Sensory deficits in ipsilesional upper-extremity in chronic stroke patients / Déficit sensorial na extremidade superior ipsilateral em pacientes com ave crônico

Objective To investigate somatosensory deficits in the ipsilesional wrist and hand in chronic stroke patients and correlate these deficits with contralesional sensorimotor dysfunctions, functional testing, laterality and handedness.Methods Fifty subjects (twenty-two healthy volunteers and twenty-eight stroke patients) underwent evaluation with Semmes-Weinstein monofilaments, the sensory and motor Fugl-Meyer Assessment, the Nottingham Sensory Assessment in both wrists and hands and functional tests.Results Twenty-five patients had sensory changes in the wrist and hand contralateral to the stroke, and eighteen patients (64%) had sensory deficits in the ipsilesional wrist and hand. The most significant ipsilesional sensory loss was observed in the left-handed patients. We found that the patients with brain damage in the right hemisphere had better scores for ipsilesional tactile sensation.Conclusions A reduction in ipsilesional conscious proprioception, tactile or thermal sensation was found in stroke subjects. Right hemisphere damage and right-handed subjects had better scores in ipsilesional tactile sensation.

Objetivo Investigar déficits somatossensoriais no punho e mão ipsilesional em pacientes com acidente vascular encefálico (AVE) crônico e correlacionar esses déficits com disfunções sensório-motoras contralesional, testes funcionais, lateralidade e preferência manual.Métodos Cinquenta indivíduos (vinte e dois voluntários saudáveis e vinte e oito pacientes com AVE) foram submetidos à avaliação com monofilamentos de Semmes-Weinstein, Avaliação Fugl-Meyer (sensorial e motora), Avaliação Sensorial Nottingham em punhos e mãos, e testes funcionais.Resultados Vinte e cinco pacientes apresentaram alterações sensoriais no punho e mão contralateral ao AVE, e dezoito pacientes (64%) apresentaram déficits sensoriais no punho e mão ipsilesional. A perda sensorial ipsilesional mais significativa foi observada nos pacientes canhotos. Pacientes com lesão cerebral no hemisfério direito tiveram melhores pontuações para sensação tátil ipsilesional.Conclusões A redução da propriocepção consciente ipsilesional, da sensibilidade tátil e térmica foi encontrada em indivíduos com AVE. Lesão no hemisfério direito e indivíduos destros apresentaram melhores pontuações na sensação tátil ipsilesional.

Sensory deficits in ipsilesional upper-extremity in chronic stroke patients.

Objective To investigate somatosensory deficits in the ipsilesional wrist and hand in chronic stroke patients and correlate these deficits with contralesional sensorimotor dysfunctions, functional testing, laterality and handedness.Methods Fifty subjects (twenty-two healthy volunteers and twenty-eight stroke patients) underwent evaluation with Semmes-Weinstein monofilaments, the sensory and motor Fugl-Meyer Assessment, the Nottingham Sensory Assessment in both wrists and hands and functional tests.Results Twenty-five patients had sensory changes in the wrist and hand contralateral to the stroke, and eighteen patients (64%) had sensory deficits in the ipsilesional wrist and hand. The most significant ipsilesional sensory loss was observed in the left-handed patients. We found that the patients with brain damage in the right hemisphere had better scores for ipsilesional tactile sensation.Conclusions A reduction in ipsilesional conscious proprioception, tactile or thermal sensation was found in stroke subjects. Right hemisphere damage and right-handed subjects had better scores in ipsilesional tactile sensation.

Desempenho sensório-motor na paresia aferente em paciente após acidente vascular encefálico crônico: relato de caso / Sensorimotor performance in afferent paresis in chronic stroke patient: case report

Introdução: Lesões no giro cerebral pós-central podem causar o fenômeno de paresia aferente. Objetivo: Descrever o desempenho sensório-motor de uma paciente com paresia aferente pós-acidente vascular encefálico (AVE) crônico. Métodos: Paciente do sexo feminino, 39 anos, com diagnóstico de hemorragia subaracnoide aguda por rompimento de aneurisma em artéria cerebral média direita foi submetida a protocolo de desempenho físico de Fugl-Meyer, avaliação sensorial de Nottingham, teste dos sinos, testes de sequência motora e dez testes funcionais, sendo os dois últimos executados com e sem privação visual. Resultados: A paciente apresentou comprometimento motor leve, hipoestesia tátil e ausência de propriocepção em punho e mão, astereognosia e dificuldade na resolução de tarefas motoras durante a privação visual. Conclusão: A paciente com sequelas crônicas pós-AVE apresentou déficits sensoriais e lentidão ou incapacidade de realização das tarefas motoras manuais na ausência da orientação visual, caracterizando, assim, a paresia aferente.

