Cuidados generales en el manejo del traumatismo craneoencefálico grave: consenso latinoamericano / General care in the management of severe traumatic brain injury: Latin American consensus

El traumatismo craneoencefálico grave (TCEg) continúa siendo prevalente en la población adulta joven. Lejos de descender, su incidencia se mantiene elevada. Uno de los pilares en los que se asienta su tratamiento es evitar, detectar y corregir complicaciones secundarias de origen sistémico que agravan la lesión primaria. Gran parte de este objetivo se logra manteniendo un microambiente fisiológico adecuado que permita la recuperación del tejido cerebral lesionado. Las medidas de cuidados generales son acciones inespecíficas destinadas a cumplir dicho objetivo. Las guías disponibles de manejo del TCEg no han incluido la mayoría de los tópicos motivo de este consenso. Para ello, hemos reunido un grupo de profesionales miembros del Consorcio latinoamericano de Injuria Cerebral (LABIC), involucrados en los diferentes aspectos del manejo agudo del TCEg (neurocirujanos, intensivistas, anestesiólogos, neurólogos, enfermeros, fisioterapeutas). Se efectuó una búsqueda bibliográfica en las bases de datos LILACS, PubMed, Embasse, Scopus, Cochrane Controlled Register of Trials y Web of Science de los tópicos seleccionados. Para establecer recomendaciones o sugerencias con su respectiva fortaleza o debilidad, fue aplicada la metodología Grading of Recommendations, Assessment, Development and Evaluation (GRADE). Adicionalmente, ciertas recomendaciones (incluidas en material complementario) no fueron valoradas por GRADE, por ser las mismas un conjunto de acciones terapéuticas de cumplimento efectivo, en las que no fue posible aplicar dicha metodología. Fueron establecidas 32 recomendaciones; 16 fuertes y 16 débiles, con su respectivo nivel de evidencia. El presente consenso intenta homogeneizar y establecer medidas de cuidados generales básicas en esta población de individuos

Severe traumatic brain injury (sTBI) remains prevalent in the young adult population. Indeed, far from descending, the incidence of sTBI remains high. One of the key bases of treatment is to avoid, detect and correct secondary injuries of systemic origin, which aggravate the primary lesion. Much of this can be achieved by maintaining an adequate physiological microenvironment allowing recovery of the damaged brain tissue. General care measures are nonspecific actions designed to meet that objective. The available guidelines on the management of sTBI have not included the topics contemplated in this consensus. In this regard, a group of members of the Latin American Brain Injury Consortium (LABIC), involved in the different aspects of the acute management of sTBI (neurosurgeons, intensivists, anesthesiologists, neurologists, nurses and physiotherapists) were gathered. An exhaustive literature search was made of selected topics in the LILACS, PubMed, Embase, Scopus, Cochrane Controlled Register of Trials and Web of Science databases. To establish recommendations or suggestions with their respective strength or weakness, the GRADE methodology (Grading of Recommendations, Assessment, Development and Evaluation) was applied. Additionally, certain recommendations (included in complementary material) were not assessed by GRADE, because they constitute a set of therapeutic actions of effective compliance, in which it was not possible to apply the said methodology. Thirty-two recommendations were established, 16 strong and 16 weak, with their respective levels of evidence. This consensus attempts to standardize and establish basic general care measures in this particular patient population

General care in the management of severe traumatic brain injury: Latin American consensus. / Cuidados generales en el manejo del traumatismo craneoencefálico grave: consenso latinoamericano.

Severe traumatic brain injury (sTBI) remains prevalent in the young adult population. Indeed, far from descending, the incidence of sTBI remains high. One of the key bases of treatment is to avoid, detect and correct secondary injuries of systemic origin, which aggravate the primary lesion. Much of this can be achieved by maintaining an adequate physiological microenvironment allowing recovery of the damaged brain tissue. General care measures are nonspecific actions designed to meet that objective. The available guidelines on the management of sTBI have not included the topics contemplated in this consensus. In this regard, a group of members of the Latin American Brain Injury Consortium (LABIC), involved in the different aspects of the acute management of sTBI (neurosurgeons, intensivists, anesthesiologists, neurologists, nurses and physiotherapists) were gathered. An exhaustive literature search was made of selected topics in the LILACS, PubMed, Embase, Scopus, Cochrane Controlled Register of Trials and Web of Science databases. To establish recommendations or suggestions with their respective strength or weakness, the GRADE methodology (Grading of Recommendations, Assessment, Development and Evaluation) was applied. Additionally, certain recommendations (included in complementary material) were not assessed by GRADE, because they constitute a set of therapeutic actions of effective compliance, in which it was not possible to apply the said methodology. Thirty-two recommendations were established, 16 strong and 16 weak, with their respective levels of evidence. This consensus attempts to standardize and establish basic general care measures in this particular patient population.

