Preliminary Study on Application of Combined Monitoring of Neuroelectrophysiology-Intracranial Pressure-Cerebral Perfusion Pressure in Craniotomy for Intracranial Aneurysm Clipping: An Anatomical and Clinical Study

SUMMARY: Intracranial aneurysm is a common cerebrovascular disease with high mortality. Neurosurgical clipping for the treatment of intracranial aneurysms can easily lead to serious postoperative complications. Studies have shown that intraoperative monitoring of the degree of cerebral ischemia is extremely important to ensure the safety of operation and improve the prognosis of patients. Aim of this study was to probe the application value of combined monitoring of intraoperative neurophysiological monitoring (IONM)-intracranial pressure (ICP)-cerebral perfusion pressure (CPP) in craniotomy clipping of intracranial aneurysms. From January 2020 to December 2022, 126 patients in our hospital with intracranial aneurysms who underwent neurosurgical clipping were randomly divided into two groups. One group received IONM monitoring during neurosurgical clipping (control group, n=63), and the other group received IONM-ICP-CPP monitoring during neurosurgical clipping (monitoring group, n=63). The aneurysm clipping and new neurological deficits at 1 day after operation were compared between the two groups. Glasgow coma scale (GCS) score and national institutes of health stroke scale (NIHSS) score were compared before operation, at 1 day and 3 months after operation. Glasgow outcome scale (GOS) and modified Rankin scale (mRS) were compared at 3 months after operation. All aneurysms were clipped completely. Rate of new neurological deficit at 1 day after operation in monitoring group was 3.17 % (2/63), which was markedly lower than that in control group of 11.11 % (7/30) (P0.05). Combined monitoring of IONM-ICP-CPP can monitor the cerebral blood flow of patients in real time during neurosurgical clipping, according to the monitoring results, timely intervention measures can improve the consciousness state of patients in early postoperative period and reduce the occurrence of early postoperative neurological deficits.

El aneurisma intracraneal es una enfermedad cerebrovascular común con alta mortalidad. El clipaje neuroquirúrgico para el tratamiento de aneurismas intracraneales puede provocar complicaciones posoperatorias graves. Los estudios han demostrado que la monitorización intraoperatoria del grado de isquemia cerebral es extremadamente importante para garantizar la seguridad de la operación y mejorar el pronóstico de los pacientes. El objetivo de este estudio fue probar el valor de la aplicación de la monitorización combinada de la monitorización neurofisiológica intraoperatoria (IONM), la presión intracraneal (PIC) y la presión de perfusión cerebral (CPP) en el clipaje de craneotomía de aneurismas intracraneales. Desde enero de 2020 hasta diciembre de 2022, 126 pacientes de nuestro hospital con aneurismas intracraneales que se sometieron a clipaje neuroquirúrgico se dividieron aleatoriamente en dos grupos. Un grupo recibió monitorización IONM durante el clipaje neuroquirúrgico (grupo de control, n=63) y el otro grupo recibió monitorización IONM-ICP-CPP durante el clipaje neuroquirúrgico (grupo de monitorización, n=63). Se compararon entre los dos grupos el recorte del aneurisma y los nuevos déficits neurológicos un día después de la operación. La puntuación de la escala de coma de Glasgow (GCS) y la puntuación de la escala de accidentes cerebrovasculares de los institutos nacionales de salud (NIHSS) se compararon antes de la operación, 1 día y 3 meses después de la operación. La escala de resultados de Glasgow (GOS) y la escala de Rankin modificada (mRS) se compararon 3 meses después de la operación. Todos los aneurismas fueron cortados por completo. La tasa de nuevo déficit neurológico 1 día después de la operación en el grupo de seguimiento fue del 3,17 % (2/63), que fue notablemente inferior a la del grupo de control del 11,11 % (7/30) (P 0,05). La monitorización combinada de IONM-ICP-CPP puede controlar el flujo sanguíneo cerebral de los pacientes en tiempo real durante el corte neuroquirúrgico; de acuerdo con los resultados de la monitorización, las medidas de intervención oportunas pueden mejorar el estado de conciencia de los pacientes en el período postoperatorio temprano y reducir la aparición de problemas postoperatorios tempranos y déficits neurológicos.