Introduction: Lesions on the postcentral gyrus may cause the phenomenon denominated afferent paresis. Objective: To describe sensorimotor performance of a patient with afferent paresis after chronic stroke. Methods: Female patient, 39 years with a diagnosis of acute subarachnoid hemorrhage caused by rupture of an aneurysm in the right middle cerebral artery underwent physiotherapy assessment. She was subjected to the Fugl-Meyer assessment, Nottingham sensory assessment, the bells test, the motor sequences and ten functional tests, the last two were performed with and without visual deprivation. Results: The patient had mild motor dysfunction, tactile hypoesthesia and absence of proprioception in the wrist and hand, astereognosis and difficulty in resolving motor tasks during visual deprivation. Conclusion: The chronic post-stroke patient exhibited significant sensory deficits in the contralesional upper extremity and slowness or inability to perform motor tasks only in the absence of visual guidance, thus characterizing the afferent paresis.

Motor and sensory effects of ipsilesional upper extremity hypothermia and contralesional sensory training for chronic stroke patients.

UNLABELLED: As hypothermia by immersion can reduce the sensory nerve conduction velocity, this study hypothesized that the reduction of sensory input to the ipsilesional upper extremity (UE) using cryotherapy would reduce the inhibitory activity of the contralesional hemisphere in chronic stroke subjects. OBJECTIVE: In this study, hypothermia was applied by immersing the ipsilesional UE in association with sensory training of the contralesional UE of stroke patients to assess the immediate (e.g. sensorimotor function, hemodynamics, and levels of comfort) and long-term (sensory and motor performances of the UEs) effects. METHODS: The sample included 27 stroke patients allocated into group 1 (n = 14), which received conventional physiotherapy for the affected UE, and group 2 (n = 13), which underwent 10 sessions of immersion hypothermia of the ipsilesional wrist and hand. Assessments were performed pre- and post-treatment and at follow-up using esthesiometry, the Fugl-Meyer Assessment (FMA), the Nottingham Sensory Assessment, functional tests, tactile and weight discrimination, motor sequence, level of comfort, and hemodynamic parameters. RESULTS: The immediate effects of hypothermia using immersion of the ipsilesional UE in association with sensory training of the contralesional UE were hemodynamic stability during and after hypothermia, the absence of sensory abnormalities in the contralesional UE, hypoesthesia in the ipsilesional extremity (dermatomes C6 and C8) (P < 0.05), the maintenance of acceptable levels of comfort, and good patient compliance to the technique. The long-term effects included significant increases in scores on tests performed without functional vision, in scores on blindfolded functional tests, and in tactile localization and joint position sense for the contralesional hand in group 2 as well as the maintenance of these gains at long-term follow-up (5 weeks). Improvement was also found in the tactile function of the C6 and C7 dermatomes of the contralesional hand (P < 0.05). CONCLUSIONS: The use of immersion hypothermia on the ipsilesional UE in association with sensory training of the contralesional UE improved motor function and sensitivity in the contralesional UE of individuals with chronic stroke. Immersion hypothermia of the ipsilesional UE in chronic stroke patients is a safe, practical, inexpensive, and easily applied technique.

Acute effects of whole-body vibration on the motor function of patients with stroke: a randomized clinical trial.

OBJECTIVE: The aim of this study was to investigate the acute effects of whole-body vibration on the motor function of patients with stroke. DESIGN: The present investigation was a randomized clinical trial studying 43 individuals with hemiparesis after stroke, with 33 subjects allocated to the intervention group and 10 subjects allocated to the control group. The intervention group was subjected to one session of vibration therapy (frequency of 50 Hz and amplitude of 2 mm) comprising four 1-min series with 1-min rest intervals between series in three body positions: bipedal stances with the knees flexed to 30 degrees and 90 degrees and a unipedal stance on the paretic limb. The analytical tests were as follows: simultaneous electromyography of the affected and unaffected tibialis anterior and rectus femoris muscles bilaterally in voluntary isometric contraction; the Six-Minute Walk Test; the Stair-Climb Test; and the Timed Get-Up-and-Go Test. The data were analyzed by independent and paired t tests and by analysis of covariance. RESULTS: There was no evidence of effects on the group and time interaction relative to variables affected side rectus femoris, unaffected side rectus femoris, affected side tibialis anterior, unaffected side tibialis anterior, and the Stair-Climb Test (P > 0.05). There was evidence of effects on the group interaction relative to variables Six-Minute Walk Test and Timed Get-Up-and-Go Test (P < 0.05). CONCLUSIONS: Whole-body vibration contributed little to improve the functional levels of stroke patients.

