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2.
Neurocrit Care ; 2020 May 22.
Artigo em Inglês | MEDLINE | ID: mdl-32445108

RESUMO

BACKGROUND/OBJECTIVE: Multivariable prognostic scores play an important role for clinical decision-making, information giving to patients/relatives, benchmarking and guiding clinical trial design. Coagulopathy has been implicated on trauma and critical care outcomes, but few studies have evaluated its role on traumatic brain injury (TBI) outcomes. Our objective was to verify the incremental prognostic value of routine coagulopathy parameters in addition to the CRASH-CT score to predict 14-day mortality in TBI patients. METHODS: This is a prospective cohort of consecutive TBI patients admitted to a tertiary university hospital Trauma intensive care unit (ICU) from March/2012 to January/2015. The prognostic performance of the coagulation parameters platelet count, prothrombin time (international normalized ratio, INR) and activated partial thromboplastin time (aPTT) ratio was assessed through logistic regression adjusted for the original CRASH-CT score. A new model, CRASH-CT-Coag, was created and its calibration (Brier scores and Hosmer-Lemeshow (H-L) test), discrimination [area under the receiver operating characteristic curve (AUC-ROC) and the integrated discrimination improvement (IDI)] and clinical utility (net reclassification index) were compared to the original CRASH-CT score. RESULTS: A total 517 patients were included (median age 39 years, 85.1% male, median admission glasgow coma scale 8, neurosurgery on 44.9%). The 14-day mortality observed and predicted by the original CRASH-CT was 22.8% and 26.2%, respectively. Platelet count < 100,000/mm3, INR > 1.2 and aPTT ratio > 1.2 were present on 11.3%, 65.0% and 27.2%, respectively, (at least one of these was altered on 70.6%). All three variables maintained statistical significance after adjustment for the CRASH-CT score. The CRASH-CT-Coag score outperformed the original score on calibration (brier scores 0.122 ± 0.216 vs 0.132 ± 0.202, mean difference 0.010, 95% CI 0.005-0.019, p = 0.036, respectively) and discrimination (AUC-ROC 0.854 ± 0.020 vs 0.813 ± 0.024, p = 0.014; IDI 5.0%, 95% CI 1.3-11.0%). Both scores showed the satisfactory H-L test results. The net reclassification index favored the new model. Considering the strata of low (< 10%), moderate (10-30%) and high (> 30%) risk of death, the CRASH-CT-Coag model yielded a global net correct reclassification of 22.9% (95% CI 3.8-43.4%). CONCLUSIONS: The addition of early markers of coagulopathy-platelet count, INR and aPTT ratio-to the CRASH-CT score increased its accuracy. Additional studies are required to externally validate this finding and further investigate the coagulopathy role on TBI outcomes.

5.
World Neurosurg ; 121: e398-e403, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30266695

RESUMO

OBJECTIVE: Although pterional craniotomy and its variants are the most used approaches in neurosurgery, few studies have evaluated their precise indications. We evaluate the pterional (PT), pretemporal (PreT), and orbitozygomatic (OZ) approaches through quantitative measurements of area, linear, and angular exposures of the major intracranial vascular structures. METHODS: Eight fresh, adult cadavers were operated with the PT, followed by the PreT, and ending with the OZ approach. The working area, angular exposure of vascular structures and linear exposure of the basilar artery were measured. RESULTS: The OZ approach presented a wider area (1301.3 ± 215.9 mm2) with an increase of 456.7 mm2 compared with the PT and of 167.4 mm2 to the PreT (P = 0.011). The extension from PT to PreT and OZ increases linear exposure of the basilar artery. When comparing the PreT and OZ, we found an increase in the horizontal and vertical angle to the bifurcation of the ipsilateral middle cerebral artery (P = 0.005 and P = 0.032, respectively), horizontal angle to the basilar artery tip (P = 0.02), and horizontal angle to the contralateral ICA bifurcation (P = 0.048). CONCLUSIONS: The OZ approach offered notable surgical advantages compared with the traditional PT and PreT regarding to the area of exposure and linear exposure to basilar artery. Regarding angle of attack, the orbital rim and zygomatic arch removal provided quantitatively wider exposure and increased surgical freedom. A detailed anatomic study for each patient and surgeon experience must be considered for individualized surgical approach indication.


