Ultrasonografía doppler transcraneal urgente: utilidad predictiva del vasoespasmo sintomático en la hemorragia subaracnoidea espontánea en pacientes con buena situación neurológica / Emergency transcranial doppler ultrasound: predictive value for the development of symptomatic vasospasm in spontaneous subarachnoid hemorrhage in patients in good neurological condition

Objetivo: Establecer el valor predictivo, para desarrollar deterioro neurológico tardío de origen isquémico (DNI), de un estudio doppler transcraneal (DTC) en pacientes con hemorragia subaracnoidea espontánea (HSA) en buena situación neurológica. Diseño: Estudio descriptivo-observacional desarrollado durante 3 años. Ámbito: Cuidados Críticos y Urgencias. Pacientes: Se incluyeron de forma consecutiva aquellos pacientes con HSA en buena situación neurológica (Hunt-Hess I-III). Variables de Interés: DNI (disminución en 2 puntos del GCS o déficit focal), velocidad media (VM) en arterias cerebrales medias, índice de Lindegaard (IL). Se consideró patrón sonográfico de vasoespasmo (PSV) cuando la VM fue>120cm/s y existía un IL>3. Resultados: La media de edad de los 122 pacientes fue de 54,1±13,7 años. El 57,3% eran mujeres. Se detectaron 24 pacientes con PSV (19,7%) encontrándose VM elevadas en 38 pacientes (31,1%). 21 pacientes desarrollaron DNI (VM 183+/-49cm/s), todos presentaron PSV. En los pacientes con DNI se detectó un aumento de VM de 22+/-5cm/s/24h durante los 3 primeros días. Al comparar aquellos pacientes que no presentaron VM elevadas (85 pacientes/VM 67+/-16,6cm/s) con respecto a los que desarrollaron DNI encontramos diferencias en las VM (p<0,001) y en el ΔVM/24h (8,30+/-4,5cm/s Vs 22+/-5cm/s) durante los 3 primeros días (p=0,009). Mediante curvas ROC, se fijó que el ΔVM/día de 21cm/s (p<0,001), era el que mejor predecía el DNI. Conclusión: Durante los 3 primeros días un incremento en la VM de 21cm/s/24h se asoció con el desarrollo de vasoespamo sintomático. El DTC es una herramienta útil para la detección de aquellos pacientes con HSA en riesgo de desarrollar DNI (AU)

Purpose: To examine the predictive value of an early transcranial Doppler ultrasound (TCD) study performed in the emergency department in patients with spontaneous subarachoniod hemorrhage (SAH) in good neurological condition, in order to know which patients are at high risk of developing delayed cerebral ischemia (DCI). Design: A descriptive observational study was carried out involving a period of 3 years. Setting: Critical Care and Emergency Department. Patients: The study consecutively included patients with SAH of grade I-III on the Hunt and Hess scale. Variables of Interest: DCI (decrease of 2 points in GCS or focal deficit), Mean Velocity (MV) of middle cerebral arteries (MCA), Lindegaard Index (IL). Sonographic vasospasm pattern (SVP) was considered if MCA-MV>120cm/sc and IL>3. Results: The mean age of the 122 patients was 54.1±13.7 years; 57.3% were women. SVP was detected in 24 patients (19.7%), although high velocities patterns (HVP) were present in 38 patients (31.1%). DCI developed in 21 patients (MV183+/-49cm/sc), all with previous SVP. In this group MV increased 22+/-5cm/sc/day during the first 3 days. The group without HVP (84 patients/MV of 67+/-16.6cm/sc), compared with DCI group, showed differences in highest MV (p<0.001), and also ΔMV/day (8.30+/-4,5cm/sc Vs 22+/-5cm/sc) during the first 3 days (p=0.009). In our series, ROC analysis selected the best cut-off value for ΔMV/day as 21cm/sc (p<0.001). Conclusion: During the first 3 days, an increase of 21cm/s/24h in MCA-MV was associated with the development of symptomatic vasospasm. TCD is a useful tool for the early detection of patients at risk of DCI after SAH (AU=

[Hyperammonemic encephalopathy: nutritional assessment and management of a case]. / Encefalopatía hiperamoniémica: valoración y manejo nutricional a propósito de un caso.