Conectividad funcional a partir de la perfusión cerebral en pacientes epilépticos y con enfermedad de Parkinson / Functional connectivity from cerebral perfusion in patients with epilepsy and Parkinson's disease

Introducción: La epilepsia y la enfermedad de Parkinson han sido descritos como trastornos de redes neurales. El estudio de la conectividad por modalidades moleculares puede ser más relevante fisiológicamente que los basados en señales hemodinámicas. Objetivo: Proponer una metodología para la descripción de patrones de conectividad funcional a partir de la perfusión cerebral por tomografía por emisión de fotón único. Métodos: La metodología incluye cuatro pasos principales: preprocesamiento espacial, corrección del volumen parcial, cálculo del índice de perfusión y obtención de la matriz de conectividad funcional mediante el coeficiente de correlación de Pearson. Se implementó en 25 pacientes con distintos trastornos neurológicos: 15 con epilepsia farmacorresistente y 10 con enfermedad de Parkinson. Resultados: Se encontraron diferencias significativas entre los índice de perfusión de varias regiones de los hemisferios ipsilateral y contralateral tanto en pacientes con epilepsia del lóbulo frontal como en pacientes con epilepsia del lóbulo temporal. Igual resultado se obtuvo en los pacientes con enfermedad de Parkinson con distintos estadios de la enfermedad. Para cada grupo se identificaron patrones de conectividad funcional que involucran a regiones relacionadas con la patología en estudio. Conclusiones: Con el desarrollo de esta metodología se ha demostrado que la tomografía por emisión de fotón único aporta información valiosa para estudiar la organización de las redes funcionales del cerebro. Futuras investigaciones con mayor número de pacientes contribuirían a hacer inferencias sobre los correlatos neurales de los distintos trastornos cerebrales(AU)

Introduction: Epilepsy and Parkinson's disease have been described as disorders of neural networks. The study of connectivity by molecular modalities may be more physiologically relevant than those based on hemodynamic signals. Aim: The aim of the present work is to propose a methodology for the description of functional connectivity patterns from brain perfusion by single photon emission tomography. Methods: The methodology includes four main steps: spatial preprocessing, partial volume correction, calculation of the perfusion index and obtaining the functional connectivity matrix using Pearson's correlation coefficient. It was implemented in 25 patients with different neurological disorders: 15 with drug-resistant epilepsy and 10 suffering Parkinson's disease. Results: Significant differences were found between the perfusion indexes of various regions of the ipsilateral and contralateral hemispheres in both patients with frontal lobe epilepsy and patients with temporal lobe epilepsy. The same result was obtained in Parkinson's disease patients with different stages of the disease. For each group, functional connectivity patterns involving regions related to the pathology under study were identified. Conclusions: With the development of this methodology, it has been demonstrated that single photon emission tomography provides valuable information to study the organization of functional brain networks. Future research with a larger number of patients would contribute to make inferences about the neural correlates of the different brain disorders(AU)

Ecografía Doppler transcraneal para estimar la presión intracraneal y presión de perfusión cerebral en pacientes pediátricos neurocríticos

RESUMEN La ecografía Doppler transcraneal es un método no invasivo que permite una adecuada monitorización de los diferentes parámetros que ayudan a definir conductas para los médicos intensivistas, sin embargo, su utilización no está generalizada entre las comunidades médicas que atienden niños con afecciones neurocríticas. Es propósito de los autores, actualizar el tema en estudio y presentar su experiencia en población pediátrica. Las indicaciones de este método provienen de investigaciones en pacientes adultos, se necesitan estudios multicéntricos en diferentes contextos clínicos para poder establecer esta técnica como un método de diagnóstico confiable en pacientes pediátricos. Concluimos que utilizar el Doppler transcraneal como prueba auxiliar en la estimación de la presión intracraneal y presión de perfusión cerebral, proporciona adoptar recursos terapéuticos frente al paciente lo más acertados posibles y brinda la posibilidad de hacer un seguimiento y evaluación de los tratamientos a pie de cama de forma mínimamente invasiva.

ABSTRACT Transcranial Doppler ultrasound is a non-invasive method that allows adequate monitoring of the different parameters that help define behaviors for intensivist physicians ; however, its use is not widespread among the medical communities that care for children with neurocritical conditions. It is the purpose of the authors to update the topic under study and present their experience with pediatric populations. The indications for this method come from research in adult patients . Multicenter studies in different clinical contexts are needed to establish this technique as a reliable diagnostic method in pediatric patients. We conclude that using transcranial Doppler as an auxiliary test in the estimation of intracranial pressure and cerebral perfusion pressure, provides the implementation of therapeutic resources in front of the patient as accurate as possible and offers the possibility of monitoring and evaluating bedside treatments in a minimally invasive way.