Carpal tunnel syndrome: treatment with small transverse incision.

OBJECTIVE: To evaluate the application of a limited transverse incision technique to treat the carpal tunnel syndrome, with concern to its safety and efficacy in the opening of the flexor retinaculum (FR). METHOD: A prospective analysis of thirty FR release procedures performed on twenty-eight patients subjected to the proposed incision technique. Safety and total opening of the FR were evaluated through a questionnaire and an endoscopic inspection respectively. RESULTS: No major complications were observed. Two cases presented small local hematoma. One patient presented with transient neuropraxia of digital branch. In two of the first five cases, incomplete FR opening was identified during endoscopic revision with need of complementary opening. All patients reported relief of paresthesias and nocturnal pain symptoms. CONCLUSION: The technique was safely performed on the prospection group, no major complications were detected and the opening of FR was observed in the majority of the patients.

Carpal tunnel syndrome: treatment with small transverse incision / Utilização de técnica de incisão transversal mínima no tratamento da síndrome do túnel do carpo

Objective: To evaluate the application of a limited transverse incision technique to treat the carpal tunnel syndrome, with concern to its safety and efficacy in the opening of the flexor retinaculum (FR). Method: A prospective analysis of thirty FR release procedures performed on twenty-eight patients subjected to the proposed incision technique. Safety and total opening of the FR were evaluated through a questionnaire and an endoscopic inspection respectively. Results: No major complications were observed. Two cases presented small local hematoma. One patient presented with transient neuropraxia of digital branch. In two of the first five cases, incomplete FR opening was identified during endoscopic revision with need of complementary opening. All patients reported relief of paresthesias and nocturnal pain symptoms. Conclusion: The technique was safely performed on the prospection group, no major complications were detected and the opening of FR was observed in the majority of the patients.

Objetivo: Avaliação de técnica de incisão limitada no tratamento da síndrome do túnel do carpo, quanto à segurança clínica e efetividade na abertura do Retináculo Flexor (RF). Método: Estudo prospectivo de trinta procedimentos realizados em vinte e oito pacientes submetidos a técnica com incisão transversa mínima. A segurança da técnica e a abertura total do RF foram avaliadas através de questionário baseado em observações clinicas e inspeção endoscópica, respectivamente. Resultados: Não foram observadas complicações maiores. Um único paciente apresentou neuropraxia de nervo interdigital. Dois pacientes apresentaram hematoma local pequeno. Em dois dos cinco primeiros casos observou-se uma abertura incompleta do RF, sendo necessária abertura complementar. Todos os pacientes apresentaram melhora do quadro clínico de dor noturna e parestesias. Conclusão: A técnica foi executada com segurança no grupo analisado, sem a ocorrência de complicações graves, e com abertura do RF na quase totalidade dos casos.

Estimulação do sistema vestibular no paciente neurológico grave / Stimulation of the vestibular system in patients with severe neurological impairment

Objetivo: Verificar a influência da estimulação do sistema vestibular no paciente com rebaixamento do nível de consciência. Métodos: Participaram do estudo cinco pacientes com rebaixamento do nível de consciência. Todos foram submetidos a um protocolo de estimulação vestibular composto de movimentos com a cabeça, uma vez ao dia no período de internação na enfermaria de neuroclínica e neurocirurgia do HC da Unicamp. Resultados: Foi observado aumento da freqüência cardíaca e freqüência respiratória (de todos os pacientes) e pressão arterial (de apenas dois pacientes) durante e após a aplicação do protocolo, apresentando um decréscimo após dez minutos da estimulação vestibular. Na escala de Coma de Glasgow, dois pacientes apresentaram pequenas alterações não significativas. Conclusão: A estimulação do sistema vestibular influencia funções dependentes da formação reticular, porém, não foi suficiente para estimular o sistema ativador reticular ascendente, não alterando o nível de consciência.

Objective: To verify the influence of stimulation of the vestibular system in patients with reduced level of consciousness. Methods: Five patients with reduced level conscience participated in the study. All of them were submitted to an initial protocol of stimulation composed of head movements once a day during an hospitalization in a neurosurgery and neuroclinic unit of the HC of Unicamp, Campinas/SP. Results: Increasing in heart rate and respiratory frequency (all patients) and blood pressure (only two patients) was observed during and after protocol application, showing decrease after ten minutes of vestibular stimulation. The Glasgow Coma Scale showed that two patients had small but not significant changes. Conclusion: The stimulation of vestibular system influences functions dependent of the reticular formation; however, it was not sufficient to stimulate the ascending reticular activating system and to modify level of consciousness.