OTC deficiency is a disorder of the urea cycle X-linked. It is manifested in men as severe hyperammonemia in the first days of life. In women the disease is milder severity. Various conditions cause decompensation with hyperammonemia. It could be fatal or cause permanent neurological damage. We report a 36 years old woman admitted for surgery, she suffered a decompensation in conjunction with surgical wound infection. Hyperammonemia caused neurological deterioration with decreased level of consciousness, tetraparesis and neurogenic dysphagia. The treatment consisting of low-protein diet, ammonium chelating drugs and dialytic measures, was effective in controlling hyperammonaemia and improving neurological status. This case illustrates the importance of nutritional support of patients with disorders of the urea cycle in the hospital because the descompensations are more frecuent here.

[Emergency transcranial doppler ultrasound: predictive value for the development of symptomatic vasospasm in spontaneous subarachnoid hemorrhage in patients in good neurological condition]. / Ultrasonografía doppler transcraneal urgente: utilidad predictiva del vasoespasmo sintomático en la hemorragia subaracnoidea espontánea en pacientes con buena situación neurológica.

PURPOSE: To examine the predictive value of an early transcranial Doppler ultrasound (TCD) study performed in the emergency department in patients with spontaneous subarachoniod hemorrhage (SAH) in good neurological condition, in order to know which patients are at high risk of developing delayed cerebral ischemia (DCI). DESIGN: A descriptive observational study was carried out involving a period of 3 years. SETTING: Critical Care and Emergency Department. PATIENTS: The study consecutively included patients with SAH of grade I-III on the Hunt and Hess scale. VARIABLES OF INTEREST: DCI (decrease of 2 points in GCS or focal deficit), Mean Velocity (MV) of middle cerebral arteries (MCA), Lindegaard Index (IL). Sonographic vasospasm pattern (SVP) was considered if MCA-MV>120cm/sc and IL>3. RESULTS: The mean age of the 122 patients was 54.1±13.7 years; 57.3% were women. SVP was detected in 24 patients (19.7%), although high velocities patterns (HVP) were present in 38 patients (31.1%). DCI developed in 21 patients (MV183+/-49cm/sc), all with previous SVP. In this group MV increased 22+/-5cm/sc/day during the first 3 days. The group without HVP (84 patients/MV of 67+/-16.6cm/sc), compared with DCI group, showed differences in highest MV (p<0.001), and also ΔMV/day (8.30+/-4,5cm/sc Vs 22+/-5cm/sc) during the first 3 days (p=0.009). In our series, ROC analysis selected the best cut-off value for ΔMV/day as 21cm/sc (p<0.001). CONCLUSION: During the first 3 days, an increase of 21cm/s/24h in MCA-MV was associated with the development of symptomatic vasospasm. TCD is a useful tool for the early detection of patients at risk of DCI after SAH.

Encefalopatía hiperamoniémica; valoración y manejo nutricional a propósito de un caso / Hyperammonemic encephalopathy; nutritional assessment and management of a case

El déficit de Ornitintranscarbamilasa (OTC) es un trastorno del ciclo de la urea ligado al cromosoma X. Se manifiesta en el varón como hiperamoniemia severa en los primeros días de vida. En la mujer la enfermedad esmás leve. Diversas situaciones pueden provocar una descompensación con hiperamoniemia que puede ser letal o provocar daños neurológicos permanentes. Presentamos una mujer de 36 años que ingresó para cirugía y que sufrió una descompensación coincidiendo con infección de la herida quirúrgica. La hiperamoniemia provocó un deterioro neurológico con disminución del nivel de conciencia, tetraparesia y disfagia neurógena. Con tratamiento, que consistió en dieta hipoproteica, quelantes de amonio y medidas dialíticas, se consiguió controlar la hiperamoniemia y mejorar el estado neurológico. Este caso ilustra la importancia del soporte nutricional especializado de los pacientes con trastornos del ciclo de laurea en el ámbito hospitalario por darse frecuentemente situaciones que favorecen las descompensaciones (AU)

OTC deficiency is a disorder of the urea cycle X-linked. It is manifested in men as severe hyperammonemia in the first days of life. In women the disease is milder severity. Various conditions cause de compensation with hyperammonemia. It could be fatal or cause permanent neurological damage. We report a 36 years old woman admitted forsurgery, she suffered a de compensation in conjunction with surgical wound infection. Hyperammonemia caused neurological deterioration with decreased level of consciousness, tetraparesis and neurogenic dysphagia. The treatment consisting of low-protein diet, ammonium chelating drugs and dialytic measures, was effective incontrolling hyperammonaemia and improving neurological status. This case illustrates the importance of nutritional support of patients with disorders of the urea cyclein the hospital because the descompensations are more frecuent here (AU)