Presión positiva al final de la espiración, presión intracraneal y presión de perfusión cerebral en el paciente pediátrico crítico con traumatismo craneoencefálico grave / Positive end expiration pressure, intracranial pressure and cerebral perfusion pressure in the severe traumatic brain injury in child / Pressão positiva ao final da expiração, pressão intracraniana e pressão de perfusão cerebral em pacientes pediátricos criticamente enfermos com traumatismo cranioencefálico grave

Resumen: Introducción: el uso de presión positiva al final de la espiración mejora la oxigenación y recluta alvéolos, aunque también provoca alteraciones hemodinámicas e incrementa la presión intracraneal. Material y métodos: se realizó un estudio preexperimental de un solo grupo en pacientes pediátricos aquejados de traumatismo craneoencefálico grave, con hipoxemia asociada, tratados con diferentes niveles de presión positiva al final de la espiración, a los que se les monitorizó la presión intracraneal y la presión de perfusión cerebral para evaluar el efecto de esta maniobra ventilatoria en las variables intracraneales. Resultados: predominaron las edades entre cinco y 17 años, 14 (73.68%) y la escala de coma de Glasgow al ingreso de ocho a nueve puntos (47.36%). La presión intracraneal aumenta cuando la presión positiva al final de la espiración supera los 12 cmH2O. La escala de coma de Glasgow al ingreso de ocho puntos se asoció con secuelas ligeras o ausencia de secuelas (47.36%), todos los niños con tres puntos fallecieron. Conclusiones: el empleo de presión positiva al final de la espiración en el traumatismo craneoencefálico grave requiere de monitorización continua de la presión intracraneal. Corregir la hipertensión intracraneal y la inestabilidad hemodinámica son condiciones necesarias previas al tratamiento.

Abstract: Introduction: the use of positive end expiratory pressure improves oxygenation and recruits pulmonary alveoli, however at the same time it leads to hemodynamic changes and increase intracranial pressure. Material and methods: a prospective descriptive study was done with pediatric patients afflicted with severe traumatic brain injury associated with hypoxemia and treated with different levels of positive end expiratory pressure, to whom the intracranial pressure and cerebral perfusion pressure were monitored so as to evaluate the effect of this ventilation maneuver over the intracranial variables. Results: patients with age between 5-17 years old as well as male sex, 14 (73.68%) were predominant. 9 (47.36%) showed Glasgow coma scale of 8 points on admission. Intracranial pressure starts to rise when the positive end expiratory pressure exceeds 12 cmH2O. Glasgow coma scale with 8 points was associated with mild disability or no disability (47.36%). All the patients that scored 3 points died. Conclusions: the use of positive end expiratory pressure to correct hypoxemia was an applicable therapeutic alternative as long as continuous intracranial pressure monitoring was available in a systematic and personalized way. The correction of intracranial hypertension and hemodynamic instability were a necessary condition before using the ventilatory maneuver in these patients.

Resumo: Introdução: o uso de pressão positiva no final da expiração melhora a oxigenação e recruta alvéolos, embora também cause alterações hemodinâmicas e aumente a pressão intracraniana. Material e métodos: realizou-se um estudo pré-experimental de um único grupo em pacientes pediátricos vítimas de traumatismo cranioencefálico grave, com hipoxemia associada, tratados com diferentes níveis de pressão positiva ao final da expiração, nos quais foram monitoradas a pressão intracraniana e a pressão de perfusão cerebral, para avaliar o efeito desta manobra ventilatória em variáveis intracranianas. Resultados: predominou a faixa etária entre 5-17 anos, 14 (73.68%) e a escala de coma de Glasgow na admissão de 8 pontos, 9 (47.36%). A pressão intracraniana aumenta quando a pressão positiva no final da expiração excede 12 cmH2O. A escala de coma de Glasgow na admissão de 8 pontos foi associada a sequelas leves ou sem sequelas (47.36%), todas as crianças com 3 pontos morreram. Conclusões: a utilização de pressão positiva no final da expiração no TCE grave requer monitorização contínua da pressão intracraniana. A correção da hipertensão intracraniana e da instabilidade hemodinâmica são condições necessárias prévias ao tratamento.

Presión de perfusión cerebral en pacientes pediátricos con traumatismo craneoencefálico grave

RESUMEN Introducción: La mortalidad por traumatismo craneoencefálico grave (TCE g) en el paciente pediátrico, crece de forma directamente proporcional con la severidad de la injuria inicial. Se estima entre el 1 y 7 % de menores de 18 años afectados por dicha enfermedad en el mundo. La incidencia de muerte por esta causa oscila entre 2,8 y 3,75 por cada 100 000 niños anualmente. Metodología: Se realizó un estudio descriptivo de tipo correlacional en el servicio de cuidados intensivos pediátricos del Hospital General Docente "Roberto Rodríguez" de Morón, Ciego de Ávila, Cuba, en el período entre enero de 2003 y diciembre de 2017. Se incluyeron pacientes menores de 18 años. Las intervenciones fueron monitorización continua de la presión intracraneal, a través de una ventriculostomía al exterior y de la presión de perfusión cerebral y las variables presión intracraneal y presión de perfusión cerebral. Resultados: Se estudiaron 41 niños. Predominaron aquellos entre 5 y 17 años con 35 casos (85,3 %). La presión de perfusión cerebral en menores de 1 año fue >47mmhg en los dos casos estudiados, de 1-4 años >47mmhg en 2 casos y de 50mmhg en 23 casos (65,7 %) y 50mmhg se asoció con el grado V de la escala de resultados de Glasgow. Discusión: El control de la presión de perfusión cerebral con valores diferentes ajustados a los diferentes grupos de edades, a través de la manipulación de la presión intracraneal y la presión arterial media en el niño, mostró una adecuada relación con los resultados favorables.