[Giant atherosclerotic aneurysm. A case report]. / Aneurisma aterosclerótico gigante. Presentación de un caso.

INTRODUCTION: Intracraneal aneurysms are frequent in medical practice, most of them never produce symptoms, that is why occasionally, they are not diagnosed before death. Sacular is the most frequent aneurysm, and atherosclerotic aneurysm is rare. CASE REPORT: In this article we present the case of a 75 year old woman who has been suffering from high blood pressure and coronary artery disease since more than 20 years and in the last four months she had been complaining of dysphagia and dysartria. She was taken to the hospital because 24 hours ago mild headache started accompanied by vertigo, nausea and vomiting. On neurological exam we found sleepiness, dysartria, and right braguio crural hemiparesis, therefore we decided admitt her, but after 48 hours left braquio crural hemiparesis was added and later respiratory sepsis appeared. The patient died due to an acute respiratory failure. CONCLUSION: Necropsy revealed a huge atherosclerotic intracraneal aneurysm (31 mm) located on basilar artery. The case has been discussed and images were shown.

Aneurisma aterosclerótico gigante. Presentación de un caso / Giant atherosclerotic aneurysm. A case report

Introducción. Los aneurismas intracraneales son frecuentes en la práctica médica. Muchos de ellos no producen manifestaciones clínicas, por lo que, en ocasiones, no se diagnostican en vida. El sacular es el tipo más frecuente y el aterosclerótico es uno de los más raros. Caso clínico. En este artículo presentamos el caso de una paciente blanca, mujer, de 75 años de edad, que padecía de hipertensión arterial y cardiopatía isquémica crónica desde hacía más de 20 años, y que en los últimos cuatro meses se había quejado de disfagia y disartria. Ingresó en el hospital 24 horas después de haberse iniciado un cuadro de cefalea moderada, acompañada de vértigo, náuseas y vómitos. En el examen neurológico se constató somnolencia, disartria y una hemiparesia braquiocrural derecha, por lo que se decidió su ingreso; pero pasadas 48 horas se añadió una hemiparesia braquiocrural izquierda y posteriormente apareció sepsis respiratoria, que desencadenó una insuficiencia respiratoria aguda y la llevó a la muerte. Conclusión. El estudio necrópsico demostró la presencia de un aneurisma intracraneal aterosclerótico gigante (31 mm) de la arteria basilar. Se discute el caso y se presentan las imágenes (AU)

Introduction. Intracraneal aneurysms are frequent in medical practice, most of them never produce symptoms, that is why occasionally, they are not diagnosed before death. Sacular is the most frequent aneurysm, and atherosclerotic aneurysm is rare. Case report. In this article we present the case of a 75 year-old woman who has been suffering from high blood pressure and coronary artery disease since more than 20 years and in the last four months she had been complaining of dysphagia and dysartria. She was taken to the hospital because 24 hours ago mild headache started accompanied by vertigo, nausea and vomiting. On neurological exam we found sleepiness, dysartria, and right braguio-crural hemiparesis, therefore we decided admitt her, but after 48 hours left braquio-crural hemiparesis was added and later respiratory sepsis appeared. The patient died due to an acute respiratory failure. Conclusion. Necropsy revealed a huge atherosclerotic intracraneal aneurysm (31 mm) located on basilar artery. The case has been discussed and images were shown (AU)

[Traumatic brain injury in paediatrics. Our results]. / Traumatismo craneoencefalico en pediatría. Nuestros resultados.