Assuntos
Craniotomia/métodos , Procedimentos Neurocirúrgicos/métodos , Órbita/cirurgia , Zigoma/cirurgia , Cadáver , Córtex Cerebral/cirurgia , Feminino , Humanos , Masculino , Órbita/anatomia & histologia , Estatísticas não Paramétricas , Zigoma/anatomia & histologia
8.
Brain Inj ; 32(10): 1208-1217, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30024781

RESUMO

BACKGROUND AND OBJECTIVE: Diffuse axonal injury (DAI) induces a long-term process of brain atrophy and cognitive deficits. The goal of this study was to determine whether there are correlations between brain volume loss, microhaemorrhage load (MHL) and neuropsychological performance during the first year after DAI. METHODS: Twenty-four patients with moderate or severe DAI were evaluated at 2, 6 and 12 months post-injury. MHL was evaluated at 3 months, and brain volumetry was evaluated at 3, 6 and 12 months. The trail making test (TMT) was used to evaluate executive function (EF), and the Hopkins verbal learning test (HVLT) was used to evaluate episodic verbal memory (EVM) at 6 and 12 months. RESULTS: There were significant white matter volume (WMV), subcortical grey matter volume and total brain volume (TBV) reductions during the study period (p < 0.05). MHL was correlated only with WMV reduction. EF and EVM were not correlated with MHL but were, in part, correlated with WMV and TBV reductions. CONCLUSIONS: Our findings suggest that MHL may be a predictor of WMV reduction but cannot predict EF or EVM in DAI. Brain atrophy progresses over time, but patients showed better EF and EVM in some of the tests, which could be due to neuroplasticity.


Assuntos
Encéfalo/diagnóstico por imagem , Transtornos Cognitivos/etiologia , Lesão Axonal Difusa/complicações , Lesão Axonal Difusa/diagnóstico por imagem , Adolescente , Adulto , Atenção/fisiologia , Transtornos Cognitivos/diagnóstico por imagem , Função Executiva , Feminino , Escala de Coma de Glasgow , Humanos , Processamento de Imagem Assistida por Computador , Estudos Longitudinais , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Testes Neuropsicológicos , Tomógrafos Computadorizados , Aprendizagem Verbal , Substância Branca/diagnóstico por imagem , Adulto Jovem
10.
Pediatr Neurosurg ; 53(4): 263-269, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29847821

RESUMO

A 4-year-old girl was admitted to the emergency department after having been buried beneath a wall. A computed tomography scan revealed anterior grade V L5-S1 spondylolisthesis, and magnetic resonance imaging showed a traumatic rupture of the fibrous annulus of the L5-S1 intervertebral disc and lesion of the anterior longitudinal and yellow ligaments. The patient underwent anterior and posterior fixation. Four months later she was able to walk independently, despite a persistent left foot drop. Additionally, we conducted a literature review on lumbosacral spondyloptosis in the pediatric population published between 1990 and 2017. We found 16 cases, 86.6% of which were male, with a mean patient age of 16 ± 5.05 years. Most patients underwent spine instrumentation. Based on the data reviewed, the neurological status at admission might be a valid predictor of outcome. Pedicle screws are a safe and reliable procedure for stable fixation of the spine in these cases. The removal of screws is discouraged.


Assuntos
Região Lombossacral/lesões , Região Lombossacral/cirurgia , Fusão Vertebral/métodos , Espondilolistese/cirurgia , Criança , Descompressão Cirúrgica/métodos , Feminino , Humanos
11.
Trials ; 19(1): 249, 2018 Apr 24.
Artigo em Inglês | MEDLINE | ID: mdl-29690927

RESUMO

BACKGROUND: Photobiomodulation describes the use of red or near-infrared light to stimulate or regenerate tissue. It was discovered that near-infrared wavelengths (800-900 nm) and red (600 nm) light-emitting diodes (LED) are able to penetrate through the scalp and skull and have the potential to improve the subnormal cellular activity of compromised brain tissue. Different experimental and clinical studies were performed to test LED therapy for traumatic brain injury (TBI) with promising results. One of the proposals of this present study is to develop different approaches to maximize the positive effects of this therapy and improve the quality of life of TBI patients. METHODS/DESIGN: This is a double-blinded, randomized, controlled trial of patients with diffuse axonal injury (DAI) due to a severe TBI in an acute stage (less than 8 h). Thirty two patients will be randomized to active coil helmet and inactive coil (sham) groups in a 1:1 ratio. The protocol includes 18 sessions of transcranial LED stimulation (627 nm, 70 mW/cm2, 10 J/cm2) at four points of the frontal and parietal regions for 30 s each, totaling 120 s, three times per week for 6 weeks, lasting 30 min. Patients will be evaluated with the Glasgow Outcome Scale Extended (GOSE) before stimulation and 1, 3, and 6 months after the first stimulation. The study hypotheses are as follows: (1) transcranial LED therapy (TCLT) will improve the cognitive function of DAI patients and (2) TCLT will promote beneficial hemodynamic changes in cerebral circulation. DISCUSSION: This study evaluates early and delayed effects of TCLT on the cognitive rehabilitation for DAI following severe acute TBI. There is a paucity of studies regarding the use of this therapy for cognitive improvement in TBI. There are some experimental studies and case series presenting interesting results for TBI cognitive improvement but no clinical trials. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03281759 . Registered on 13 September 2017.


