The delayed detection of an acute neurological worsening increases traumatic brain injury lethality / [La detección tardía del deterioro neurológico agudo incrementa la letalidad por trauma craneoencefálico.]

Introduction: Traumatic brain injury is a leading worldwide cause of death and disability in young people. Severity classification is based on the Glasgow Coma Scale. However, the neurological worsening in an acute setting does not always correspond to the initial severity suggesting an underestimation of the real magnitude of the injury. Objective: To study the correlation between the initial severity according to the Glasgow Coma Scale and the patient outcome in the context of different clinical and tomography variables. Materials and methods: We analyzed a retrospective cohort of 490 patients with closed traumatic brain injury requiring a stay in the intensive care unit of two third-level hospitals in Barranquilla. The risk was estimated by calculating the OR (95% CI). The significance level was established at an alpha value of 0.05. Results: Forty-one percent of all patients required orotracheal intubation; 51.2% were initially classified with moderate trauma and 6,0% as mild. The delay in the aggressive management of the traumas affected mainly those patients with traumas classified as moderate in whom lethality increased to 100% when there was delay in the detection of the neurological worsening and in the establishment of the aggressive treatment beyond 4 to 8 hours while the lethality in patients who received this treatment within the first hour reduced to <20%. Conclusions: The risk of lethality in traumatic brain injury increases with the delayed detection of neurological worsening in an acute setting, especially when aggressive management is performed after the first hour post-trauma.

Introducción. El trauma craneoencefálico es una de las principales causas de muerte y discapacidad en adultos jóvenes. Su gravedad se define según la escala de coma de Glasgow. Sin embargo, el deterioro neurológico agudo no siempre concuerda con la gravedad inicial indicada por la escala, lo que implica una subestimación de la magnitud real de la lesión. Objetivo. Estudiar la correlación entre la gravedad inicial del trauma craneoencefálico según la escala de coma de Glasgow y la condición final del paciente, en el contexto de diferentes variables clínicas y de los hallazgos de la tomografía. Materiales y métodos. Se analizó una cohorte retrospectiva de 490 pacientes con trauma craneoencefálico cerrado que requirieron atención en la unidad de cuidados intensivos de dos centros de tercer nivel de Barranquilla. La estimación del riesgo se estableció con la razón de momios (odds ratio, OR) y un intervalo de confianza (IC) del 95 %. Se utilizó un alfa de 0,05 como nivel de significación. Resultados. El 41,0 % de los pacientes requirió intubación endotraqueal; el 51,2 % había presentado traumas inicialmente clasificados como moderados y, el 6,0 %, como leves. El retraso en la implementación de un tratamiento agresivo afectó principalmente a aquellos con trauma craneoencefálico moderado, en quienes la letalidad aumentó al 100 % cuando no se detectó a tiempo el deterioro neurológico y, por lo tanto, el tratamiento agresivo se demoró más de 4 a 8 horas. Por el contrario, la letalidad fue de menos de 20 % cuando se brindó el tratamiento agresivo en el curso de la primera hora después del trauma. Conclusiones. El riesgo de letalidad del trauma craneoencefálico aumentó cuando el deterioro neurológico se detectó tardíamente y el tratamiento agresivo se inició después de transcurrida la primera hora a partir del trauma.

Atención a pacientes con grados buenos de hemorragia subaracnoidea aneurismática en la unidad de ictus / Care of patients with good grades of aneurysmal subarachnoid hemorrhage in the stroke uni

Objetivo: estimar el impacto de la atención a pacientes con grados buenos de hemorragia subaracnoidea aneurismática (HSA-A). Métodos: estudio prospectivo y descriptivo de una cohorte de pacientes con grados buenos de HSA-A ingresados en la Unidad de Ictus Agudo del Hospital Hermanos Ameijeiras de La Habana, durante el período octubre, 2005-diciembre, 2009. La información fue procesada de forma automatizada (SPSS versión 11.5). Resultados: se estudiaron 165 pacientes con edad media de 49,7 años y predominio femenino (66,7 por ciento). Se logró aislar el aneurisma cerebral en 141, en 131 por cirugía y en 10, por vía endovascular. El tratamiento fue realizado antes del tercer día de evolución en 21 casos. Las principales complicaciones observadas fueron: resangrado (18,8 por ciento), vasospasmo sintomático (15,2 por ciento), hidrocefalia (23 por ciento), hiponatremia (11,5 por ciento) y neumonía (10,3 por ciento). El promedio de estadía hospitalaria fue 17,1 d. Egresaron con secuelas discapacitantes 20 pacientes y fallecieron 27. Las variables relacionadas con malos resultados en el momento del egreso fueron: intensidad de las manifestaciones clínicas al ingreso, magnitud del sangrado en la TAC, resangrado, vasospasmo sintomático y neumonía. Conclusiones: la atención especializada centrada en la Unidad de Ictus, parece ser una organización asistencial apropiada para la atención a pacientes con grados buenos de HSA-A(AU)

