Presentation and management of cerebral proliferative angiopathy: a systematic review and meta-analysis on treatment outcomes.

Cerebral Proliferative Angiopathy (CPA) is a rare brain vascular malformation, similar to Arteriovenous Malformations (AVM) but lacking of early venous drainage. Presentation and treatment outcomes were investigated, examining for morbidity, mortality and complications. A meta-analysis was conducted according to PRISMA guidelines. PubMed, Embase and Web Of Science were searched with keywords such as "cerebral proliferative angiopathy" and "management". We pooled and meta-analyzed outcomes on documented CPA cases. 11,079 studies were pooled as a result of manual citation searching, 50 studies were included, adding up to 115 CPA cases. The majority of patients were females (1.38:1), with a mean age of presentation of 26.9 (19.4) years. Headache (46%) and seizures (34%) were the most common presenting symptoms. 37% of patients presented with focal neurologic deficit. Patients managed conservatively from the surgical standpoint (i.e. nonoperative management) did not undergo homogenous treatment strategies, and major complications were at 47% (95% CI: 17%, 76%), with a 1% mortality (95% CI: 0%, 6%). Surgical and embolization interventions presented the highest proportion of major complications, 66% (95% CI: 33%, 99%) and 73% (95% CI: 42%, 100%), respectively. The embolization subgroup led in mortality, with 3% (95% CI: 0%, 10%). No death was documented in patients undergoing surgery. CPA has a similar presentation to brain arteriovenous malformations, but its treatment outcomes are potentially worse. This difference is not attributable to heterogeneity in assigning patient treatment strategies. This highlights the need for more accurate diagnostic methods.

Vasculitis and cerebral hemorrhage due to Streptococcus gordonii infectious endocarditis: A case report.

Infective endocarditis is an infection of the heart with systemic consequences, both infectious and non-infectious. Infective endocarditis can affect several systems, one of which is the central nervous system. The most common form of presentation is ischemic stroke; however, intracranial hemorrhage can occur due to immune-mediated damage to the vessel wall. The former further complicates cardiac surgical procedures when necessary. We present here the case of a 21-year-old male patient, with no personal medical history, who presented with intracranial hemorrhage due to a vasculitis phenomenon, caused by Streptococcus gordonii infective endocarditis. The patient underwent emergency drainage of the intracranial hemorrhage and minimally invasive valve surgery in 17 days, with satisfactory postoperative recovery and follow-up.

The clinical effect of minimally invasive stereotactic puncture intracranial hematoma removal in the treatment of patients with cerebral hemorrhage: a meta-analysis.

OBJECTIVE: The objective of the study was to systemically evaluate the clinical efficacy of minimally invasive stereotactic puncture for intracranial hematoma evacuation in patients with cerebral hemorrhage. MATERIALS AND METHODS: Relevant studies in PubMed, Web of Science, MEDLINE, China National Knowledge Infrastructure, Wanfang, and VIP databases were searched. A meta-analysis was performed following the inclusion and exclusion criteria screening, data extraction, and literature quality evaluation. RESULTS: Fifteen studies involving 1312 patients were included with 673 participants in the experimental group and 639 in the control group. The results of the meta-analysis showed that, compared with traditional craniotomy or treatment, minimally invasive stereotactic puncture intracranial hematoma removal had a higher clinical total effective rate in patients with cerebral hemorrhage, an outcome that could significantly shorten the hospitalization time of patients with cerebral hemorrhage. The level of post-operative activities of daily living was significantly higher, the incidence of postoperative complications was lower, and the mortality rate was lower. However, there was no significant difference in the degree of post-operative neurological deficit. CONCLUSION: Compared with traditional craniotomy or conservative treatment, minimally invasive stereotactic puncture intracranial hematoma removal has a higher clinical efficacy in the treatment of patients with cerebral hemorrhage, which can improve the post-operative daily life and abilities of patients.

OBJETIVO: Evaluación sistemática de la eficacia clínica de la punción estereotáctica mínimamente invasiva para la evacuación de hematomas intracraneales en pacientes con hemorragia cerebral. MATERIAL Y MÉTODOS: Se realizaron búsquedas en estudios relevantes en PubMed, Web of Science, MEDLINE, Infraestructura Nacional de Conocimiento de China, base de datos Wanfang y base de datos VIP. El metanálisis se realizó después de la selección de criterios de inclusión y exclusión, la extracción de datos y la evaluación de la calidad de la literatura. RESULTADOS: Se incluyeron 15 estudios en los que participaron 1.312 sujetos, 673 en el grupo experimental y 639 en el grupo control. En comparación con la Craneotomía tradicional o el tratamiento, el aclaramiento estereotáctico mínimamente invasivo de hematomas intracraneales tiene una alta eficiencia clínica total en pacientes con hemorragia intracerebral y puede acortar significativamente el tiempo de hospitalización de los pacientes con hemorragia intracerebral. El nivel de actividad de la vida diaria postoperatoria (ADL) aumentó significativamente, la incidencia de complicaciones postoperatorias disminuyó y la mortalidad disminuyó. Sin embargo, no hubo diferencia significativa en el grado de déficit neurológico postoperatorio. CONCLUSIÓN: En comparación con la Craneotomía tradicional o el tratamiento conservador, la Craneotomía estereotáctica mínimamente invasiva tiene un mayor efecto clínico en el tratamiento de la hemorragia cerebral y puede mejorar la capacidad de la vida diaria de los pacientes después de la operación.