Assuntos
Lesões Encefálicas Traumáticas/radioterapia , Encéfalo/efeitos da radiação , Cognição/efeitos da radiação , Lesão Axonal Difusa/radioterapia , Lasers Semicondutores/uso terapêutico , Terapia com Luz de Baixa Intensidade/instrumentação , Adolescente , Adulto , Encéfalo/irrigação sanguínea , Encéfalo/fisiopatologia , Lesões Encefálicas Traumáticas/diagnóstico , Lesões Encefálicas Traumáticas/fisiopatologia , Lesões Encefálicas Traumáticas/psicologia , Brasil , Circulação Cerebrovascular/efeitos da radiação , Lesão Axonal Difusa/diagnóstico , Lesão Axonal Difusa/fisiopatologia , Lesão Axonal Difusa/psicologia , Método Duplo-Cego , Feminino , Escala de Coma de Glasgow , Humanos , Lasers Semicondutores/efeitos adversos , Terapia com Luz de Baixa Intensidade/efeitos adversos , Masculino , Pessoa de Meia-Idade , Exame Neurológico , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Recuperação de Função Fisiológica , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
12.
Trials ; 19(1): 17, 2018 Jan 08.
Artigo em Inglês | MEDLINE | ID: mdl-29310710

RESUMO

BACKGROUND: Photobiomodulation using low-level laser therapy (LLLT) has been tested as a new technique to optimize recovery of patients with traumatic brain injury (TBI). The aim of this study is to evaluate inhibitory attentional control after 18 sessions of active LLLT and compare with the placebo group (sham LLLT). Our exploratory analysis will evaluate the efficacy of the active LLLT on verbal and visuospatial episodic memory, executive functions (working memory, verbal and visuospatial fluency, attentional processes), and anxiety and depressive symptoms compared to the sham group. METHODS/DESIGN: A randomized double-blinded trial will be made in 36 patients with moderate and severe TBI. The active LLLT will use an optical device composed of LEDs emitting 632 nm of radiation at the site with full potency of 830 mW. The cranial region with an area of 400 cm2 will be irradiated for 30 min, giving a total dose per session of 3.74 J/cm2. The sham LLLT group contains only an LED device with power < 1 mW, only serving to simulate the irradiation. Each patient will be irradiated three times per week for six weeks, totaling 18 sessions. Neuropsychological assessments will be held one week before the beginning of the sessions, after one week, and three months after the end of LLLT sessions. Memory domain, attention, executive functioning, and visual construction will be evaluated, in addition to symptoms of depression, anxiety, and social demographics. DISCUSSION: LLLT has been demonstrated as a safe and effective technique in significantly improving the memory, attention, and mood performance in healthy and neurologic patients. We expect that our trial can complement previous finds, as an effective low-cost therapy to improve cognitive sequel after TBI. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02393079 . Registered on 20 February 2015.


Assuntos
Ansiedade/terapia , Lesões Encefálicas Traumáticas/radioterapia , Lesão Encefálica Crônica/radioterapia , Encéfalo/efeitos da radiação , Depressão/terapia , Terapia com Luz de Baixa Intensidade/métodos , Adolescente , Adulto , Afeto/efeitos da radiação , Ansiedade/diagnóstico , Ansiedade/fisiopatologia , Ansiedade/psicologia , Atenção/efeitos da radiação , Lesões Encefálicas Traumáticas/diagnóstico , Lesões Encefálicas Traumáticas/fisiopatologia , Lesões Encefálicas Traumáticas/psicologia , Lesão Encefálica Crônica/diagnóstico , Lesão Encefálica Crônica/fisiopatologia , Lesão Encefálica Crônica/psicologia , Brasil , Depressão/diagnóstico , Depressão/fisiopatologia , Depressão/psicologia , Método Duplo-Cego , Função Executiva/efeitos da radiação , Feminino , Humanos , Terapia com Luz de Baixa Intensidade/efeitos adversos , Masculino , Memória Episódica , Pessoa de Meia-Idade , Estudos Multicêntricos como Assunto , Testes Neuropsicológicos , Estudos Prospectivos , Doses de Radiação , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
13.
Front Neurol ; 8: 164, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28512443

