finalmente se insiste en lo relevante que deben ser las medidas de prevención, basadas en un correcto control y estricto tratamiento de la hipertensión arterial sistemática, principal factor de riesgo. De ahí la responsabilidad del médico generalista en el conocimiento y manejo de esta patología

Hemorragia intratumoral em esclerose tuberosa: relato de caso / Intratumoral hemorrhage in tuberous sclerosis: a case report

Os autores relatam o caso de uma paciente de 19 anos de idade, com quadro característico de esclerose tuberosa, que evoluiu com hemorragia maciça em astrocitoma subependimário de células gigantes e óbito súbito. Aspectos da fisiopatologia do sangramento säo discutidos