Muerte encefálica: repercusión sobre órganos y tejidos / Brain death: Repercussion on the organs and tissues

La muerte encefálica se acompaña de una serie de efectos sistémicos, hemodinámicos, hormonales e inflamatorios que tienen una repercusión relevante en los órganos y los tejidos de la economía. Cada vez hay más evidencias de que los órganos provenientes de donantes fallecidos en muerte encefálica presentan un grado de respuesta inflamatoria secundaria al daño encefálico y, en ocasiones, proporcional a la intensidad y a la velocidad de progresión de éste. Tanto estudios clínicos como estudios experimentales han mostrado que el resultado de los órganos de donantes fallecidos en parada cardíaca o donantes vivos tienen iguales o mejores resultados clínicos que los obtenidos en donantes en muerte encefálica que han presentado el proceso inflamatorio secundario a ésta. Hay pruebas de que esta respuesta inflamatoria acontece en el pulmón, el corazón, los riñones, el hígado y el intestino, e igualmente se incrementan también las pruebas de que el grado de respuesta inflamatoria observada en los órganos tiene una influencia importante en el resultado final del trasplante. En consecuencia, el desarrollo del conocimiento de las vías que interrelacionan el daño encefálico con la respuesta orgánica inflamatoria abre una importante área de conocimiento y posibilita que futuras estrategias terapéuticas encaminadas a modular la respuesta sistémica al daño encefálico permitan mejorar la calidad de los órganos obtenidos para trasplante, así como incrementar la supervivencia del injerto y de los receptores de trasplantes de órganos sólidos (AU)

Brain death is accompanied by a series of hemodynamic, hormonal and inflammatory systemic effects that have an important repercussion on the economy of the organs and tissues. There is increasing evidence that the organs from brain death donors have an inflammatory response grade secondary to brain death and sometimes proportional to the intensity and rate of its progression. Both clinical and experimental studies have shown that the result of organs from heart arrest deceased donors or live donors have the same or better clinical results than those obtained in brain death donors and who have suffered the inflammatory process secondary to it. There is proof that this inflammatory response occurs in the lung, heart, kidneys, liver, intestine. Furthermore, the evidence also shows that the grade of inflammatory response observed in the organs has an important influence on the final outcome of the transplant. Consequently, the development of the knowledge regarding the pathways that interrelate brain death with the inflammatory organ response provides us with an important area of knowledge, which allow for future therapeutic strategies aimed at modulating the systemic response to brain death to improve the quality of the organs obtained for transplant and also to increase graft survival of the solid organ transplant recipients (AU)

[Brain death: repercussion on the organs and tissues]. / Muerte encefálica: repercusión sobre órganos y tejidos.

Brain death is accompanied by a series of hemodynamic, hormonal and inflammatory systemic effects that have an important repercussion on the economy of the organs and tissues. There is increasing evidence that the organs from brain death donors have an inflammatory response grade secondary to brain death and sometimes proportional to the intensity and rate of its progression. Both clinical and experimental studies have shown that the result of organs from heart arrest deceased donors or live donors have the same or better clinical results than those obtained in brain death donors and who have suffered the inflammatory process secondary to it. There is proof that this inflammatory response occurs in the lung, heart, kidneys, liver, intestine. Furthermore, the evidence also shows that the grade of inflammatory response observed in the organs has an important influence on the final outcome of the transplant. Consequently, the development of the knowledge regarding the pathways that interrelate brain death with the inflammatory organ response provides us with an important area of knowledge, which allow for future therapeutic strategies aimed at modulating the systemic response to brain death to improve the quality of the organs obtained for transplant and also to increase graft survival of the solid organ transplant recipients.

[Improving the outcomes in spontaneous subarachnoid haemorrhage: the EHSA project]. / Mejora de los resultados en la hemorragia subaracnoidea espontánea: proyecto EHSA.

