Fratura traumática da coluna torácica limitada entre T1 e T10 / Traumatic thoracic spine fractures limited between T1 and T10

Objetivo: Estudo retrospectivo de uma série de 79 pacientes com fratura traumática da coluna torácica,limitada entre T1 e T10,hospitalizados entre 1995 e 2004 no Serviço de Neurocirurgia do Centro Hospitalar Universitário(CHU), Norte de Marseille, França.Métodos:As fraturas foram classificadas de acordo com a classificação da AO(Arbeitsgemeinschaft für Osteosynthesefragen)e o quadro neurológico por meio da classificação de Frankel na hospitalização,aos seis meses e um ano.Resultados:A etiologia mais frequente das fraturas foram os acidentes automobilísticos(68,3 por cento), e o tipo de fratura, o B(54,4 por cento); 57 pacientes foram considerados politraumatizados e 82,3 por cento apresentavam lesão medular. O tratamento cirúrgico foi empregado em 96,2 por cento dos casos, sendo a via posterior a mais utilizada com objetivo de estabilização,descompressão medular, correção do alinhamento da coluna, diminuição da dor e mobilização precoce.Conclusão:As incidências, as causas, os tipos de fraturas e os manejos destas foram analisados e comparados com a literatura e os resultados confirmaram a gravidade das lesões neste segmento da coluna, o número elevado de lesões associadas, a raridade de recuperação neurológica, assim como o benefício do tratamento cirúrgico por via posterior.

Craniocerebral penetrating injury caused by a spear gun through the mouth: case report.

The authors report a case of a craniocerebral penetrating injury caused by the shaft of a spear gun. The entry point of the spear was located in the mouth without an obvious exit point. The authors first note the presentation of the patient, whose airway was obstructed by the shaft, and then discuss the surgical procedure, which was focused on removing the shaft in an anterograde direction because of an articulated wishbone located at the tip of the shaft.

Análise da cirurgia do hematoma subdural crônico em cem pacientes idosos / Analysis of the surgical tratment of chronic subdural hematoma in 100 elderly patients

Objetivo: avaliar o tratamento cirúrgico do hematoma subdoral crônico em pacientes idosos, com idade a partir de 75 anos. Método: estudo retrospectivo de série consecutiva de 100 pacientes dessa faixa etária, com hematoma subdural, operados em um período de oito anos, no Service de Neurochirurgie-Professeur Bernard Alliez do Hôpital Nord, AP-HM, Centre Hospitalier Universitaire de Marseille, França. Resultados: os sintomas de alrme e o quadro clínico foram variados e enganadores, diferente do observado em pacientes mais jovens. Houve predominância masculina, a média etária foi de 82 anos; traumatismo craniano foi realtado em 42 casos; 96 pacientes foram operados, obtendo-se cura completa em 59 (61,4 por cento); 22(23 por cento) ficaram com sequelas neurológicas, e 15(15,6 por cento) faleceram. Conclusão: apesar da idade avançada dos pacientes, a resposta ao tratamento cirúrgico foi boa com mais de 60 por cento de cura completa. A idade avançada dos pacientes não deve ser considerada contra-indicação à cirurgia.

Pulmonary contusion in severe head trauma patients: impact on gas exchange and outcome.

STUDY OBJECTIVE: To evaluate the impact on morbidity and mortality of pulmonary contusion in multiple-trauma patients with severe head trauma. DESIGN: Matched-paired, case-control study SETTING: ICU at a tertiary university hospital. PATIENTS: During a 3-year period, 313 consecutive multiple-trauma patients with severe head trauma (Glasgow coma scale [GCS],

Decompressive craniectomy for severe traumatic brain injury: Evaluation of the effects at one year.

OBJECTIVE: To assess the effect on outcome (1 yr) of decompressive craniectomy performed within or after the first 24 hrs post-trauma in severely head-injured trauma patients with intractable cerebral hypertension. DESIGN: Retrospective cohort study. SETTINGS: Intensive care unit of a university hospital. PATIENTS: Among 816 patients with severe head trauma (Glasgow Coma Scale < or =8), 40 underwent decompressive craniectomy. After data collection, patients were divided into two groups: early and late decompressive craniectomy. An early decompressive craniectomy was performed within the first 24 hrs in patients according to the following criteria: a Glasgow Coma Scale score <6 and the existence of clinical signs of cerebral herniation (absence of pupillary reflexes), correlated with abnormalities in computed tomography scan including hematoma, appearance of diffuse or unilateral brain swelling, and/or cerebral herniation. The intracranial pressure in these patients was not measured before the decompressive craniectomy was performed. A late decompressive craniectomy (>24 hrs) was performed according to following criteria: an intractable intracranial hypertension with intracranial pressure >35 mm Hg, a unilateral or bilateral absence of pupillary reflexes, and the same abnormalities in computed tomography scan as previously described. INTERVENTION: Twenty-seven patients with signs of cerebral herniation required the procedure at the time of initial evacuation of a mass lesion. In 13 patients, decompressive craniectomy was performed because of elevated intracranial pressure refractory to medical treatment consisting of cerebrospinal fluid derivation, deep sedation, osmotherapy, hyperventilation, and nesdonal or propofol. MEASUREMENTS AND MAIN RESULTS: Five patients (19%) in whom an early decompressive craniectomy was performed had good recoveries (social rehabilitation), eight patients (30%) remained in a persistent vegetative state or with a severe disability, and 14 died (52%). On the other hand, the performance of late decompressive craniectomy in case of medical treatment failure was followed by social rehabilitation in five patients (38%) and death in three patients (23%). A persistent vegetative state or a severe disability was observed in five patients (38%). Meningitis or cerebral abscess occurred in six patients after decompressive craniectomy and were easily cured by antibiotic treatment. CONCLUSIONS: In 40 patients with intractable intracranial hypertension and at very high risk of brain death, decompressive craniectomy allowed 25% of patients to attain social rehabilitation at 1 yr.