Intracranial hemorrhages in patients with COVID-19: a systematic review of the literature, regarding six cases in an Amazonian population / Hemorragias intracranianas em pacientes com COVID-19: uma revisão sistemática da literatura, a propósito de seis casos na população amazônica

Abstract Background Coronavirus disease 2019 (COVID-19) has emerged as a public health emergency worldwide, predominantly affecting the respiratory tract. However, evidence supports the involvement of extrapulmonary sites, including reports of intracranial hemorrhages. Objective To describe six original cases and review the literature on intracranial hemorrhages in patients diagnosed with COVID-19 by molecular methods. Methods A systematic literature review was performed on MEDLINE, PubMed, and NCBI electronic databases to identify eligible studies. Of the total 1,624 articles retrieved, only 53 articles met the inclusion criteria. Results The overall incidence of intracranial hemorrhage in patients hospitalized for COVID-19 was 0.26%. In this patient group, the mean age was 60 years, and the majority were male (68%) with initial respiratory symptoms (73%) and some comorbidity. Before the diagnosis of hemorrhage, 43% of patients were using anticoagulants, 47.3% at therapeutic doses. The intraparenchymal (50%) was the most affected compartment, followed by the subarachnoid (34%), intraventricular (11%), and subdural (7%). There was a predominance of lobar over non-lobar topographies. Multifocal or multicompartmental hemorrhages were described in 25% of cases. Overall mortality in the cohort studies was 44%, while around 55% of patients were discharged from hospital. Conclusion Despite the unusual association, the combination of these two diseases is associated with high rates of mortality and morbidity, as well as more severe clinicoradiological presentations. Further studies are needed to provide robust evidence on the exact pathophysiology behind the occurrence of intracranial hemorrhages after COVID-19 infection.

Resumo Antecedentes A COVID-19 emergiu como uma emergência de saúde pública em todo o mundo, proporcionando lesão principalmente do trato respiratório. No entanto, várias evidências apontam para acometimento de sítios extrapulmonares, incluindo relatos de hemorragias intracranianas. Objetivo Descrever seis casos originais e revisar a literatura sobre hemorragias intracranianas em pacientes com diagnostico de COVID-19 por métodos moleculares. Métodos A revisão sistemática da literatura foi feita nas bases de dados eletrônicas da MEDLINE, PubMed e NCBI para identificar os estudos elegíveis. Do total de 1.624 artigos recuperados, apenas 53 artigos preencheram os critérios de inclusão. Resultados A incidência geral de hemorragia intracraniana nos pacientes internados por COVID-19 foi de 0,26%. A média de idade foi de 60 anos, e a maioria dos pacientes era do sexo masculino (68%) com sintomas respiratórios iniciais (73%) e alguma comorbidade. Antes do diagnóstico de hemorragia, 43% estavam em uso de anticoagulantes, 47,3% destes em doses terapêuticas. O compartimento mais acometido foi o intraparenquimatoso (50%), seguido do subaracnoideo (34%), intraventricular (11%) e subdural (7%). Houve predomínio de topografias lobares sobre as não-lobares. Hemorragias multifocais ou multicompartimentais foram descritas em 25% dos casos. A mortalidade geral nos estudos de coorte foi de 44%, enquanto houve alta hospitalar em cerca de 55% dos pacientes. Conclusão Apesar da associação incomum, a combinação dessas doenças está relacionada com altas taxas de mortalidade e morbidade, bem como apresentações clínico-radiológicas mais graves. Mais estudos são necessários para oferecer evidências robustas sobre a fisiopatologia exata por trás da ocorrência de hemorragias intracranianas após infecção por COVID-19.

Common Mutation in the HFE Gene Modifies Recovery After Intracerebral Hemorrhage.

BACKGROUND: Intracerebral hemorrhage (ICH) is characterized by bleeding into the brain parenchyma. During an ICH, iron released from the breakdown of hemoglobin creates a cytotoxic environment in the brain through increased oxidative stress. Interestingly, the loss of iron homeostasis is associated with the pathological process of other neurological diseases. However, we have previously shown that the H63D mutation in the homeostatic iron regulatory (HFE) gene, prevalent in 28% of the White population in the United States, acts as a disease modifier by limiting oxidative stress. The following study aims to examine the effects of the murine homolog, H67D HFE, on ICH. METHODS: An autologous blood infusion model was utilized to create an ICH in the right striatum of H67D and wild-type mice. The motor recovery of each animal was assessed by rotarod. Neurodegeneration was measured using fluorojade-B and mitochondrial damage was assessed by immunofluorescent numbers of CytC+ (cytochrome C) neurons and CytC+ astrocytes. Finally, the molecular antioxidant response to ICH was quantified by measuring Nrf2 (nuclear factor-erythroid 2 related factor), GPX4 (glutathione peroxidase 4), and FTH1 (H-ferritin) levels in the ICH-affected and nonaffected hemispheres via immunoblotting. RESULTS: At 3 days post-ICH, H67D mice demonstrated enhanced performance on rotarod compared with wild-type animals despite no differences in lesion size. Additionally, H67D mice displayed higher levels of Nrf2, GPX4, and FTH1 in the ICH-affected hemisphere; however, these levels were not different in the contralateral, non-ICH-affected hemisphere. Furthermore, H67D mice showed decreased degenerated neurons, CytC+ Neurons, and CytC+ astrocytes in the perihematomal area. CONCLUSIONS: Our data suggest that the H67D mutation induces a robust antioxidant response 3 days following ICH through Nrf2, GPX4, and FTH1 activation. This activation could explain the decrease in degenerated neurons, CytC+ neurons, and CytC+ astrocytes in the perihematomal region, leading to the improved motor recovery. Based on this study, further investigation into the mechanisms of this neuroprotective response and the effects of the H63D HFE mutation in a population of patients with ICH is warranted.