Intrinsic tectal low grade astrocytomas: is surgical removal an alternative treatment? Long-term outcome of eight cases.

Low-grade gliomas arising in dorsal midbrain in children and young patients usually present few neurological symptoms and findings, and patients management is controversial. Some authors propose only clinical observation until the patient present signs of increased intracranial pressure when a shunt with or without biopsy, is inserted; others recommend radiotherapy after stereotactic or open biopsy. Microsurgical total removal of tumor may be curative. We present a retrospective analysis of eight patients (mean age 16.6 +/- 11.5 years-old) with low-grade astrocytoma of the tectal region operated on using an infratentorial/supracerebellar approach between 1981 and 2002. All patients presented hydrocephalus and had a shunt insertion before surgical resection of the lesion. The tumour could be totally resected in seven patients. In one case radical removal was not possible due to infiltrative pattern of the lesion. Postoperative radiotherapy was performed in two cases, one patient at the beginning of this series and in the case with infiltrative tumor. This patient presented progressive tumor growth and died five years after surgery. No recurrence occurred after total removal. Post-surgical follow-up time ranged from 2 1/2 to 22 1/2 years (mean 9.9 +/- 5.9 years). Radical microsurgical removal of non invasive tumors is possible without mortality or significant morbidity. It may be curative and should remain as an alternative to be discussed with the patient.

Intrinsic tectal low grade astrocytomas: is surgical removal an alternative treatment? Long-term outcome of eight cases

Gliomas de baixo grau originários da porção dorsal do mesencéfalo ocorrem em crianças e adultos jovens. Geralmente apresentam pouca sintomatologia e tardia, com hipertensão intracraniana por hidrocefalia não-comunicante. O seu tratamento é controverso. Alguns autores propõem somente observação clínica até o aparecimento de sintomas decorrentes de hipertensão intracraniana, quando é realizada derivação ventrículo-peritoneal (DVP), com ou sem biópsia da lesão. Outros recomendam radioterapia após comprovação histológica por biópsia estereotáxica. A remoção cirúrgica total pode ser curativa. Analisamos retrospectivamente 8 pacientes com astrocitoma de baixo grau na região tectal operados entre 1981 e 2002. A idade média foi 16,6 ±11,5 anos (variando de 8 a 44 anos). As lesões foram abordadas por acesso infratentorial / supra-cerebelar. Todos os pacientes apresentaram hidrocefalia e uma DVP foi colocada em todos antes da remoção cirúrgica da lesão. A lesão tumoral foi removida completamente em 7 dos 8 casos. Em um único caso a remoção total foi impossível devido ao caráter infiltrativo do tumor. Radioterapia pós-operatória foi indicada em 2 casos, o primeiro no início da série e o segundo caso com tumor de caráter infiltrativo. Este último paciente apresentou crescimento tumoral progressivo e veio a falecer 5 anos após a cirurgia. Nos demais 7 pacientes não houve recurrência tumoral. O tempo de acompanhamento foi 2,5 a 22,5 anos (média 9,9 ± 5,9 anos). Remoção microneurocirúrgica radical pode e deve ser sempre cogitada em pacientes com tumores não-invasivos, pois a baixa morbi/mortalidade é possível e aceitável, além do procedimento poder ser curativo.

Benefícios da hemisferectomia em pacientes com hemimegalencefalia / Hemispherectomy of hemimegalencephaly

A hemisferectomia é realizada em muitos casos de hemimegalencefalia para controlar a epilepsia refratária ao tratamento medicamentoso. No entanto, apesar de haver concordância sobre a efetividade desse procedimento para controle das crises, a escolha da técnica cirúrgica utilizada ainda é motivo de debate. Relatamos os casos de três crianças com hemimegalencefalia submetidas à hemisferectomia para tratamento de suas crises refratárias: uma foi submetida à hemisferectomia anatômica e as outras duas, à hemisferectomia funcional. Os resultados confirmam a efetividade da hemisferectomia para o controle das crises epilépticas nesses casos.

Implataçäo torácica infraclavilcular da válvla de Hotter na derivaçäo ventrículo peritoneal do lactente / Implantation of the Holter valve in the thoracic sbcutaneum for ventriculo peritonial shunting in newborns

Os autores sugerem o posicionamento torácico, subcutâneo, sobre o gradeado costal, da válvula de Holter, nas derivaçöes ventriculoperitoniais de lactente com hidrocefalia. A técnica é de fácil execuçäo e é proposta para recém-nascidos, principalmente de baixo peso, que têm couro cabeludo muito delgado e útil também em crianças com escaras cranianas causadas pelos procedimentos convencionais