Objective: estimate the impact of care to patients with good grades of aneurysmal subarachnoid hemorrhage (ASH-A) . Methods: a prospective descriptive study was conducted of a cohort of patients with good grades of ASH-A admitted to the Stroke Unit at Hermanos Ameijeiras Hospital in Havana from October 2005 to December 2009. Data was processed with the statistical software SPSS version 15.0. Results: 165 patients were studied. Mean age was 49.7 and female sex predominated (66.7 percent). The cerebral aneurysm could be isolated in 141 cases: 131 by surgery and 10 by endovascular procedure. In 21 cases treatment was performed before the third day of evolution. The main complications observed were rebleeding (18.8 percent), symptomatic vasospasm (15.2 percent), hydrocephaly (23 percent), hyponatremia (11.5 percent) and pneumonia (10.3 percent). Average hospital stay was 17.1 days. 20 patients were discharged with disabling sequelae; 27 died. The variables associated with a bad outcome at discharge were intensity of clinical manifestations at admission, magnitude of bleeding on CT brain scans, rebleeding, symptomatic vasospasm and pneumonia. Conclusions: stroke Unit specialized care seems to be appropriate for patients with good grades of ASH-A(AU)

Devemos monitorar a pressão intracraniana de pacientes com TCE grave Marshall II? / Should we monitor ICP in severe brain trauma injury Marshall II patients?

Objetivos: Avaliar a relação da PIC com o crescimento de lesões e morbimortalidade em pacientes Marshall II e determinar a necessidade de sua monitorização. Método: Estudo de coorte observacional prospectivo em pacientes com TCE grave classificados como Marshall II. Resultados: Setenta pacientes foram divididos em dois grupos baseados na PIC; G1: PIC ≤ 20 mmHg (49 pacientes) e G2 PIC > 20 mmHg (21 pacientes). Os achados mais comuns foram hemorragias subaracnóideas e contusões.A mortalidade foi maior em G2 que em G1 (OR: 11,7) (IC 95%: 2,2 a 63,1). A mediana da Escala de Desfecho de Glasgow após 90 dias foi de 2 para o G2 e de 5 para o G1. O surgimento ou progressões de lesões ocorreram em 71% dos pacientes no G2 contra 10% no G1 (p < 0,05). Em comparação ao G1, o OR de um novo achado na TC foi 22 vezes maior no G2 (IC 95%: 5,02 a 106,9). Dois pacientes do G2 precisaram de cirurgia e nenhum do G1. Conclusões: Pacientes Marshall II, com hipertensão intracraniana, apresentam maior risco para crescimento de lesões na TC de controle, pior prognóstico e maior mortalidade que aqueles sem hipertensão. A monitorização desses pacientes foi definitiva para determinar o prognóstico. Pacientes Marshall II devem ser monitorados.

Objectives: Evaluate the relationship of intracranial hypertension with an increase of brain lesions, morbimortality in Marshall II patients and determine whether these patients need to have ICP monitored. Method: Prospective observational cohort study on severe TBI patients (GCS ≤ 8), Marshall CT classification II. Results: A total of 70 patients were divided into two groups based on ICP; G1: ICP ≤ 20 mmHg (49 patients) and G2 ICP > 20 mmHg (21 patients). The most common CT findings were: subarachnoid hemorrhages and contusions. Mortality was higher in G2 than in G1 (OR: 11.7) (95% CI: 2.2 to 63.1). The median Glasgow Outcome Score after 90 days was 2 for G2 and 5 to G1. The onset or progression of lesions occurred in 71% of patients in G2, against 10% in G1 (p < 0.05). Compared toG1, the OR for a new finding on CT was twenty-two times higher in G2 (95% CI: 5.02 to 106.9). Two G2 patients needed surgery and none of the G1. Conclusions: Severe TBI patients with Marshall score II and intracranial hypertension, are at greater risk for new CT abnormalities, worse prognosis, and higher mortality than those with no hypertension. ICP monitoring was crucial to define prognosis. Severe TBI Marshall II patients should be monitored.

[Tissue plasminogen activator and intravitreal gas for the treatment of Terson's syndrome: case report]. / Ativador do plasminogênio tecidual e gás intravítreo no tratamento da síndrome de Terson: relato de caso.

The case of a 35 year-old male patient is reported. The patient had a clinical history of craniocerebral trauma and premacular hemorrhage of Terson syndrome in the left eye. After waiting for 45 days, without hemorrhage resolution, the patient received an intravitreal injection of sulfur hexafluoride gas and tPA; an almost complete hemorrhage absorption occurred after a week as well as a considerable improvement of visual acuity. In the report, relevant aspects of Terson syndrome and of intravitreal injection of gas and tPA are also described through a literature review.

Ativador do plasminogênio tecidual e gás intravítreo no tratamento da síndrome de Terson: relato de caso: [revisão] / Tissue plasminogen activator and intravitreal gas for the treatment of Terson's syndrome: case report: [review]

Relata-se o caso de um paciente de 35 anos de idade, sexo masculino, com história de trauma cranioencefálico, que evoluiu com hemorragia pré-macular da síndrome de Terson no olho esquerdo. Após 45 dias de conduta expectante, sem resolução da hemorragia, foi realizada injeção intravítrea de gás hexafluoreto de enxofre e tPA, evoluindo com absorção quase completa da hemorragia após uma semana e considerável melhora da acuidade visual. Descreve-se também aspectos importantes da síndrome de Terson e da injeção intravítrea de gás e tPA por meio de revisão da literatura.

The case of a 35 year-old male patient is reported. The patient had a clinical history of craniocerebral trauma and premacular hemorrhage of Terson syndrome in the left eye. After waiting for 45 days, without hemorrhage resolution, the patient received an intravitreal injection of sulfur hexafluoride gas and tPA; an almost complete hemorrhage absorption occurred after a week as well as a considerable improvement of visual acuity. In the report, relevant aspects of Terson syndrome and of intravitreal injection of gas and tPA are also described through a literature review.