Hemorrhagic Cerebrovascular Disease: An Unusual Presentation of Hyperhomocysteinemia / Accidente cerebrovascular hemorrágico: una inusual presentación de hiperhomocisteinemia / Acidente vascular cerebral hemorrágico: uma apresentação incomum da hiper-homocisteinemia

Introduction: Stroke is a major cause of morbidity and mortality worldwide, with hemorrhagic stroke being the deadliest form of acute stroke. Therefore, the cause of the event should be determined to direct the associated therapy and take preventive measures. Hyperhomocysteinemia has been described as a rare etiology of stroke. Although hyperhomocysteinemia has been associated with venous thrombotic events, altered endothelial function, and procoagulant states, its clinical role in stroke remains controversial. Case description: We present a case of a 60-year-old male patient with primary autoimmune hypothyroidism who presented with dysarthria, facial paresis, and left upper-limb monoparesis after sexual intercourse. A simple skull computed tomography scan showed hyperintensity in the right basal ganglion, indicating an acute hemorrhagic event. Etiological studies were performed, including ambulatory blood pressure monitoring, cerebral angiography, and transthoracic echocardiogram, which ruled out underlying vascular pathology. During follow-up, vitamin B12 deficiency and hyperhomocysteinemia were detected, without other blood biochemical profile alterations. Supplementation was initiated, and homocysteine levels gradually decreased, without new neurological deficits observed during follow-up. Conclusion: Quantification of homocysteine should be considered in patients with a cerebrovascular disease without apparent cause, as documenting hyperhomocysteinemia and correcting its underlying etiology are essential not only for providing appropriate management but also for preventing future events.

Introducción: el accidente cerebrovascular es una causa importante de morbilidad y mortalidad en todo el mundo, y el accidente cerebrovascular hemorrágico es la forma más mortífera de accidente cerebro- vascular agudo. La determinación de la causa del evento es esencial para dirigir la terapia asociada y poder tomar medidas preventivas. La hiperhomocisteinemia se ha descrito como una etiología poco frecuente de accidente cerebrovascular. Aunque esta se ha asociado con eventos trombóticos venosos, disfunción endotelial alterada y estados procoagulantes, sigue siendo controvertido su papel clínico en el accidente cerebrovascular. Descripción del caso: se presenta el caso de un hombre de 60 años con hipotiroidismo autoinmune primario que presentó disartria, paresia facial y monoparesia del miembro superior izquierdo después de un encuentro sexual. Una simple tomografía computarizada de cráneo mostró hipointensidad en la región del ganglio basal derecho, que indicaba un evento hemorrágico agudo. Se realizaron estudios etiológicos, incluyendo monitorización ambulatoria de la presión arterial, angiografía cerebral y ecocardiograma transtorácico, que descartaron patología vascular subyacente. Durante el seguimiento, se detectó deficiencia de vitamina B12 e hiperhomocisteinemia, sin otras alteraciones en el perfil bioquímico sanguíneo. Se inició la suplementación y los niveles de homocisteína disminuyeron gradualmente, sin observar nuevos déficits neurológicos durante el seguimiento. Conclusión: la cuantificación de homocisteína debe ser considerada en casos de enfermedad cerebrovascular sin causa aparente, dado que documentar la hiperhomocisteinemia y corregir su etiología subyacente es esencial no solo para proporcionar un manejo adecuado, sino también para prevenir eventos futuros.

Introdução: o acidente vascular cerebral (AVC) é uma das principais causas de morbidade e mortalidade em todo o mundo, sendo o AVC hemorrágico a forma mais letal de AVC agudo. A determinação da causa do evento é essencial para direcionar a terapia associada e poder tomar medidas preventivas. A hiperhomocisteinemia tem sido descrita como uma etiologia rara de acidente vascular cerebral. Embora a hiper-homocisteinemia tenha sido associada a eventos trombóticos venosos, disfunção endotelial alterada e estados pró-coagulantes, seu papel clínico no AVC permanece controverso. Descrição do caso: apresentamos o caso de um homem de 60 anos com hipotireoidismo autoimune primário que apresentou disartria, paresia facial e monoparesia do membro superior esquerdo após relação sexual. A tomografia computadorizada de crânio mostrou hipointensidade na região do gânglio da base direito, indicando evento hemorrágico agudo. Foram realizados estudos etiológicos, incluindo monitorização ambulatorial da pressão arterial, angiografia cerebral e ecocardiograma transtorácico, que descartaram patologia vascular subjacente. Durante o acompanhamento, foram detectados deficiência de vitamina B12 e hiper-homocistei- nemia, sem outras alterações no perfil bioquímico sanguíneo. A suplementação foi iniciada e os níveis de homocisteína diminuíram gradualmente, sem novos déficits neurológicos observados durante o acompanhamento. Conclusão: a quantificação da homocisteína deve ser considerada em casos de doença vascular cerebral sem causa aparente, pois documentar a hiper-homocisteinemia e corrigir sua etiologia subjacente é essencial não apenas para fornecer manejo adequado, mas também para prevenir eventos futuros.

The Impact of Intraventricular Hemorrhage and Periventricular Leukomalacia on Mortality and Neurodevelopmental Outcome in Very Preterm and Very Low Birthweight Infants: A Prospective Population-based Cohort Study.