RESUMO

BACKGROUND: Mild traumatic brain injury (MTBI) represents 70-80% of all treated brain injuries. A considerable proportion of MTBI patients experience post-concussion symptoms for a prolonged period after MTBI, and these symptoms are diagnosed as persistent post-concussion syndrome (PPCS). PPCS is defined as a range of physical, cognitive, and emotional symptoms. However, memory and executive dysfunction seems to be one of the most debilitating symptoms. Recently, non-invasive brain stimulation has been studied as a potential treatment method for traumatic brain injury (TBI) patients. Therefore, our primary goal is to verify the effects of transcranial direct current stimulation (tDCS) in patients with PPCS who demonstrate cognitive deficits in long-term episodic memory, working memory, and executive function following MTBI. METHODS/DESIGN: This is a randomized crossover trial of patients with a history of MTBI with cognitive deficits in memory and executive function. Thirty adult patients will be randomized in a crossover manner to receive three weekly sessions of anodal tDCS (2 mA) at left dorsolateral prefrontal cortex, left temporal cortex, and sham stimulation that will be performed at 7-day intervals (washout period). The clinical diagnosis of PPCS will be determined using the Rivermead Post-Concussion Symptoms Questionnaire. Patients who meet the inclusion criteria will be assessed with a neuropsychological evaluation. A new battery of computerized neuropsychological tests will be performed before and immediately after each stimulation. Statistical analysis will be performed to determine trends of cognitive improvement. DISCUSSION: There is paucity of studies regarding the use of tDCS in TBI patients, and although recent results showed controversial data regarding the effects of tDCS in such patients, we will address specifically patients with PPCS and MTBI and no brain abnormalities on CT scan other than subarachnoid hemorrhage. Moreover, due to the missing information on literature regarding the best brain region to be studied, we will evaluate two different regions to find immediate effects of tDCS on memory and executive dysfunction. CLINICAL TRIAL REGISTRATION: www.ClinicalTrials.gov, identifier NCT02292589 (https://register.clinicaltrials.gov).

14.
J Clin Neurosci ; 42: 122-128, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28347684

RESUMO

Traumatic brain injury (TBI) is an important cause of death and disability worldwide. The prognosis evaluation is a challenge when many variables are involved. The authors aimed to develop prognostic model for assessment of survival chances after TBI based on admission characteristics, including extracranial injuries, which would allow application of the model before in-hospital therapeutic interventions. A cohort study evaluated 1275 patients with TBI and abnormal CT scans upon admission to the emergency unit of Hospital das Clinicas of University of Sao Paulo and analyzed the final outcome on mortality. A logistic regression analysis was undertaken to determine the adjusted weigh of each independent variable in the outcome. Four variables were found to be significant in the model: age (years), Glasgow Coma Scale (3-15), Marshall Scale (MS, stratified into 2,3 or 4,5,6; according to the best group positive predictive value) and anysochoria (yes/no). The following formula is in a logistic model (USP index to head injury) estimates the probability of death of patients according to characteristics that influence on mortality. We consider that our mathematical probability model (USP Index) may be applied to clinical prognosis in patients with abnormal CT scans after severe traumatic brain injury.


Assuntos
Lesões Encefálicas Traumáticas/diagnóstico por imagem , Adolescente , Adulto , Idoso , Lesões Encefálicas Traumáticas/epidemiologia , Lesões Encefálicas Traumáticas/mortalidade , Lesões Encefálicas Traumáticas/patologia , Estudos de Coortes , Feminino , Escala de Coma de Glasgow , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Prognóstico , Cintilografia , Análise de Sobrevida
16.
Front Neurol ; 7: 178, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27812349

RESUMO

Diffuse axonal injury (DAI), a type of traumatic injury, is known for its severe consequences. However, there are few studies describing the outcomes of DAI and the risk factors associated with it. This study aimed to describe the outcome for patients with a primary diagnosis of DAI 6 months after trauma and to identify sociodemographic and clinical factors associated with mortality and dependence at this time point. Seventy-eight patients with DAI were recruited from July 2013 to February 2014 in a prospective cohort study. Patient outcome was analyzed using the Extended Glasgow Outcome Scale (GOS-E) within 6 months of the traumatic injury. The mean Injury Severity Score was 35.0 (SD = 11.9), and the mean New Injury Severity Score (NISS) was 46.2 (SD = 15.9). Mild DAI was observed in 44.9% of the patients and severe DAI in 35.9%. Six months after trauma, 30.8% of the patients had died, and 45.1% had shown full recovery according to the GOS-E. In the logistic regression model, the severity variables - DAI with hypoxia, as measured by peripheral oxygen saturation, and hypotension with NISS value - had a statistically significant association with patient mortality; on the other hand, severity of DAI and length of hospital stay were the only significant predictors for dependence. Therefore, severity of DAI emerged as a risk factor for both mortality and dependence.