ABSTRACT Introduction: Mortality from severe head injury (TBI g) in pediatric patients increases in direct proportion to the severity of the initial injury. It is estimated between 1 and 7% of children under 18 years of age affected by this disease in the world. The incidence of death from this cause ranges from 2.8 to 3.75 per 100,000 children annually. Methodology: A correlational descriptive study was carried out in the pediatric intensive care service of the General Teaching Hospital "Roberto Rodríguez" in Morón, Ciego de Ávila, Cuba, in the period between January 2003 and December 2017. Minor patients were included of 18 years. The interventions were continuous monitoring of intracranial pressure, through an external ventriculostomy and cerebral perfusion pressure and the variable intracranial pressure and cerebral perfusion pressure. Results: 41 children were studied. Those between 5 and 17 years old predominated with 35 cases (85.3%). Cerebral perfusion pressure in children under 1 year of age was> 47mmhg in the two cases studied, from 1-4 years> 47mmhg in 2 cases and 50mmhg in 23 cases (65.7%) and 50mmhg was associated with grade V on the Glasgow Outcome Scale. Discussion: The control of cerebral perfusion pressure with different values adjusted to the different age groups, through the manipulation of intracranial pressure and mean arterial pressure in the child, showed an adequate relationship with the favorable results.

Características anatómicas y fisiológicas que influyen en la presión intracraneal y la presión de perfusión cerebral en el paciente pediátrico con traumatismo craneoencefálico grave

RESUMEN La lesión cerebral traumática, es la de mayor potencial para el desarrollo de secuelas devastadoras de todos los tipos de trauma en los niños. La hipertensión intracraneal está presente en más del 65% de los que sufren de un TCE grave y se relaciona con más de la mitad de las muertes por esta causa. No existe consenso sobre los valores normales de PIC y PPC en los niños, se estima que son dependientes de la edad, pero es un tema en controversia en la actualidad. El objetivo es identificar los elementos anatómicos y fisiológicos en el compartimiento craneal y su contenido en los niños que influyen en las posibles variaciones de los valores de presión intracraneal y de la presión de perfusión cerebral en el paciente menor de 18 años con traumatismo craneoencefálico grave. Las características anatómicas y fisiológicas del paciente pediátrico en sus diferentes etapas de desarrollo definen valores de presión intracraneal y de presión de perfusión cerebral diferentes a los valores en el adulto. Se aborda un tema controversial, que permite identificar aspectos anatómicos y fisiológicos importantes que pueden influir sobre el tratamiento del traumatismo craneoencefálico pediátrico.

ABSTRACT Traumatic brain injury is one with the greatest potential for the development of devastating sequelae of all types of trauma in children. Intracranial hypertension is present in more than 65% of those who suffer from a severe TBI and is related to more than half of deaths from this cause. There is no consensus on the normal values of ICP and CPP in children, it is estimated that they are dependent on age, but it is currently a controversial issue. The objective was to identify the anatomical and physiological characteristics in the cranial compartment and its content in children that influence the possible variations in intracranial pressure and cerebral perfusion pressure in patients less than 18 years of age with severe head injury. The anatomical and physiological characteristics of the pediatric patient in their different stages of development define values of intracranial pressure and cerebral perfusion pressure different from those in adults. A controversial issue is addressed, which allows identifying important anatomical and physiological aspects that may influence the treatment of pediatric head trauma.

Reemplazo de aorta ascendente con paro circulatorio con hipotermia sistémica moderada y perfusión cerebral retrógrada / Total replacement of the ascending aorta with moderate systemic hypothermic circulatory arrest and retrograde cerebral perfusion