OBJECTIVE: To survey the incidence of intraventricular hemorrhage (IVH) and periventricular leukomalacia (PVL) by gestational age and to report the impact on mortality and neurodevelopmental outcome in very preterm/very low birthweight infants. STUDY DESIGN: This was a population-based cohort study of 1927 very preterm/very low birthweight infants born in 2014-2016 and admitted to Flemish neonatal intensive care units. Infants underwent standard follow-up assessment until 2 years corrected age with the Bayley Scales of Infant and Toddler Development and neurological assessments. RESULTS: No brain lesion was present in 31% of infants born at <26 weeks of gestation and 75.8% in infants born at 29-32 weeks of gestation. The prevalence of low-grade IVH/PVL (grades I and II) was 16.8% and 12.7%, respectively. Low-grade IVH/PVL was not related significantly to an increased likelihood of mortality, motor delay, or cognitive delay, except for PVL grade II, which was associated with a 4-fold increase in developing cerebral palsy (OR, 4.1; 95% CI, 1.2-14.6). High-grade lesions (III-IV) were present in 22.0% of the infants born at <26 weeks of gestational and 3.1% at 29-32 weeks of gestation, and the odds of death were ≥14.0 (IVH: OR, 14.0; 95% CI, 9.0-21.9; PVL: OR, 14.1; 95% CI, 6.6-29.9). PVL grades III-IV showed an increased odds of 17.2 for motor delay and 12.3 for cerebral palsy, but were not found to be associated significantly with cognitive delay (OR, 2.9; 95% CI, 0.5-17.5; P = .24). CONCLUSIONS: Both the prevalence and severity of IVH/PVL decreased significantly with advancing gestational age. More than 75% of all infants with low grades of IVH/PVL showed normal motor and cognitive outcome at 2 years corrected age. High-grade PVL/IVH has become less common and is associated with adverse outcomes.

Hipernatremia en pacientes con estado crítico por afecciones neurológicas

Fundamento: los trastornos del sodio son los más comunes y menos entendidos en pacientes con lesión cerebral aguda debido al papel principal que desempeña el sistema nervioso central en la regulación de la homeostasis del sodio y agua lo que puede llevar a complicaciones graves y resultados adversos, incluyendo la muerte. Objetivo: determinar la contribución a la mortalidad de la hipernatremia en pacientes con estado crítico por afecciones neurológicas. Métodos: estudio observacional analítico sobre 55 pacientes que ingresaron en las unidades de atención al grave del Hospital Universitario Arnaldo Milián Castro, entre octubre del 2020 y mayo del 2022, con independencia del valor del sodio plasmático a su admisión en el servicio, así como durante su estadía en las unidades de atención al grave. Se emplearon métodos estadísticos univariados y bivariados en el análisis de los datos. Resultados: el promedio de edad fue de 60±16 años. Los diagnósticos más relevantes fueron la hemorragia intraparenquimatosa (56,37 %), el trauma craneoencefálico y el accidente cerebrovascular isquémico (ambos 30 %). Las concentraciones plasmáticas de sodio mostraron diferencias significativas (pX2= 0,000), siendo la media mayor a las 24 horas de ingreso (174,2±133,6) y la menor al 5to día (102,9±72,9). Existió correlación significativa entre las concentraciones plasmáticas de sodio al ingreso ( 24 h y 72 h) y el estado al egreso. En el análisis bivariado individual por período, solo a las 24 horas hubo relación significativa, en este periodo la hipernatremia contribuyó a la mortalidad en 1,78 veces más que en aquellos que no tenían el sodio elevado (OR=1,78 con IC: 1,39-3,4). Conclusiones: la hipernatremia en el paciente con estado crítico por afecciones neurológicas se asocia con incremento de la mortalidad.

Background: sodium disorders are the most common and least understood in patients with acute brain injury due to the major role played by the central nervous system in regulating sodium and water homeostasis, which can lead to serious complications and adverse outcomes, including death. Objective: to determine the hypernatremia contribution to mortality in patients with neurological conditions in critical state. Methods: longitudinal analytical observational study on 55 patients who were admitted to the acute care units at the Arnaldo Milián Castro University Hospital, between October 2020 and May 2022, regardless of the plasma sodium value upon admission to the service, as well as during their stay in the critical care units. Univariate and bivariate statistical methods were used in data analysis. Results: the average age was 60 ± 16 years. The most relevant diagnoses were intraparenchymal hemorrhage (56.37%), head trauma, and ischemic stroke (both 30%). Plasma sodium concentrations showed significant differences (pX2= 0.000), with the highest average at 24 hours of admission (174.2 ± 133.6) and the lowest at the 5th day (102.9 ± 72.9). There was a significant correlation between plasma sodium concentrations at admission, 24h and 72h with the state at discharge. In the individual bivariate analysis by period, there was only a significant relationship after 24 hours. In this period, hypernatremia contributed 1.78 times more to mortality than in those who did not have elevated sodium (OR=1.78 with CI: 1,39-3,4). Conclusions: hypernatremia in critically ill patients with neurological conditions is associated with increased mortality.

Acute kidney injury in neurocritical patients: a retrospective cohort study.

BACKGROUND /OBJECTIVE: Acute kidney injury (AKI) is a significant complication in critical care units (CCU). Non-neurological complications such as AKI are an independent predictor of poor clinical outcomes, with an increase in morbidity and mortality, financial costs, and worse functional recovery. This work aims to estimate the incidence of AKI and evaluate the risk factors and complications of AKI in neurocritical patients hospitalized in the CCU. METHODS: A retrospective cohort study was conducted. Patients admitted to the neurocritical care unit between 2016 and 2018 with a stay longer than 48 h were retrospectively analyzed in regard to the incidence, risk factors, and outcomes of AKI. RESULTS: The study population comprised 213 neurocritical patients. The incidence of AKI was 23.5%, with 58% KDIGO 1 and 2% requiring renal replacement therapy. AKI was an independent predictor of prolonged use of mechanical ventilation, cerebral edema, and mortality. Cerebral edema [OR 4.40 (95% CI 1.98-9.75) p < 0.001] and a change in chloride levels greater than 4 mmol/L at 48 h (OR 2.44 (95% CI 1.10-5.37) p = 0.027) were risk factors for developing AKI in the first 14 days of hospitalization. CONCLUSION: There is a high incidence of AKI in neurocritical patients; it is associated with worse clinical outcomes regardless of the CCU admission etiology or AKI severity.