AIM: To investigate our clinical practices with the aim of identifying opportunities to improve the medico-surgical management of spontaneous subarachnoid haemorrhages (SAH). PATIENTS AND METHODS A prospective, longitudinal cohort study was conducted of the cases of SAH attended consecutively in the critical care and emergency services in 29 public hospitals in Andalusia over a period of 20 months, between the years 2000 and 2002. SAH were considered to be acute haemorrhagic cerebrovascular accidents diagnosed as such by imaging. Results at 12 months and care management (medical and surgical therapy, diagnostic techniques, care times and specific neurological complications) were analysed and the latter was then compared with the clinical practices that scientific evidence has proved to be the most useful. Deaths due to rebleeding in patients with no arteriographic study or without exclusion of the aneurysm were catalogued as potentially avoidable deaths. RESULTS: A total of 506 SAH were included. During the follow-up 5% of the sample were lost. In all 155 patients died. The non-modifiable independent risk variables for mortality were: age, being male, history of arterial hypertension, coma on arrival at the hospital and hydrocephalus. The independent risk variables for death that can be influenced were: absence of urgent analgesic, no arteriographic diagnosis, appearance of ischaemic neurological impairment and rebleeding. Twenty per cent of the overall mortality could be considered potentially avoidable. CONCLUSIONS: Although fatality is mostly dependent on variables that cannot be influenced (sex, age, history, clinical severity and hydrocephalus), 20% of deaths are associated to modifiable factors.

Mejora de los resultados en la hemorragia subaracnoidea espontánea: proyecto EHSA / Improving the outcomes in spontaneous subarachnoid haemorrhage: The Ehsa project

Objetivo. Investigar nuestras prácticas clínicas, a fin de identificar oportunidades de mejora en el manejo medicoquirúrgicode las hemorragias subaracnoideas (HSA) espontáneas. Pacientes y métodos. Estudio de cohortes, longitudinal,prospectivo, de las HSA atendidas consecutivamente en los servicios de cuidados críticos y urgencias de 29 hospitales públicosde Andalucía durante 20 meses, de 2000 a 2002. Se consideraron HSA los accidentes cerebrovasculares hemorrágicosagudos con este diagnóstico tomográfico. Se analizaron los resultados a 12 meses y el manejo asistencial (terapéutica médicay quirúrgica, técnicas diagnósticas, tiempos asistenciales y complicaciones neurológicas específicas), comparándolo conlas prácticas clínicas que la evidencia científica ha demostrado de mayor utilidad. Se catalogaron como muertes potencialmenteevitables los óbitos por resangrado en pacientes sin estudio arteriográfico o sin exclusión del aneurisma. Resultados.Se incluyeron 506 HSA. Se perdió durante el seguimiento el 5% de la muestra. Fallecieron 155 enfermos. Las variables no modificablesde riesgo independiente para la mortalidad fueron: edad, género masculino, antecedente de hipertensión arterial,coma a la recepción hospitalaria e hidrocefalia. Las variables influenciables de riesgo independiente para fallecer resultaronser: ausencia de analgesia urgente, carencia de diagnóstico arteriográfico, aparición de deterioro neurológico isquémico yresangrado. El 20% de la mortalidad global podría considerarse potencialmente evitable. Conclusiones. Aunque la letalidades mayoritariamente dependiente de variables médicamente no influenciables (sexo, edad, antecedentes, gravedad clínica ehidrocefalia), los decesos, en un 20%, están asociados a factores modificables (AU)

Aim. To investigate our clinical practices with the aim of identifying opportunities to improve the medico-surgicalmanagement of spontaneous subarachnoid haemorrhages (SAH). Patients and methods. A prospective, longitudinal cohortstudy was conducted of the cases of SAH attended consecutively in the critical care and emergency services in 29 publichospitals in Andalusia over a period of 20 months, between the years 2000 and 2002. SAH were considered to be acutehaemorrhagic cerebrovascular accidents diagnosed as such by imaging. Results at 12 months and care management (medicaland surgical therapy, diagnostic techniques, care times and specific neurological complications) were analysed and the latterwas then compared with the clinical practices that scientific evidence has proved to be the most useful. Deaths due torebleeding in patients with no arteriographic study or without exclusion of the aneurysm were catalogued as potentiallyavoidable deaths. Results. A total of 506 SAH were included. During the follow-up 5% of the sample were lost. In all 155patients died. The non-modifiable independent risk variables for mortality were: age, being male, history of arterial hypertension,coma on arrival at the hospital and hydrocephalus. The independent risk variables for death that can be influenced were: absence of urgent analgesic, no arteriographic diagnosis, appearance of ischaemic neurological impairment and rebleeding. Twenty per cent of the overall mortality could be considered potentially avoidable. Conclusions. Although fatality is mostly dependent on variables that cannot be influenced (sex, age, history, clinical severity and hydrocephalus), 20% of deaths are associated to modifiable factors (AU)

Electrolytic disorders, hyperosmolar states, and lactic acidosis in brain-dead patients.