Resumen: Antecedentes: El daño neurológico es una complicación devastadora de la cirugía con paro circulatorio del cayado aórtico y aorta ascendente. La perfusión anterógrada del encéfalo permite disminuir la incidencia de esta complicación, pero es un procedimiento engorroso que interfiere el campo quirúrgico. Para procedimientos más simples que requieran de paro circulatorio de menor duración, la Perfusión Cerebral Retrógrada (PCR) es una alternativa válida. Objetivo: Evaluar nuestros resultados en la cirugía del reemplazo total de la aorta ascendente tubular con paro circulatorio con hipotermia sistémica moderada y PCR. Material y Método: Entre enero de 2015 y enero de 2020 se identificaron los pacientes en la Base de Datos del Servicio de Cirugía Cardiaca de nuestra institución, se revisaron los protocolos operatorios, registros de perfusión y epicrisis, para obtener datos demográficos, clínicos y quirúrgicos pertinentes. La supervivencia alejada se certificó a través del "Servicio Registro Civil e Identificación de Chile". Resultados: En el periodo en estudio, 27 pacientes (21 hombres) tuvieron un reemplazo total de la aorta ascendente tubular con paro circulatorio con hipotermia moderada y PCR. Ocho pacientes tenían una cirugía previa; 7 de estos un reemplazo valvular aórtico. El 75% de los otros 20 pacientes tenía una válvula aórtica bicúspide. El diámetro máximo de la aorta ascendente fue en promedio 53,7 mm (45 a 67), y fue reemplazada en el 52% de los casos con un tubo protésico de 34 mm (promedio:32,4 mm; margen:30 a 34 mm). En 20 pacientes se efectuó un reemplazo valvular aórtico (15 con prótesis biológica). El tiempo promedio de circulación extracorpórea fue 174,6 min (97 a 243) y la temperatura sistémica mínima promedio fue 21ºC (18 a 25). El tiempo promedio de paro circulatorio fue 22,3 min (12 a 40) y de PCR 13 min (6 a 27). No hubo mortalidad operatoria. La morbilidad más frecuente fue la fibrilación auricular (33%). Una paciente presentó un episodio convulsivo aislado y otro fue reoperado por hemorragia postoperatoria. Una paciente falleció a los 48 meses de su operación. Conclusión: El paro circulatorio con hipotermia sistémica moderada y PCR para la cirugía de reemplazo total de la aorta ascendente facilitó la operación, con baja mortalidad y morbilidad en este grupo de pacientes.

Abstract: Background. Neurological damage is a devastating complication of aortic arch and ascending aorta surgery with deep hypothermic circulatory arrest. Antegrade cerebral perfusion significantly decreases the incidence of this complication, but it is a cumbersome procedure that interfere the surgical field. For more simple procedures, requiring a shorter period of circulatory arrest, retrograde cerebral perfusion (RCP) would be a valid alternative. Objective. To evaluate the results of total surgical replacement of the tubular ascending aorta with moderate hypothermic circulatory arrest and retrograde cerebral perfusion (RCP). Methods. Patients operated between January 2015 and January 2020 were included.Demographic, clinical and surgical information was obtained from the operatives notes, perfusion registry and discharge reports. Long-term survival was certified by the "Chilean Civil and Identification Registry". Results. 27 patients (21 men) underwent a total replacement of the tubular ascending aorta with circulatory arrest with moderate hypothermia and RCP. Eight patients had been previously operated on;7 of them had a previous aortic valve replacement. Of the remaining 20 patients, 75% had a bicuspid aortic valve. Average maximum diameter of the ascending aorta was 53.7 mm (45 - 67). Average size of the ascending aorta replacement graft was 32.4 mm (30 -34). In 20 patients a concomitant aortic valve replacement was performed (15 with a biological valve). Mean extracorporeal circulation time was 174.6 min (97 - 243) and mean minimal systemic temperature was 21ºC (18 - 25). Mean circulatory arrest time was 22.3 min (12 - 40) and mean RCP time was 13 min (6 - 27), There was no operative mortality. Atrial fibrillation was the most frequent post-operative morbidity (33%). One patient presented an isolated convulsive episode and another was re-operated due to postoperative hemorrhage. One patient died, 48 months after her operation. Conclusion. Moderate hypothermic circulatory arrest with RCP simplifies total tubular ascending aorta replacement, with low mortality and morbidity.

[Neurological changes and outcomes of paediatric surgery of the aortic arch using selective cerebral perfusion]. / Evolución neurológica y resultados de la cirugía pediátrica del arco aórtico mediante perfusión cerebral selectiva.

INTRODUCTION: The aims of this article are to analyse the neuropsychological changes in the medium-term in children subjected to aortic arch surgery using selective cerebral perfusion (SCP), as well as to detect any modifiable factors in the surgical technique that may contribute to minimising the subsequent neurological involvement. MATERIAL AND METHODS: Inclusion criteria were established as: aortic arch disease operated on using SCP during the first year of life, between 10 August 2004 and 24 May 2016, biventricular physiology, and gestational age greater than 31 weeks. In the absence of a chromosomal disease, they were classified, from a neurological point of view, using the Rankin score. Children over 4-years of age were subjected to intelligence studies, including attention level, development, and psycho-lingual skills. RESULTS: The study included a total of 82 patients with a mean age of 1.8 months. The mean SCP flow was 32ml/kg/min. The mean time of SCP was 31minutes. The overall mortality of the series was 14.8%. Neurological dysfunction was observed in 35.9% of patients, and the following were detected as risk factors: surgery in patients less than 10-days-old, duration of SCP greater than 40minutes, and the time required for the cooling down and/or warming-up. Attention deficit was diagnosed in 35.2% of patients greater than 5-years-old. CONCLUSIONS: Patients operated on using SCP in in the first year of life required a neuropsychological follow-up, and there are modifiable surgical factors that may have an influence on neurological development.