Awake craniotomy removal of a corticospinal tract developmental venous anomaly hemorrhage: A case report.

Developmental venous anomalies (DVAs) are composed of mature venous vessels that lack malformed or neoplastic elements. Although the hemorrhage risk is considered negligible, some patients may have neurological symptoms attributable to acute infarction or intracranial hemorrhage secondary to thrombosis, in the absence of a coexisting cavernous malformation. We report the case of a 42-year-old patient who presented with acute left-hand paresis secondary to a subcortical hemorrhage. This bleeding originated from a DVA in the corticospinal tract area and was surgically drained through an awake craniotomy. To accomplish this, we used a trans-precentral sulcus approach. After the complete removal of the coagulum, small venous channels appeared, which were coagulated. No associated cavernoma was found. Although the main DVA trunk was left patent, no signs of ischemia or venous infarction were observed after coagulating the small venous channels found inside the hematoma cavity. Two weeks after the procedure, the patient's hand function improved, and he was able to resume desktop work. DVA-associated hemorrhage within the cortico-spinal tract could be safely removed with modern awake mapping techniques. This technique allowed the patient to rapidly improve his hand function.

Hematoma cerebral intraparenquimatoso e intraventricular por cocaína: reporte de un caso

Introducción: La cocaína es una de las sustancias psicoactivas más consumidas mundialmente. Es altamente adictiva y puede producir cuadros graves por su consumo, esporádico o habitual o, por su abstinencia, a nivel sistémico y neurológico. La exposición aguda a esta sustancia desencadena manifestaciones psiquiátricas inmediatas, como cambios en el afecto o conducta: sensación de irritabilidad, hiperactividad, ansiedad, desasosiego, euforia o psicosis. Esta sintomatología contrasta con inducción en ciertos casos de depresión, aislamiento o tristeza con la cronificación en su consumo. Además de los diversos efectos sensoperceptuales descritos, la sustancia puede generar daños neurológicos y/o cardiovasculares graves, como trastornos del ritmo cardíaco, arritmias malignas, emergencias hipertensivas, síndromes coronarios y enfermedades cerebrovasculares. Métodos: Presentamos el caso de un paciente quien ingresó al Hospital Universitario del Valle, en la ciudad de Santiago de Cali, departamento del Valle del Cauca, en Colombia, por un cuadro neurológico que permitía sospechar origen central. Este paciente no tenía factores de riesgo cardiovasculares, pero sí antecedentes de síndrome de Guillain Barré y de consumo de cocaína desde su adolescencia. Resultados: Al mencionado paciente se le realizaron múltiples estudios, destacándose los imagenológicos (tomografía, resonancia y angiorresonancia magnética de cerebro) y la estrategia invasiva de angiografía cerebral, en la cual logró documentarse que las manifestaciones neurológicas del paciente obedecían a una enfermedad cerebrovascular hemorrágica severa secundaria al consumo de cocaína. Conclusiones: Siempre indagar en pacientes con sangrados intraparenquimatosos el consumo de psicoactivos, en especial la cocaína, por su efecto lesivo sobre la vasculatura cerebral.

Introduction: Cocaine is one of the most widely consumed psychoactive substances worldwide. It is highly addictive and can produce serious systemic and neurological symptoms due to sporadic or habitual use or withdrawal. Acute exposure to this substance triggers immediate psychiatric manifestations such as changes in affect or behavior: feelings of irritability, hyperactivity, anxiety, restlessness, euphoria or psychosis; this symptomatology contrasts with induction in certain cases of depression, isolation or sadness with the chronification of its consumption. In addition to the various sensory-perceptual effects described, the substance can cause serious neurological and/or cardiovascular damage, such as heart rhythm disorders, malignant arrhythmias, hypertensive emergencies, coronary syndromes and cerebrovascular diseases. Methods: We present the case of a patient who was admitted to the Hospital Universitario del Valle, in the city of Santiago de Cali, department of Valle del Cauca, in Colombia, for a neurological condition that suggested a central origin. This patient had no cardiovascular risk factors, but had a history of Guillain Barré syndrome and cocaine use since adolescence. Results: The aforementioned patient underwent multiple studies, highlighting the imaging studies (CT, MRI and MRA of the brain) and the invasive strategy of cerebral angiography, in which it was possible to document that the patient's neurological manifestations were due to severe hemorrhagic cerebrovascular disease secondary to cocaine consumption. Conclusions: Always inquire in patients with intraparenchymal bleeds the consumption of psychoactives, especially cocaine, for its injurious effects on the cerebral vasculature.

Cerebrovascular mortality: trend and seasonality in Brazilian capitals, 2000-2019 / Mortalidade cerebrovascular: tendência e sazonalidade nas capitais brasileiras, 2000-2019

ABSTRACT OBJECTIVE To evaluate the trend and seasonality of cerebrovascular mortality rates in the adult population of Brazilian capitals from 2000 to 2019. METHODS This is an ecological and descriptive study of a time series of mortality due to cerebrovascular causes in adults (≥ 18 years) living in Brazilian capitals from 2000 to 2019, based on the Brazilian Mortality Information System. Descriptive statistical techniques were applied in the exploratory analysis of data and in the summary of specific, standardized rates and ratios by sociodemographic characteristics. The jointpoint regression model was used to estimate the trend of cerebrovascular mortality rates by gender, age groups, and geographic regions. The seasonal variability of rates by geographic regions was estimated using the generalized additive model by smoothing cubic splines. RESULTS People aged over 60 years comprised 77% of all cerebrovascular deaths. Women (52%), white individuals (47%), single people (59%), and those with low schooling (57%, elementary school) predominated in our sample. Recife (20/1,000 inhab.) and Vitória (16/1,000 inhab.) showed the highest crude mortality rates. Recife (49/10,000 inhab.) and Palmas (47/10,000 inhab.) prevailed after we applied standardized rates. Cerebrovascular mortality rates in Brazil show a favorable declining trend for adults of all genders. Seasonality influenced rate increase from July to August in almost all region capitals, except in the North, which rose in March, April, and May. CONCLUSIONS Deaths due to cerebrovascular causes prevailed in older single adults with low schooling. The trend showed a tendency to decline and winter, the greatest risk. Regional differences can support decision-makers in implementing public policies to reduce cerebrovascular mortality.

