Barriers to patient recruitment in a poststroke neurorehabilitation multicenter trial in Brazil.

There is a high demand for stroke rehabilitation in the Brazilian public health system, but most studies that have addressed rehabilitation for unilateral spatial neglect (USN) after stroke have been performed in high-income countries. Therefore, the aim of this study was to analyze USN patient recruitment in a multicenter noninvasive brain stimulation clinical trial performed in Brazil and to provide study design recommendations for future studies. We evaluated the reasons for exclusion of patients from a multicenter, randomized, double-blinded clinical trial of rehabilitation of USN patients after stroke. Clinical and demographic variables were compared between the included and excluded patients. A descriptive statistical analysis was performed. Only 173 of the 1953 potential neglect patients (8.8%) passed the initial screening. After screening evaluation, 87/173 patients (50.3%) were excluded for clinical reasons. Cognitive impairment led to the exclusion of 21/87 patients (24.1%). Low socioeconomic status led to the exclusion of 37/173 patients (21.4%). Difficulty obtaining transportation to access treatment was the most common reason for their exclusion (16/37 patients, 43.3%). The analyzed Brazilian institutions have potential for conducting studies of USN. The recruitment of stroke survivors with USN was restricted by the study design and limited financial support. A history of cognitive impairment, intracranial stenting or craniectomy, and lack of transportation were the most common barriers to participating in a multicenter noninvasive brain stimulation trial among patients with USN after stroke.

Barriers to patient recruitment in a poststroke neurorehabilitation multicenter trial in Brazil

There is a high demand for stroke rehabilitation in the Brazilian public health system, but most studies that have addressed rehabilitation for unilateral spatial neglect (USN) after stroke have been performed in high-income countries. Therefore, the aim of this study was to analyze USN patient recruitment in a multicenter noninvasive brain stimulation clinical trial performed in Brazil and to provide study design recommendations for future studies. We evaluated the reasons for exclusion of patients from a multicenter, randomized, double-blinded clinical trial of rehabilitation of USN patients after stroke. Clinical and demographic variables were compared between the included and excluded patients. A descriptive statistical analysis was performed. Only 173 of the 1953 potential neglect patients (8.8%) passed the initial screening. After screening evaluation, 87/173 patients (50.3%) were excluded for clinical reasons. Cognitive impairment led to the exclusion of 21/87 patients (24.1%). Low socioeconomic status led to the exclusion of 37/173 patients (21.4%). Difficulty obtaining transportation to access treatment was the most common reason for their exclusion (16/37 patients, 43.3%). The analyzed Brazilian institutions have potential for conducting studies of USN. The recruitment of stroke survivors with USN was restricted by the study design and limited financial support. A history of cognitive impairment, intracranial stenting or craniectomy, and lack of transportation were the most common barriers to participating in a multicenter noninvasive brain stimulation trial among patients with USN after stroke.

Microcirurgia de tumor orbital guiada por imagem (navegação): Relato de Caso / Orbital tumor microsurgery guided by computerized image: a case report

Descrição de caso de tumor orbital extraconal subperiostal superior, produzindo proptose e desvio caudal do globo ocular, sem interferência nos movimentos oculares, com dezoito meses de evolução, em paciente feminina, com 39 anos de idade. Ausência de alterações ósseas, ao R, TC e RM, demonstrava presença de massa tumoral medindo 3 x 1,5 cm, extraconal, sobre o músculo elevador da pálpebra e sob o periósteo, no segmento orbital superior direito. Cirurgia programada, com sistema de navegação (cirurgia guiada por imagem) com superposição de imagens, de TC e RM. Ressecção completa da lesão, sem comprometimento neurológico ou funcional do globo, e excelente resultado estético.

[Epilepsy and cerebral tumor]. / Epilepsia y tumor cerebral.

OBJECTIVE: To determine clinical and pathological features with seizures associated brain tumors. PATIENTS AND METHODS: This was a retrospective study through of an Epilepsy Program Protocol where we studied fifty patients admitted at Hospital Universitário Cajuru of Curitiba, Brazil, in 1996-1997. RESULTS: We studied 36 males and 14 females, aged 6 and 81 years old (mean 40.5). Twenty six patients had tonic-clonic seizures, 13 had simple partial secondarily generalized, 8 had simple partial, 2 complex partial and one with simple partial progressing to complex partial seizure. CT showed parietal expansive lesion on 14 cases, frontal expansive lesion on 14 cases, frontoparietal on 5; intraventricular tumor, sella turcica, temporal temporoparietal and fronto-temporo-parietal expansive lesion 2 on each case, and suprasellar lesion, centrum semiovale, cerebello-pontine angle, ventricular trigone, fronto-naso-etmoidal and brain stem 1 on each case. All patients were submitted to a biopsy and/or resection of the lesion. The principal brain tumors were meningioma in 30%, astrocytoma in 22%, glioblastoma multiform in 14%, oligodendroglioma in 4% and pituitary adenoma in 4%.

[Epilepsy and arteriovenous malformations]. / Epilepsia asociada a malformación arteriovenosa.