INTRODUCTION: 75% of all children admitted to hospital with traumatic injuries involve traumatic brain injuries (TBI), 70% of the deaths occur within the first 48 hours and mortality fluctuates between 20 and 35%. It is estimated that every year 600,000 consultations are made for this reason, 300 out of every 100,000 children suffer a TBI and about 250,000 cases involve hospitalisation. PATIENTS AND METHODS: A descriptive observational study was carried out of all the patients of paediatric age who attended our Casualty Department in the period between January and December 2001, and had suffered a TBI in any of its clinical variations. The Glasgow coma scale (GCS) was used to classify cases according to their seriousness and results were defined by employing the Glasgow results scale (GRS). RESULTS: A survey of 339 cases with TBI was performed, of which 329 (97%) were mild, eight (2.4%) moderate and two (0.6%) were serious. Of the first, 122 (36%) required hospitalisation and the remaining 217 (64%) were given ambulatory treatment (all of them had mild TBI). Complementary examinations carried out were simple head X rays in 117 (95.9%). CAT (computerised axial tomography) scans were only performed in three cases (2.5%). Only two (1.8%) deaths occurred in our series and there were no cases of disability, according to the GRS. CONCLUSIONS: Mild TBI was the common event in our series. Application of treatment systems that are suited to the conditions in each medical centre helps to reduce the number of hospital admissions for mild TBI.

Antibioticoprofilaxis perioperatoria en neurocirugía / Perioperative antibiotic prophylaxis in neurological surgery

Introducción. La antibioticoprofilaxis perioperatoria constituye un tema de actualidad, pero en la neurocirugía no existen estudios controlados, ni informes suficientes, que avalen su utilización. Por otro lado, nos hemos percatado de la ausencia de uniformidad en el uso de los antibióticos en este tipo de cirugía. Este método se ha utilizado en otras especialidades y ha logrado reducir el riesgo de sepsis postoperatoria, por lo que a nuestro juicio puede aplicarse a la neurocirugía, tomando en consideración ciertas particularidades. Objetivos. Conocer los resultados respecto a la sepsis postoperatoria en un grupo consecutivo de pacientes a quienes se aplicó la profilaxis en intervenciones neuroquirúrgicas. Pacientes y métodos. Se realizó un estudio prospectivo, observacional y descriptivo de 100 pacientes que requirieron intervenciones neuroquirúrgicas y en los que se administraron antimicrobianos para prevenir la sepsis . Se relacionó la cirugía intracraneal y extracraneal con el uso o no de estos agentes, así como la aparición de sepsis o no. Para aplicar el método se utilizó la clasificación del National Research Council de EE.UU. Resultados. En la cirugía espinal fue donde más se utilizó el método. No existieron diferencias entre el uso o no de antibióticos en la cirugía espinal cervical con respecto a la aparición de sepsis. Los factores exógenos desempeñaron un papel importante en el desarrollo de sepsis no relacionadas con la técnica quirúrgica. Conclusión. Las complicaciones relacionadas con la cirugía fueron mínimas, mientras que las generales fueron más frecuentes (AU)

[Perioperative antibiotic prophylaxis in neurological surgery]. / Antibioticoprofilaxis perioperatoria en neurocirugía.

INTRODUCTION: Perioperative antibiotic prophylaxis is a current topic of interest. However, in neurosurgery there are no controlled studies or full reports to support its use. We have also observed that there is little consistency in the use of antibiotics in this type of surgery. This method has been used in other specialities, reducing the risk of postoperative sepsis. We therefore consider that it may be used in neurosurgery, bearing in mind certain specific aspects. OBJECTIVES: To find the postoperative sepsis in a consecutive group of patients in whom prophylaxis was used for neurosurgical operations. PATIENTS AND METHODS: We made a prospective, observational, descriptive study of 100 patients who needed neurosurgical operations and were given antimicrobial agents to prevent sepsis. The relation between intracranial and extracranial surgery, the use or not of these agents and the occurrence or not of sepsis was observed. The method was applied using the classification of the National Research Council of the USA. RESULTS. In spinal surgery, the method was used most and no difference was found with or without the use of antibiotics in cervical spinal surgery, with regard to the occurrence of sepsis. Exogenous factors played an important part in the development of sepsis unrelated to the surgical technique. CONCLUSIONS: The complications related to surgery were minimal. However, general complications occurred more frequently.