RESUMO OBJETIVO Avaliar a tendência e a sazonalidade das taxas de mortalidade cerebrovascular na população adulta das capitais brasileiras de 2000 a 2019. MÉTODOS Estudo ecológico e descritivo de séries temporais de mortalidade por causas cerebrovasculares em adultos (≥ 18 anos) residentes nas capitais do Brasil no período 2000-2019, obtidas do Sistema de Informações sobre Mortalidade. Técnicas de estatística descritiva foram aplicadas na análise exploratória dos dados e no resumo de taxas específicas, padronizadas e razões por características sociodemográficas. A regressão de pontos de junção (jointpoint regression model) estimou a tendência das taxas de mortalidade cerebrovascular por sexo, grupos etários e regiões geográficas. A variabilidade sazonal por regiões geográficas das taxas foi estimada utilizando o modelo aditivo generalizado por meio de splines de suavização cúbica. RESULTADOS As pessoas maiores de 60 anos representaram 77% dos óbitos cerebrovasculares. Predominaram o sexo feminino (52%), a raça branca (47%), os solteiros (59%) e a baixa escolaridade (57%, ensino fundamental). As capitais Recife (20/1.000 hab.) e Vitória (16/1.000 hab.) apresentaram as maiores taxas brutas de mortalidade. Aplicando as taxas padronizadas Recife (49/10.000 hab.) e Palmas (47/10.000 hab.) prevaleceram. As taxas de mortalidade cerebrovascular no Brasil apresentam uma tendência favorável ao declínio em ambos os sexos e em adultos. A sazonalidade mostrou influenciar na elevação das taxas entre os meses de julho a agosto em quase todas as capitais das regiões, exceto na Norte, que se elevaram nos meses de março, abril e maio. CONCLUSÕES Os óbitos por causa cerebrovascular prevaleceram em pessoas idosas, solteiras e com baixa escolaridade. A tendência foi favorável ao declínio, sendo o inverno o período de maior risco. As diferenças regionais permitem subsidiar os tomadores de decisões em relação à implementação de políticas públicas para reduzir a mortalidade cerebrovascular.

Basal Ganglia Traumatic Hematoma: Case Series and Literature Review / Hematoma traumático em gânglios da base: Série de casos e revisão da literatura

Introduction Basal ganglia traumatic hematoma (BGTH) is rare, occurring in 3% of closed traumatic brain injuries, and it is associated with a poor prognosis. In the present paper, the authors present a series of 16 BGTH cases, describing their causes, treatment, and results. Patients and Methods Thisis a retrospective study of 16 patients diagnosed with BGTH, associated with a literature review in the PubMed, ScienceDirect, and Google Scholar databases, using the terms craniocerebral trauma AND basal ganglia and basal ganglia AND hematoma AND trauma. Articles published in the period from 1986 to 2019 were selected, resulting in a total of 19 articles that met the inclusion criteria taking into account their citations and their respective impacts. Results Sixteen patients were studied. They were all male, with an average age of 21 years and 5 months. The main cause of BGTH was traffic accident (12). The mean score in the Glasgow coma scale at admission was 8. All patients underwent a computed tomography (CT) scan of the skull. The putamen was the most affected structure (5). Thirteen patients underwent conservative treatment, and three drained the associated intracranial hematoma. Nine patients died, and seven, and four had neurological sequel. Conclusions The neurosurgeon's knowledge of GBTH, including diagnosis and clinical surgical management, is extremely important, as this type of lesion is associated with a poor prognosis.

Introdução O hematoma traumático dos gânglios da base (HTGB) é raro, ocorrendo em 3% dos traumatismos cranioencefálicos fechados, estando associado a mau prognóstico. Neste artigo, os autores apresentam uma série de 16 casos de HTGB, descrevendo suas causas, tratamento e resultados. Pacientes e métodos Estudo retrospectivo de 16 pacientes com diagnóstico de HTGB, associado a uma revisão de literatura nas bases de dados PubMed, ScienceDirect e Google Scholar, utilizando os termos: "Craniocerebral Trauma" AND "Basal Ganglia" and "Basal Ganglia"AND "Hematoma"AND "Trauma." Foram selecionados artigos com período de 1986 a 2019, resultando em um total de 19 artigos que atenderam aos critérios de inclusão levando em consideração suas citações e seus respectivos impactos. Resultados Dos 16 pacientes foram estudados, todos do sexo masculino e com idade média de 21 anos e 5 meses. A principal causa de HTGB foi acidente de trânsito (12). A pontuação média na escala de coma de Glasgow na admissão foi de 8. Todos foram submetidos a uma tomografia computadorizada do crânio. Putamen foi o mais afetado (5). Treze pacientes foram submetidos a tratamento conservador e três apresentaram o hematoma intracraniano associado. Nove pacientes morreram e sete, e quatro tiveram sequelas neurológicas. Conclusões O conhecimento dos neurocirurgiões sobre HTGB, diagnóstico e manejo clínico cirúrgico é de extrema importância, pois está associado a um mau prognóstico.