Unruptured intracranial aneurysm presenting with epiletic seizure.

Intracranial aneurysms are frequently present with subarachnoid hemorrhage. Less often they produce suggestive symptoms of cranial nerve dysfunction or intracranial tumor when very large. Their association with epilepsy has rarely been reported; such concurrence may not be a coincidence. When the patient presents with epileptiforme attacks the presence of an intracranial aneurysm is rarely considered. In this paper we report the case of a 45-years-old patient with an unruptured aneurysm of the middle cerebral artery with a 10 years history of epileptic seizure.

Unruptured intracranial aneurysm presenting with epiletic seizure

Intracranial aneurysms are frequently present with subarachnoid hemorrhage.Less often they produce suggestive symptoms of cranial nerve dysfunction or intracranial tumor when very large. Their association with epilepsy has rarely been reported; such concurrence may not be a coincidence. When the patient presents with epileptiforme attacks the presence of an intracranial aneurysm is rarely considered. In this paper we report the case of a 45-years-old patient with an unruptured aneurysm of the middle cerebral artery with a 10 years history of epileptic seizure

Isovolume hypertonic solutes (sodium chloride or mannitol) in the treatment of refractory posttraumatic intracranial hypertension: 2 mL/kg 7.5% saline is more effective than 2 mL/kg 20% mannitol.

OBJECTIVE: To evaluate the clinical benefit of increasing the osmotic load of the hypertonic solution administered for the treatment of refractory intracranial hypertension episodes in patients with severe head injury. DESIGN: Prospective, randomized study. SETTINGS: A trauma center in a university hospital. PATIENTS: Twenty consecutive patients with head trauma and persistent coma who required infusions of an osmotic agent to treat episodes of intracranial hypertension resistant to well-conducted standard modes of therapy were studied. Intracranial hypertension was considered refractory when it persisted despite deep sedation, optimal hemodynamic status, and, in some patients, drainage of cerebral spinal fluid. INTERVENTIONS: Patients were randomly assigned to receive isovolume infusions of either 7.5% hypertonic saline solution (2400 mOsm/kg/H(2)O) or 20% mannitol (1160 mOsm/kg/H(2)O). The patients were given 2 mL/kg (body weight) of either solution, i.e., 361 +/- 13 mOsm of saline or 175 +/- 12 mOsm of mannitol per injection. MEASUREMENTS AND MAIN RESULTS: The main variables studied were the number and the duration of episodes of intracranial hypertension per day during the study period, which was stopped after the last episode of intracranial hypertension was recorded from intracranial pressure monitoring or after the allocated treatment failure. Patients in the HHS group were monitored for 7 +/- 5 days and those in the mannitol group for 7 +/- 6 days (not significant). The rate of failure for each treatment was also evaluated. Failure was defined as the persistence of intracranial hypertension despite two successive infusions of the same osmotic agent. The mean number of osmotic solute infusions was 3.7 +/- 5.3 in the mannitol group and 3.3 +/- 4.1 in the hypertonic saline solution group (not significant). The mean number (6.9 +/- 5.6 vs. 13.3 +/- 14.6 episodes) of intracranial hypertension episodes per day and the daily duration (67 +/- 85 vs. 131 +/- 123 min) of intracranial hypertension episodes were significantly lower in the hypertonic saline solution group (p <.01). The rate of clinical failure was also significantly lower in the hypertonic saline solution group: 1 of 10 patients vs. 7 of 10 patients (p <.01). CONCLUSION: In this study, when a hypertonic solute was required for the treatment of refractory intracranial hypertension episodes in patients with severe head trauma, increasing the osmotic load by giving 2 mL/kg (body weight) of 7.5% saline (361 +/- 13 mOsm) was more effective than giving 2 mL/kg (body weight) of 20% mannitol (175 +/- 12 mOsm). Within the limitations of the present study, these data suggest that giving 2 mL/kg hypertonic saline solution (approximately 480 mOsm/70 kg body weight) is an effective and safe initial treatment for intracranial hypertension episodes in head-trauma patients when osmotherapy is indicated.

Brain tissue penetration of ciprofloxacin following a single intravenous dose.

Ciprofloxacin distribution was assessed in cerebral tissues in 14 patients undergoing craniotomy. The study objective was to determine the brain tissue/serum concentration ratio of ciprofloxacin. Patients received a single intravenous (iv) 200 mg dose of ciprofloxacin. Mean (+/- S.D.) tissue/serum concentration ratios were (mg/kg): parietal fat during opening 1.40 +/- 1.05, during closure 1.34 +/- 1.17, in the dura mater 2.26 +/- 1.36, in skull bone during opening 0.44 +/- 0.29, during closure 0.97 +/- 1.57 and in brain tissue 0.88 +/- 0.99. Mean (+/- S.D.) concentrations of ciprofloxacin in brain tissue were 0.87 +/- 0.08 mg/kg, suggesting that a dose >200 mg iv ciprofloxacin is required to ensure therapeutic concentrations in brain tissue.