Despite the use of well-accepted protocols for donor maintenance, the severe electrolytic disorders are not infrequent with deleterious consequences to the organs. The objective of our survey was to determine the incidence of episodes of electrolyte disorders among brain-dead patients (despite of rigid protocols of maintenance) and the rate of anaerobic metabolism in these patients (suggestive of an occult systemic hypoperfusion). The study group of 50 brain-dead patients underwent therapy to maintain normal arterial pressure, urine output, and body temperature. Standard monitoring for brain-dead patients was followed, except for a frequent evaluation of electrolytes, including glucose, sodium, potassium, phosphorus, osmolality, base excess, and lactate plasma levels. Our results demonstrate that with frequent determinations of electrolytes, despite following strict protocols of maintenance, there was a high incidence of hyperglycemia, hypophosphotemia, hypokaemia, and hyperosmolality. Interesting findings were the high incidence of elevated lactate, and the relationship between lactate levels and bases deficit as well as hypernatremia. It can be concluded that, even following rigid protocols, the maintenance of brain-dead patients demands a close evaluation of electrolyte levels. Our results also suggest that the inclusion in the monitoring protocol of anerobic metabolism data including lactate levels can help to avoid occult ischemia of organs, and consequently improve their quality for transplantation.

Identification by CT scan of ischemic stroke patients with high risk of brain death.

The identification of patients with high risk of evolution to brain death is one of the more important tasks of transplant coordination teams. Although most of pool of potential donors come from the group of patients who suffer a head injury or hemorrhagic stroke, the procurement of organs from brain-dead patients suffering an ischemic stroke as the cause of brain damage must also be considered. The main objective of this study was to investigate the radiological signs that in the CT scan of admission to a neurological ICU are more frequently associated with progression to brain death. We studied the CT scans of 15 brain-dead patients after an ischemic stroke versus the scans of 15 recovered patients admitted to ICU with the same diagnosis. The radiological signs included: insular ribbon sign, hyperintensities inside the big arteries of the base of the skull, hemispheric hypodensities, midline shift, and compression of the cerebrospinal fluid spaces. There were two signs significantly associated with brain death: midline shifts and the compression of the ambiens cistern. It may be concluded that analysis of the CT scan at admission of patients with an ischemic stroke in the ICU can predict the risk of evolution to brain death.

Diagnosis of brain death by transcranial Doppler sonography: solutions for cases of difficult sonic windows.

Delays in diagnosis of brain death have definite consequences for the organ retrieval and transplantation process. It is advisable to use accurate diagnostic methods. Transcranial Doppler sonography is a well-accepted technique for diagnosing cerebral circulatory arrest. However, in some cases, the access to the intracranial circulation via the temporal window is difficult. In 43 brain-dead patients we evaluated the rate of impossibility of insonation of middle cerebral artery using a temporal window and the usefulness of an orbital window for insonation of the carotid siphon. In 39 patients the usual protocol of insonation (temporal window and foramen magnum window) was sufficient to demonstrate cerebral circulatory arrest. In 10 patients, including all the cases in which it was impossible to use a temporal approach, the carotid siphon was successfully insonated, showing in all the cases the existence of a sonographic pattern compatible with cerebral circulatory arrest. It may be concluded that the use of an orbital window for exploring intracranial circulation by transcranial Doppler sonography can be a useful tool in cases of difficult sonic windows.

Brain death due to supratentorial masses: diagnosis using transcranial Doppler sonography.

Since cadaveric donation is the main source of organs for transplantation in many countries, the diagnosis of brain death is an important issue. The cessation of cerebral circulation is one phenomenon closely related to brain death. Transcranial Doppler sonography is one of the accepted techniques to establish cessation of cerebral circulation. One of the limitations attributed to Doppler is the lack of sensitivity for this diagnosis. The objective of this research was to establish whether transcranial Doppler sonography showed acceptable sensitivity and whether this was affected by the location of the intracranial mass effect. Twenty-four patients underwent transcranial Doppler sonography to establish the incidence of the three sonographic patterns associated with brain death: separation diastole-systole, reverberating flow, and systolic spikes. In all the cases the insonation of the arteries of the base of the skull was performed. In supratentorial lesions, the predominant pattern was a reverberating flow, while in infratentorial lesions systolic spikes pattern was most frequent. Our study showed a high sensitivity of transcranial Doppler sonography for the diagnosis of brain death and the existence of different mechanisms of cerebral circulatory arrest depending on the location of the intracranial pressure wedge.