Cuidados de enfermería para reducir el riesgo de hemorragia en pacientes con trombolisis por ICTUS isquémico

Objetivo: Describir las intervenciones de enfermería en pacientes con trombolisis en ictus isquémico para reducir el riesgo de hemorragia. Metodología: Investigación secundaria, revisión; integrativa. Se realizó una pregunta con la estrategia PICO: ¿Cuáles son las intervenciones de enfermería en pacientes con trombolisis en ictus isquémico para reducir el riesgo de hemorragia antes, durante y después de trombolizar al paciente? Se construyó una ecuación de búsqueda utilizando booleanos, DeCS/MeSH para facilitar la búsqueda en bases de datos. Los artículos encontrados fueron leídos críticamente y clasificados por nivel de evidencia y grados de recomendación. Estudio sin riesgo ético por ser de tipo documental. Se respetaron los derechos de autor de acuerdo con la Ley 44 de 1993. Resultados: Con las 14 unidades de análisis finales fueron construidos 3 dominios que realzan la importancia de los conocimientos y el actuar del personal de enfermería en la reducción del riesgo de hemorragia en pacientes con ictus isquémico. Dichos dominios son: 1) control y monitorización de la tensión arterial; principal cuidado de enfermería antes, durante y después de la trombolisis, 2) terapia combinada; disminución de riesgos hemorrágicos - aumento de la ventana terapéutica, 3) dosificación segura de alteplasa en situaciones contraindicadas. Conclusiones: La intervención de enfermería más significativa durante esta terapia es la monitorización y control de las cifras tensionales, debido a que su aumento mayor a 185/110 mmHg es el factor de riesgo más significativo en la aparición de hemorragias.

Objective: Describe nursing interventions in patients with thrombolysis in ischemic stroke to reduce the risk of bleeding. Methodology: Secondary research, type of review; integrative. A question was asked with the PICO strategy: What are the nursing interventions in patients with thrombolysis in ischemic stroke to reduce the risk of bleeding before, during, and after thrombolyzing the patient? A search equation was constructed using Boolean, DeCS / MeSH to facilitate database searching. The articles were critically read and classified by level of evidence and degrees of recommendation. Study without ethical risk because it is documentary type, copyright was respected according to Law 44 of 1993. Results: With the 14 final analysis units, 3 domains were constructed that highlight the importance of knowledge and the actions of the nursing staff in reducing the risk of bleeding in patients with ischemic stroke. These domains are: 1) control and monitoring of blood pressure; main nursing care before, during, and after thrombolysis, 2) combined therapy; decreased bleeding risks - increased therapeutic window, 3) safe dosage of alteplase in contraindicated situations. Conclusions: The most significant nursing intervention during this therapy is the monitoring and control of blood pressure figures, since and increase larger than 185/110 mmHg is the most significant risk factor in the appearance of bleeding.

Anticoagulation and Stroke / Anticoagulação e AVC

Abstract In 2019, the American Heart Association did not recommend the emergent use of anticoagulation to prevent recurrence or progression of acute ischemic stroke. However, its indication in patients with extracranial artery intraluminal thrombus with artery-to-artery cerebral embolization must be analyzed. In this article, we will also discuss other indications of anticoagulation. This treatment could be indicated in patients with ischemic stroke caused by embolization from cervical artery dissection, catastrophic antiphospholipid antibodies syndrome (APS) and some cases of Covid 19. For secondary prevention, anticoagulation is recommended for Cardioembolic stroke such as nonvalvular atrial fibrillation and other cardiopathies, some patients with cervical artery dissection, stroke associated with cancer, and thrombophilia such as APS. The timing to restart anticoagulation after a large ischemic stroke or after a cerebral hemorrhagic transformation always represent a challenge. Even in patients with high risk of thromboembolism it should be delayed at least two weeks, ideal after four weeks.

Resumo Anticoagulação na fase aguda do acidente vascular isquêmico (AVCI) ainda é um tema bastante controverso. Em 2019, a American Heart Association (AHA) não recomendou o uso precoce da anticoagulação para evitar a progressão ou recorrência de AVCIs de grandes artérias. Mas sugere que a anticoagulação em pacientes com AVCI por embolização a partir de trombos intraluminais aderidos a parede de vasos extracranianos fosse analisada. Tanto a antiagregação como anticoagulação são opções terapêuticas nos casos de AVCI por dissecção arterial cervical. Mas em pacientes com AVCI por mecanismo de embolização, a anticoagulação poderia ser indicada. Pacientes com AVCI e sindrome catastrófica por anticorpos antifosfolípides devem ser anticoagulados além de receber tratamento específico. Outra indicação seriam casos de trombofilia como Covid 19. Nesse artigo de revisão será discutida a prevenção secundária de AVCI em situações específicas (AVCI cardioembólico em pacientes com fibrilação atrial não valvular ou outras cardiopatias, AVCI em casos oncológicos, além de outras trombofilias), além do período ideal para se introduzir ou reiniciar a anticoagulação após transformação hemorrágica.

Predictores de mortalidad intrahospitalaria y de mal pronóstico funcional en pacientes sometidos a evacuación quirúrgica de hemorragia intracerebral / Predictors of in-hospital mortality and poor functional outcomes in patients who underwent surgical evacuation of intracerebral hemorrhage

RESUMEN Objetivo : Determinar predictores de mortalidad intrahospitalaria y mal pronóstico funcional en pacientes sometidos a cirugía por hemorragia intracerebral. Materiales y métodos : Se analizaron las historias clínicas, reportes operatorios y tomografías cerebrales de pacientes con hemorragia intracerebral desde marzo 2018 hasta marzo de 2020. Se realizó un análisis de regresión logística univariado y multivariado para determinar predictores independientes de mortalidad intrahospitalaria y mal pronóstico funcional al alta. Resultados : La mortalidad intrahospitalaria fue de 33,7 % (n = 31 pacientes). Predictores independientes de mortalidad fueron el sexo femenino (OR = 3.01; p = 0.031) y un Glasgow < 8 puntos al ingreso (OR = 3.19; p = 0.031). Un mal pronóstico funcional luego de la intervención se encontró en 77 pacientes (83,7 %). Predictores independientes de mal pronóstico funcional fueron una Escala de Rankin modificada > 3 (OR = 15.5; p = 0.01) y déficit motor pre-operatorio (OR = 8.95; p = 0.042). Conclusiones : En pacientes con diagnóstico de hemorragia intracerebral tratados con cirugía se encontró una alta mortalidad y morbilidad. El sexo femenino y factores clínicos como el estado de conciencia y el estado funcional al ingreso fueron predictores independientes de mortalidad intrahospitalaria y mal pronóstico funcional.