Experimental rat model of chronic cerebral hypoperfusion-reperfusion mimicking normal perfusion pressure breakthrough phenomenon.

BACKGROUND: Normal perfusion pressure breakthrough (NPPB) phenomenon is a major life-threatening complication that restricts the treatment of complex intracranial arteriovenous malformations. The aim of the study it to develop a rat model mimicking NPPB phenomenon that enables the evaluation of any therapy to prevent such complication. METHODS: Twenty Wistar male rats were randomly assigned to either a study or a control group. Study animals underwent an end-to-side left external jugular vein-common carotid artery anastomosis and ligation of bilateral external carotid arteries. Control animals only underwent ligation of bilateral external carotid arteries. All animals were sacrificed sixty days after the procedure. Hemodynamic parameters [mean arterial pressure (MAP), intracranial pressure (ICP) and cerebral perfusion pressure (CPP)], blood-brain barrier (BBB) permeability (measured by fluorescein staining) and histological features were then compared between both groups. RESULTS: A significant decrease in MAP and CPP was confirmed in the study group. An increase in ICP was also observed. A significant decrease in MAP and CPP was also present in the study group when comparing preoperative values with those recorded on days 0 (postoperative), 7 and 60. Fluorescein staining findings were consistent with signs of BBB disruption in study animals. Histological analysis demonstrated an increased number of pyknotic neurons in the ipsilateral hemisphere of rat brains included in the study group. CONCLUSION: These results confirm that this model mimics a vascular steal state with chronic cerebral hypoperfusion comparable to patients with AVMs behavior and disruption of the BBB after fistula closure comparable to NPPB phenomenon disorders.

99mTc-HMPAO brain SPECT in the monitoring of cerebral vasculitis therapy. / 99mTc-HMPAO SPECT cerebral en la monitorización de la terapia de vasculitis.

OBJECTIVE: The central nervous system (CNS) may be involved in a variety of inflammatory diseases of the blood vessels, generally known as vasculitis. The clinical diagnosis of such involvement in early stages is difficult, since a mild cognitive impairment can be the only symptom. It was hypothesized that brain-perfusion SPECT would be able to reveal CNS involvement and to monitor the course of the disease. The purpose of this study was assess if and when an improvement of cerebral perfusion can be registered by SPECT during the follow-up of these diseases. MATERIAL AND METHODS: Eighteen patients affected by Systemic Lupus Erythematosus (SLE), 22 by undifferentiated vasculitis (UV), 5 by Behcet's disease (BD) and 5 by primary Sjogren's Syndrome (pSS) were enrolled in this prospective study. A 99mTc-HMPAO brain perfusion SPECT was performed before the treatment and was repeated during the follow-up at different time intervals. Image analysis was performed on 10 cerebral areas using a specific software. RESULTS: In the SLE patients, no significant improvement of brain perfusion was found. On the contrary, in the UV the cerebral uptake of the tracer significantly improved from the twenty-fourth month (18/22 patients). Patients with BD showed an improvement of scintigraphic findings (5/5 patients), while a similar result was obtained only in 2 of the patients with pSS. CONCLUSIONS: In conclusion, brain SPECT seems to be able to monitor the disease in UV, indicating the moment when an improvement of the cerebral perfusion is achieved. In SLE patients this scintigraphic technique did not show a significant improvement in CNS perfusion.

Cerebral oximetry monitoring in the management of severe hypoxaemia associated with transposition of the great arteries with balloon atrial septostomy. / Monitorización de la oximetría cerebral en el manejo de la hipoxemia severa asociada a la transposición de grandes arterias mediante atrioseptostomía con balón.

Transposition of the great arteries (D-TGA) is one of the most common congenital heart diseases requiring neonatal surgical intervention. In the desperately ill neonate with TGA and the resultant hypoxaemia, acidemia, and congestive heart failure, improvement is often obtained with balloon atrial septostomy (BAS). Current methods employed to evaluate oxygen delivery and tissue consumption are frequently nonspecific. Near infrared spectroscopy (NIRS) allows a continuous non-invasive measurement of tissue oxygenation which reflects perfusion status in real time. Because little is known about the direct effect of BAS on the neonatal brain and on cerebral oxygenation, we measured the effectiveness of BAS in two patients with D-TGA using NIRS before and after BAS. We concluded BAS improves cerebral oxygen saturation in neonates with D-TGA.