[Spontaneous subarachnoid hemorrhage,: is emergency transcranial Doppler sonography useful?]. / Hemorragia subaracnoidea espontánea: ¿ Es útil la ultrasonografía Doppler transcraneal urgente?

OBJECTIVE: To ascertain the value of transcranial Doppler ultrasonography (TCD) in the first 24 hours of hospital admission in patients suffering good-grade spontaneous subarachnoid hemorrhage (SAH) in order to detect a high-risk group for symptomatic vasospasm. METHOD: Forty-nine spontaneous good-grade SAH were included. The first TCD studies were carried out at the Emergency Department. At least one more TCD recording was performed between the 4th and 14th day. Patients were classified according to whether they came to the hospital during the first 72 hours after the haemorrhage (Group 1) or later (Group 2). FINDINGS: Thirty three patients were included in Group 1 and sixteen patients in Group 2. Thirteen patients (26.5%) had sonographic vasospasm. In eight of these patients (61 %), the vasospasm was symptomatic. The initial mean velocity (MV) for Group 1 was normal. The increase in MV/24h (MV/24h) within the first 72 hours after SAH was higher (p< 0.007), in those whose developed sonographic vasospasm. In Group 2, the initial MV was greater (p< 0.001)) in patients who suffered sonographic vasospasm, with or without symptoms. CONCLUSIONS: The ability of TCD recorded in the first 24 hours of hospital admission to detect high-risk vasospasm patients for SAH with low clinical severity helps decide the most efficient patient destination. During the first three days the MV/24h is of value but not the absolute figure of the MV. In contrast, between the 4th and 14th day after SAH, the absolute figure of MV was useful to predict vasospasm.

Hemorragia subaracnoidea espontánea: ¿es útil la ultrasonografía Doppler transcraneal urgente? / Subarachnoid hemorrhage, transcranial doppler ultrasonography, delayed ischemic deficit, vasospasm

Objetivo: Establecer el valor de la ultrasonografía Doppler transcraneal (TCD) en las primeras 24 horas de asistencia hospitalaria de la hemorragia subaracnoidea espontánea (HSA) en buen estado neurológico, para detectar un grupo de alto riesgo de vasoespasmo sintomático. Material y Método: Estudio prospectivo de cohortes. Se incluyen 49 HSA espontáneas, grado clínico de I a III en la escala de Hunt-Hess. Se efectúo estudio de TCD (velocidad media, Vm), en las primeras 24 horas de estancia hospitalaria, con control entre el 4° y 14° día. Los enfermos se clasificaron según acudieran al hospital en las primeras 72 horas del sangrado (Grupo 1) o con posterioridad (Grupo 2).Resultados: Treinta y tres HSA accedieron al Hospital en las primeras 72 horas (Grupo 1) y 16 ulteriormente (Grupo 2). Trece pacientes (26,5 por ciento) presentaron vasoespasmo sonográfico (Vm>120 cm x seg., con IL>3). En ocho de los 13 (61 por ciento) el vasoespasmo fue sintomático. Las Vm iniciales del Grupo 1 fueron siempre normales. El incremento de Vm/24h (-Vm/24h), en las primeras 72 horas tras la HSA, fue significativamente superior (p<0,007) en quienes sufrieron posteriormente vasoespasmo sonográfico. En el grupo 2, la Vm inicial fue mayor (p<0.01) en los enfermos que evolucionaban a vasoespasmo sonográfico, tanto sintomático como asintomático. Conclusiones: La realización de un TCD urgente en las primeras 24 horas de una HSA de baja gravedad clínica permite seleccionar un grupo de pacientes con alto riesgo de vasoespasmo sintomático y por tanto es útil para decidir el destino óptimo del paciente. En los tres primeros días de la HSA el valor absoluto de la velocidad media no es útil, pero si el - Vm/24h . A partir del 4° día es suficiente el registro de la velocidad media (AU)

[The EHSA project: the study of spontaneous subarachnoid haemorrhages in Andalusia. Incidence and results]. / Proyecto EHSA: estudio de hemorragias subaracnoideas espontáneas en Andalucia. Incidencia y resultados.