OBJECTIVE: To describe the characteristics of the patients with epilepsy, associated to arteriovenous malformation. PATIENTS AND METHODS: We introduced 11 patients assisted in 1997, at University Cajuru Hospital, with arteriovenous malformation associated to refractory epileptic seizures. RESULTS: Six men and five women, with age between 12 and 40 years old (27 years in mean), were interned with epileptic crises, 4 generalized tonic-clonic, 3 partial simple secondarily generalized, one with complex partial and one with simple partial that the complex developed with secondary generalization. CT showed temporal lesion in 3 patients, parietal in 3 patient, ventricular in 3, parietal fose and temporoparietal on one patient, respectively. MRI was accomplished in 5 patients presenting temporal lesion in 3 and temporo-parietal in 2. It was possible to accomplish the EEG in 8 patients, all with epileptiform activity. The arteriography showed arteriovenous malformations in all the patients, 3 of the which died. Eight patients were guided for surgical treatment evidencing cavernous angioma in 6 patient and hemangioma in 2. CONCLUSIONS: We observed that cortical and not cortical arteriovenous malformation associates to epileptic seizures and in the cases in which it is possible, the surgical treatment favors the control of the seizures.

[Syndrome of Munchausen and pseudoparaplegia. Case report]. / Síndrome de Munchausen e pseudoparaplegia. Relato de caso.

We present a 36 years old female, with a 8 years history of "paraplegia", who was admitted to our department to have "some needles withdrawn" from her back. She referred previous admittances to general and psychiatric hospitals in order to treat several episodes of renal failure, combined with other clinical conditions like pulmonary tuberculosis and esophagus, ovary and breast cancer. On the psychiatric evaluation, we found a patient who seemed to be indifferent to her disease, giving accurate and very elaborated description of her symptoms. She was always complaining about previous medical therapies. She moved her both legs simultaneously, without any impairment on reflexes and sensibility. We did not find evidence of tumor processes. The electromyography, cranial CT scan, abdominal ultrasound scan and chest X-ray were normal. Lumbosacral X-ray and CT scan showed 16 sewing needles widespread in the lumbosacral soft tissues. A diagnosis of Munchausen syndrome was formed. After a 15-day trial of anti depressive drug, physiotherapy and psychotherapy, her clinical status significantly improved, reverting its neurological picture after treatment.

Dissinergia cerebelar mioclônica de Ramsay-Hunt. Estudo clínico, eletroencefalográfico e por tomografia axial computadorizada - Diagnóstico diferencial / Ramsay-Hunt cerebellar myoclonic dyssynergia

Os autores descrevem um caso de dissinergia cerebelar mioclônica de Ramsay-Hunt, associada a epilepsia em uma menina de 14 anos. O diagnóstico foi baseado em um quadro cerebelar associado a mioclonias, epilepsia grande mal e história familiar. O ECG mostrou uma atividade de fundo normal, associado a ondas agudas, polipontas e polipontas ondas, que näo sofrem alteraçäo pela alcalose cerebral, mas que é ativado pela fotoestimulaçäo intermitente. Os autores concluem que o diagnóstico pode ser dado pelo quadro clínico, traçado eletroencefalográfico característico, e a inclui entre as epilepsias mioclônicas progressivas e degenertivas

Guillain-Barré syndrome after varicella-zoster infection. Case report.

The authors report a case of Guillain-Barrè syndrome (GBS) following a varicella infection in a 13 year-old boy. During his admission he developed respiratory insufficiency and dysautonomic events, as well as a severe sensitive peripheral neuropathy. Some aspects related to the etiology and pathogenesis of GBS are discussed.

Illiteracy and brain damage. 2. Manifestations of unilateral neglect in testing "auditory comprehension" with iconographic materials.

This report concerns the sentence-picture matching behavior of 100 neurologically healthy and 169 brain-damaged subjects, all of whom were unilingual adult right-handers. Within this population, 144 subjects were totally unschooled illiterates and the remaining 125 had received school education and thereafter had retained writing skills and reading habits. Brain-damaged subjects were tested less than 2 months after a first left- or right-hemisphere stroke. All subjects were administered an aphasia screening battery including, among other subtests, a set of six sentence-picture matching stimuli. For each of these six stimuli, subjects heard a sentence uttered by the examiner and were then requested to match this sentence with one of four drawings presented within a single display divided into four quadrants of equal surface. Three sentences were syntactically "simple" (noun subject + verb) and three were relatively more "complex" (noun subject + verb + one or two noun complements). Evidence of unilateral neglect was found in both left- and right-brain-damaged illiterates and literates. Moreover, the right neglect of left-brain-damaged subjects was manifest mostly when target sentences were relatively "complex" whereas the left neglect of right-brain-damaged subjects was manifest irrespective of the syntactic complexity of target sentences. Our data are interpreted as indicative of an interaction between two cognitive disorders resulting from dysfunctions of asymmetrically represented cognitive mechanisms. The implications of these findings with respect to clinical and research aphasia testing are discussed.