Monitorización de la presión intracraneal en traumatismo craneoencefálico severo / Monitoring intracranial pressure in severe traumatic brain injury

Introducción: El traumatismo craneoencefálico severo (TCES) es una entidad grave. La monitorización de la presión intracraneal (PIC) permite dirigir el tratamiento, el cual es de limitado acceso en países en vías de desarrollo. Objetivo: Describir la experiencia clínica de pacientes pediátricos con TCES. Pacientes y método: Se incluyeron pacientes con TCES, edad entre 1 y 17 años, previo consentimiento informado de los padres y/o tutores. Se excluyeron pacientes con enfermedades crónicas o retraso psicomotor. Los pacientes ingresaron desde el Servicio de Urgencia, donde se les realizó scanner cerebral (TAC), clasificándose las lesiones por Escala de Marshall. Los pacientes fueron divididos en 2 grupos según criterio neuroquirúrgico: con monitorización (CM) y sin monitorización (SM) de presión intracraneana. La monitorización de la PIC se realizó a través de un catéter intraparenquimatoso 3PN Spiegelberg conectado a un monitor Spiegelberg HDM 26. Los pacientes fueron tratados de acuerdo a las guías pediátricas para TCES. Se consideró la supervivencia como los días transcurridos entre el ingreso hospitalario y el fallecimiento, o su evaluación por Escala de Glasgow para un seguimiento de 6 meses. Resultados: Cuarenta y dos pacientes (CM = 14 y SM= 28). Aquellos con monitorización tenían menor puntuación de la escala de coma de Glasgow y clasificación de Marshall con peor pronóstico. En ellos la supervivencia fue menor y el resultado moderado a bueno. No se registraron complicaciones con el uso del catéter de PIC. Conclusión: Pacientes con monitorización tuvieron mayor gravedad al ingreso y una mayor mortalidad; sin embargo, el resultado funcional de los sobrevivientes fue de moderado a bueno. Se requiere de la realización de ensayos clínicos aleatorizados para definir el impacto de la monitorización de la PIC en la supervivencia y calidad de vida en estos pacientes.

Introduction: Severe traumatic brain injury (TBI) is a serious condition. Intracranial pressure (ICP) monitoring can be used to direct treatment, which is of limited access in developing countries. Objective: To describe the clinical experience of pediatric patients with severe TBI. Patients and Method: A clinical experience in patients with severe TBI was conducted. Age was 1-17 years, exclusion criteria were chronic illness and psicomotor retardation. Informed consent was obtained in each case. Two groups were formed based on the criterion of neurosurgeons: with and without intracraneal pressure (ICP) monitoring. PIC monitoring was performed through a 3PN Spiegelberg catheter and a Spiegelberg HDM 26 monitor. Patients were treated according international pediatric guides. The characteristics of both groups are described at 6 months of follow-up. Results: Forty-two patients (CM=14 and SM=28). Those in the CM Group had lower Glasgow coma scale score and Marshall classification with poorer prognosis. Among them survival rate was lower, although the outcome was from moderate to good. No complications were reported with the use of the ICP catheter. Conclusion: Patients with ICP monitoring had greater severity at admission and an increased mortality; however, the outcome for the survivors was from moderate to good. It is necessary to conduct randomized clinical trials to define the impact of ICP monitoring on survival and quality of life in severe TBI patients.

[Monitoring intracranial pressure in severe traumatic brain injury]. / Monitorización de la presión intracraneal en traumatismo craneoencefálico severo.

INTRODUCTION: Severe traumatic brain injury (TBI) is a serious condition. Intracranial pressure (ICP) monitoring can be used to direct treatment, which is of limited access in developing countries. OBJECTIVE: To describe the clinical experience of pediatric patients with severe TBI. PATIENTS AND METHOD: A clinical experience in patients with severe TBI was conducted. Age was 1-17 years, exclusion criteria were chronic illness and psicomotor retardation. Informed consent was obtained in each case. Two groups were formed based on the criterion of neurosurgeons: with and without intracraneal pressure (ICP) monitoring. PIC monitoring was performed through a 3PN Spiegelberg catheter and a Spiegelberg HDM 26 monitor. Patients were treated according international pediatric guides. The characteristics of both groups are described at 6 months of follow-up. RESULTS: Forty-two patients (CM=14 and SM=28). Those in the CM Group had lower Glasgow coma scale score and Marshall classification with poorer prognosis. Among them survival rate was lower, although the outcome was from moderate to good. No complications were reported with the use of the ICP catheter. CONCLUSION: Patients with ICP monitoring had greater severity at admission and an increased mortality; however, the outcome for the survivors was from moderate to good. It is necessary to conduct randomized clinical trials to define the impact of ICP monitoring on survival and quality of life in severe TBI patients.

Contribution of brain perfusion SPECT in the diagnosis of a case of cerebral malaria. / Aportación diagnóstica de la SPECT de perfusión cerebral en un caso de malaria cerebral.