AIM: To evaluate the incidence and results of spontaneous subarachnoid haemorrhages (SAH) in Andalusia. PATIENTS AND METHODS: We conducted a longitudinal prospective study of the cases of SAH attended in 28 hospitals in Andalusia over a three month period in 2000. SAH was defined as cases of acute haemorrhagic strokes diagnosed by tomography. The gross incidence rate (GR) was determined from census information from the Instituto Andaluz de Estad stica. Standard rates (SR) were estimated with relation to the European population. Results were evaluated on hospital discharge according to the Glasgow Outcome Score (GOS) and at 12 months, according the Barthel index (BI). RESULTS: The GR per 100,000 inhabitants/year was found to be 5.7 cases and the SR was 5.8. A comparison of incidences by province or sex showed no statistically significant differences. The period of maximum risk was the age bracket between 55 74 years (GR: 14.1). The acute fatality GR and SR rose to 1.9 per 100,000 inhabitants and year. Mortality was concentrated in a statistically significant way (p< 0.01) among those over the age of 65; sex did not exert any influence, but clinical gravity (p< 0.001) and the amount of bleeding did (p< 0.005). CONCLUSIONS: The incidence of spontaneous SAH in Andalusia was found to be within the average rates. Unfavourable results were high, although similar to those in other series. Fatality is significantly associated with factors that cannot be modified medically (age, clinical gravity and volume of bleeding)

Proyecto EHSA: estudio de hemorragias subaracnoideas espontáneas en Andalucía. Incidencia y resultados / The EHSA project: the study of spontaneous subarachnoid haemorrhages in Andalusia. Incidence and results

Objetivo. Valorar la incidencia y resultados de las hemorragias subaracnoideas (HSA) espontáneas en Andalucía. Pacientes y métodos. Estudio longitudinal, prospectivo, de las HSA asistidas en 28 hospitales de Andalucía, durante tres meses del año 2000. Se consideraron HSA los ictus hemorrágicos agudos con este diagnóstico tomográfico. La incidencia bruta (TB) se estableció mediante la información censal del Instituto Andaluz de Estadística. Las tasas estandarizadas (TEE) se estimaron con relación a la población europea. Los resultados se valoraron al alta hospitalaria según el GOS (del inglés, Glasgow Outcome Score) y a los 12 meses, según el índice de Barthel (IB). Resultados. La TB por 100.000 habitantes/año se situó en 5,7 casos y la TEE en 5,8. La comparación de incidencias según provincia o sexo no mostró diferencias estadísticamente significativas. El período de máximo riesgo corresponde al intervalo 55-74 años (TB: 14,1). La TB y TEE de letalidad aguda coincidió en 1,5. A los 12 meses, la TB y TEE de letalidad ascendió a 1,9 por 100.000 habitantes y año. La mortalidad se concentró de forma estadísticamente significativa (p< 0,01) entre los mayores de 65 años; no influyó el sexo, pero sí la gravedad clínica (p< 0,001) y la cuantía del sangrado (p< 0,005). Conclusiones. La incidencia de las HSA espontáneas en Andalucía se sitúa en tasas medias. La proporción de resultados desfavorables es elevada, aunque similar a la de otras series. La letalidad se asocia significativamente a factores (edad, gravedad clínica y volumen de sangrado) no modificables médicamente (AU)

Aim. To evaluate the incidence and results of spontaneous subarachnoid haemorrhages (SAH) in Andalusia. Patients and methods. We conducted a longitudinal prospective study of the cases of SAH attended in 28 hospitals in Andalusia over a threemonth period in 2000. SAH was defined as cases of acute haemorrhagic strokes diagnosed by tomography. The gross incidence rate (GR) was determined from census information from the Instituto Andaluz de Estadística. Standard rates (SR) were estimated with relation to the European population. Results were evaluated on hospital discharge according to the Glasgow Outcome Score (GOS) and at 12 months, according the Barthel index (BI). Results. The GR per 100,000 inhabitants/year was found to be 5.7 cases and the SR was 5.8. A comparison of incidences by province or sex showed no statistically significant differences. The period of maximum risk was the age bracket between 55-74 years (GR: 14.1). The acute fatality GR and SR rose to 1.9 per 100,000 inhabitants and year. Mortality was concentrated in a statistically significant way (p< 0.01) among those over the age of 65; sex did not exert any influence, but clinical gravity (p< 0.001) and the amount of bleeding did (p< 0.005). Conclusions. The incidence of spontaneous SAH in Andalusia was found to be within the average rates. Unfavourable results were high, although similar to those in other series. Fatality is significantly associated with factors that cannot be modified medically (age, clinical gravity and volume of bleeding) (AU)

[Cerebral palsy in childhood: 250 cases report]. / Paralisis cerebral infantil: estudio de 250 casos.