17.
Arq. bras. neurocir ; 35(3): 207-211, 20/09/2016.
Artigo em Inglês | LILACS | ID: biblio-910722

RESUMO

Traumatic brain injury (TBI) is responsible for high rates of morbidity and mortality, constituting an important public health problem throughout the world. Improving medical research on systemic trauma is a critical issue to understand its impact and develop strategies for prevention and treatment. This paper presents an overview of medical research performed in Brazil about TBI comparing it with the production on the same topic with other countries and with publications about different neurological and non-neurological diseases. It is possible to notice that Brazil has a deficiency in the scientific production on TBI given its importance. Greater integration between the research centers could help meliorate the production and quality of the papers and encourage further studies on the theme, in the quest to minimize the shortage of publications that can be seen today.


O trauma cranioencefálico (TCE) é responsável por altas taxas de morbidade e mortalidade, constituindo um importante problema de saúde pública em todo o mundo. Melhorar a investigação médica sobre trauma sistêmico é uma questão crítica para compreender seu impacto e desenvolver estratégias para a sua prevenção e tratamento. Este artigo apresenta uma visão geral da pesquisa médica realizada no Brasil sobre TCE comparando-a com a produção sobre o mesmo tema com outros países e com publicações sobre diferentes doenças neurológicas e não neurológicas. É possível notar que o Brasil tem uma deficiência na produção científica sobre TCE dada a sua importância. Maior integração entre os centros de pesquisa poderia ajudar a aperfeiçoar a produção e a qualidade dos trabalhos e incentivar novos estudos sobre o tema, na busca de minimizar a escassez de publicações vista atualmente.


Assuntos
Brasil , Indicadores Bibliométricos , Lesões Encefálicas Traumáticas
19.
Rev Assoc Med Bras (1992) ; 62(4): 377-84, 2016 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-27437685

RESUMO

In clinical practice, hospital admission of patients with altered level of consciousness, sleepy or in a non-responsive state is extremely common. This clinical condition requires an effective investigation and early treatment. Performing a focused and objective evaluation is critical, with quality history taking and physical examination capable to locate the lesion and define conducts. Imaging and laboratory exams have played an increasingly important role in supporting clinical research. In this review, the main types of changes in consciousness are discussed as well as the essential points that should be evaluated in the clinical management of these patients.


Assuntos
Transtornos da Consciência/diagnóstico , Algoritmos , Anticonvulsivantes/uso terapêutico , Antidepressivos Tricíclicos/uso terapêutico , Estado de Consciência , Transtornos da Consciência/classificação , Transtornos da Consciência/tratamento farmacológico , Diagnóstico Diferencial , Humanos , Exame Físico , Prognóstico
20.
Rev. Assoc. Med. Bras. (1992) ; 62(4): 377-384, tab, graf
Artigo em Inglês | LILACS-Express | LILACS | ID: lil-787773

RESUMO

Summary In clinical practice, hospital admission of patients with altered level of consciousness, sleepy or in a non-responsive state is extremely common. This clinical condition requires an effective investigation and early treatment. Performing a focused and objective evaluation is critical, with quality history taking and physical examination capable to locate the lesion and define conducts. Imaging and laboratory exams have played an increasingly important role in supporting clinical research. In this review, the main types of changes in consciousness are discussed as well as the essential points that should be evaluated in the clinical management of these patients.


Resumo Abordagem Na prática clínica é extremamente comum a admissão hospitalar de pacientes com nível de consciência alterado, sonolentos ou em estado não responsivo. Essa condição clínica demanda uma investigação eficaz e um tratamento precoce. É fundamental a realização de uma avaliação focada e objetiva, com a realização de anamnese e exame físico de qualidade para localizar a lesão e definir condutas. Exames de imagem e laboratoriais têm desempenhado papéis cada vez mais relevantes no suporte à investigação clínica. Nesta revisão, são discutidos os principais tipos de alterações de consciência e os pontos imprescindíveis que devem ser avaliados na abordagem clínica desses pacientes.

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