Cerebral malaria is a serious complication of infection with Plasmodium falciparum. Its pathophysiological mechanisms and clinical manifestations are still currently being studied. Structural imaging techniques such as CT and MRI provide non-specific information during the diagnostic process. However, there are hardly any references on the use and potential benefits of radioisotope procedures for this pathology. In this article we present the case of a patient diagnosed with cerebral malaria treated in our centre, subjected to progressive monitoring using SPECT perfusion.

Canulación de la arteria innominada para conexión a circulación extracorpórea en cirugía de la aorta / Innominate artery cannulation for aortic artery surgery with extracorporeal circulation

Surgery of the ascending aorta and its arc with extracorporeal circulation require an arterial cannulation that assures and adequate systemic circulation and reduces the risk of neurological complications. A peripheral cannulation such as the femoral artery, a central extra-thoracic approach such as axillary, subclavian or carotid arteries or a central intra-thoracic approach such as aorta and innominate arteries, are valid alternatives. Innominate artery cannulation can be carried out without the need of a second incision. It is an easily accessible and large bore vessel. It allows an anterograde brain and visceral flow. In cases of aortic arch surgery, the clamping of the artery in its origin, allows a selective anterograde brain perfusion. The surgical technique for innominate artery cannulation is herein described.

La cirugía de la aorta ascendente y cayado con circulación extra corpórea requiere de una canulación arterial que permita asegurar una perfusión sistémica adecuada y disminuir las complicaciones neurológicas. El sitio ideal de canulación es aún un tema de discusión entre los cirujanos. Entre las alternativas de abordaje están la canulación periférica (arteria femoral), la canulación central extratorácica (arterias axilar, subclavia o carótidas) y la canulación central intratorácica (aorta, arteria innominada). La canulación de la arteria innominada es una técnica que se puede realizar sin necesidad de una segunda incisión, es un vaso de fácil abordaje y habitualmente de gran calibre. Permite entregar un flujo cerebral y visceral anterógrado y, en caso de cirugía sobre el cayado, el pinzamiento de la arteria a nivel de su origen permite entregar una perfusión cerebral selectiva anterógrada. Se describen la técnica quirúrgica y los reparos operatorios que nos parecen importantes en su realización.

[Regional cerebral blood flow-SPECT "OFF-ON": a case report of catatonia]. / SPECT-perfusión cerebral regional «off-on¼: a propósito de un caso de catatonia.

We report the case of a patient with a long history of dysthymia and major depressive episodes requiring repeated hospitalization. We describe the most recent episode, associated with catatonia symptomatology and features suggestive of cognitive impairment. The absence of a clear initial psychopharmacological response alongside the clinical severity made the patient a potential candidate for electroconvulsive therapy (ECT). A regional cerebral blood flow SPECT (SPECT-rCBF), performed to rule out concomitant Alzheimer disease (AD), revealed a markedly decreased neocortical uptake, with no definitive pattern of concomitant primary cognitive impairment. Because a gradual clinical improvement was observed in the patient, with evidence of enhanced cerebral reperfusion in a second SPECT-rCBF study at two weeks after admission, the application of ECT was discounted and an expectant attitude was adopted.

[Perfusion magnetic resonance imaging for high grade astrocytomas: Can cerebral blood volume, peak height, and percentage of signal intensity recovery distinguish between progression and pseudoprogression?]. / Resonancia magnética de perfusión en astrocitomas de alto grado: el volumen sanguíneo cerebral, la altura del pico y el porcentaje de recuperación de intensidad de señal ¿pueden discriminar entre progresión y seudoprogresión?

OBJECTIVES: To study the usefulness of common MRI perfusion parameters for identifying pseudoprogression in high grade astrocytomas. MATERIAL AND METHODS: This retrospective case-control study compared the relative cerebral blood volume (rCBV), the relative percentage of signal intensity recovery (rPSR), and the relative peak height (rPH) recorded in a sample of 17 cases of anaplastic astrocytomas and gliomas considered to be undergoing pseudoprogression by biopsy or follow-up with those recorded in a sample of histologically similar tumors that were treated and considered to be undergoing progression by histologic study or follow-up. We evaluated the accuracy of these parameters and the correlations among them. Statistical significance was set at P<.05. RESULTS: The rCBV, rPSR, and rPH were significantly different between the two groups (P=.001). The cutoff values rPH=1.37, rCBV=0.9, and rPSR=99% yielded sensitivity (S)=88% and specificity (Sp)=82.2% for rPH, S=100% and Sp=100% for rCBV, and S=100% and Sp=70.6% for rPSR, respectively. We found negative correlations between rPRS and rPH (-0.76) and between rPRS and rCBV (-0.81) and a high positive correlation between rPH and rCBV (0.87). CONCLUSION: The variables rPH and rCBV were useful for differentiating between pseudoprogression and true progression in our sample. The variable rPRS was also very sensitive, although the overlap in the values between samples make it less useful a priori.