OBJECTIVE: To know the etiological factors of cerebral palsy (CP) incident during pregnancy and neonatal/perinatal periods. To know evolution of a child with a CP diagnosis. PATIENTS, MATERIAL AND METHODS: Bibliographical review of paediatric and rehabilitation texts and databases in Internet. Elaboration of a data collecting questionnaire for reviewing clinical records of patients treated in Paediatric Rehabilitation between 1996 and 2000. RESULTS: 250 patients records reviewed. Most frequent illnesses during pregnancy: first twelve weeks haemorrhages: 17.9% and diabetes 8.4%. Child birth: preterm births 32%, cephalic presentation 78.8%, caesarean operations 32%. Mean birth weight 2,714 g, low birth weight babies 27.2%. Needed hospitalary treatment 48%. Mean time in incubator: 46 days among preterm and 26.6 among full term. Mean time in intensive care units: 44.4 days among preterm and 22.7 among full term. Associated diagnoses: CRP 8%, birth asphyxia 24%, neonatal jaundice 27.2%, neonatal respiratory distress 24%, neonatal sepsis 10%, congenital cardiological illnesses 2.4%, dismorphia 2.4%, epilepsy in 40%. Diagnostic imaging: atrophy 38.8%, hydrocephalus 29.4%, ischemia 14.9%, haemorrhage 11.6%. No findings in 23.8%. Children were sent to Paediatric Rehabilitation at mean age of 8 months. Most frequent disorders: spastic quadriplegia (36.1%) spastic diplegia (26.5%) and hemiplegia (17%). Mental retardation 55%. School attendance 81.2%. CP postnatal in 5.2%. CONCLUSIONS: Incidence of CP (2.5/1,000 alive new born) hardly avoidable for persistent rates of prematurity and complications in child births. Good quality of life and survival until adult ages.

Parálisis cerebral infantil: estudio de 250 casos / Cerebral palsy in childhood: 250 cases report

Objetivos. Conocer los factores etiológicos de la parálisis cerebral infantil (PCI) que influyan en la gestación y períodos neonatal, perinatal y posnatal. Conocer su evolución. Pacientes, material y métodos. Búsqueda bibliográfica en textos de Internet. Elaboración de protocolo de recogida de datos de historias de pacientes con PCI vistos en consultas externas de Rehabilitación Neurológica infantil entre los años 1996 y 2000. Resultados. 250 pacientes con PCI. Patologías más frecuentes en la gestación: hemorragias de primer trimestre (17,9 por ciento) y diabetes gestacional (8,4 por ciento). Partos: pretérmino (32 por ciento), presentación cefálica (78,8 por ciento), cesáreas (32 por ciento). Peso medio al nacimiento: 2.714 g. Bajo peso para edad gestacional: 27,2 por ciento. Requirieron ingreso hospitalario el 48 por ciento. Media de días de estancia en incubadora: prematuros (46), a término (26,6). Media de días de estancia en UCI: prematuros (44,4), a término (22,7). Diagnósticos asociados: RCP (8 por ciento), asfixia perinatal (24 por ciento), ictericia neonatal (27,2 por ciento), membrana hialina (24 por ciento), sepsis neonatal (10 por ciento), cardiopatías congénitas (2,4 por ciento), dismorfias (2,4 por ciento), epilepsia (40 por ciento). Pruebas de neuroimagen: con atrofia (38,8 por ciento), hidrocefalia (29,4 por ciento), isquemia (14,9 por ciento), hemorragia (11,6 por ciento). Sin hallazgos en 23,8 por ciento. Edad media de envío a Rehabilitación: 8 meses. Déficit más frecuente: tetraparesia espástica (36,1 por ciento), seguido de diplejía espástica (26,5 por ciento) y hemiparesia (17 por ciento). Retraso mental: 55 por ciento. Escolarizados el 81,2 por ciento. PCI posnatal en 5,2 por ciento. Conclusiones. Incidencia de PCI (2,5/1.000 nacidos vivos), difícilmente evitable por mantenimiento esperable de índices similares de prematuridad y partos distócicos. Buena calidad de vida y supervivencia hasta edad adulta (AU)