ABSTRACT Objective : To determine predictors of in-hospital mortality and poor functional prognosis in patients undergoing surgery for intracerebral hemorrhage. Materials and Methods : Clinical records, operative reports, and cerebral CT scans of patients with intracerebral hemorrhage from March 2018 to March 2020 were analyzed. Univariate and multivariate logistic regression analyses were performed for determining independent predictors of in-hospital mortality and poor functional prognosis at discharge. Results : In-hospital mortality was 33.7% (n= 31 patients). Independent predictors for mortality were female sex (OR= 3.01, p= 0.031) and Glasgow score <8 on admission (OR= 3.19, p= 0.031). A poor functional prognosis after the intervention was found in 77 patients (83.7%). Independent risk factors for a poor functional prognosis were score >3 in the modified Rankin scale (OR= 15.5; p= 0.01), and preoperative motor deficit (OR= 8.95; p= 0.042). Conclusions : In patients with intracerebral hemorrhage who were surgically treated, high morbidity and mortality rates were found. Female sex and clinical factors, such as consciousness condition and functional status on admission were independent predictors for in-hospital mortality and poor functional prognosis.

Acute Kidney Injury at the Neurocritical Care Unit.

Neurocritical care has advanced substantially in recent decades, allowing doctors to treat patients with more complicated conditions who require a multidisciplinary approach to achieve better clinical outcomes. In neurocritical patients, nonneurological complications such as acute kidney injury (AKI) are independent predictors of worse clinical outcomes. Different research groups have reported an AKI incidence of 11.6% and an incidence of stage 3 AKI, according to the Kidney Disease: Improving Global Outcomes, that requires dialysis of 3% to 12% in neurocritical patients. These patients tend to be younger, have less comorbidity, and have a different risk profile, given the diagnostic and therapeutic procedures they undergo. Trauma-induced AKI, sepsis, sympathetic overstimulation, tubular epitheliopathy, hyperchloremia, use of nephrotoxic drugs, and renal hypoperfusion are some of the causes of AKI in neurocritical patients. AKI is the result of a sum of events, although the mechanisms underlying many of them remain uncertain; however, two important causes that merit mention are direct alteration of the physiological brain-kidney connection and exposure to injury as a result of the specific medical management and well-established therapies that neurocritical patients are subjected to. This review will focus on AKI in neurocritical care patients. Specifically, it will discuss its epidemiology, causes, associated mechanisms, and relationship to the brain-kidney axis. Additionally, the use and risks of extracorporeal therapies in this group of patients will be reviewed.

Ulinastatin alleviates early brain injury after intracerebral hemorrhage by inhibiting necroptosis and neuroinflammation via MAPK/NF-κB signaling pathway

Purpose: Spontaneous intracerebral hemorrhage (ICH) is a major public health problem with a huge economic burden worldwide. Ulinastatin (UTI), a serine protease inhibitor, has been reported to be anti-inflammatory, immune regulation, and organ protection by reducing reactive oxygen species production, and inflammation. Necroptosis is a programmed cell death mechanism that plays a vital role in neuronal cell death after ICH. However, the neuroprotection of UTI in ICH has not been confirmed, and the potential mechanism is unclear. The present study aimed to investigate the neuroprotection and potential molecular mechanisms of UTI in ICH-induced EBI in a C57BL/6 mouse model. Methods: The neurological score, brain water content, neuroinflammatory cytokine levels, and neuronal damage were evaluated. The anti-inflammation effectiveness of UTI in ICH patients also was evaluated. Results: UTI treatment markedly increased the neurological score, alleviate the brain edema, decreased the inflammatory cytokine TNF-α, interleukin­1ß (IL­1ß), IL­6, NF­κB levels, and RIP1/RIP3, which indicated that UTI-mediated inhibition of neuroinflammation, and necroptosis alleviated neuronal damage after ICH. UTI also can decrease the inflammatory cytokine of ICH patients. The neuroprotective capacity of UTI is partly dependent on the MAPK/NF-κB signaling pathway. Conclusions: UTI improves neurological outcomes in mice and reduces neuronal death by protecting against neural neuroinflammation, and necroptosis.

Ulinastatin alleviates early brain injury after intracerebral hemorrhage by inhibiting oxidative stress and neuroinflammation via ROS/MAPK/Nrf2 signaling pathway

Purpose: Spontaneous intracerebral hemorrhage (ICH) is still a major public health problem, with high mortality and disability. Ulinastatin (UTI) was purified from human urine and has been reported to be anti-inflammatory, organ protective, and antioxidative stress. However, the neuroprotection of UTI in ICH has not been confirmed, and the potential mechanism is unclear. In the present study, we aimed to investigate the neuroprotection and potential molecular mechanisms of UTI in ICH-induced early brain injury in a C57BL/6 mouse model. Methods: The neurological score, brain water content, neuroinflammatory cytokine levels, oxidative stress levels, and neuronal damage were evaluated. Results: UTI treatment markedly increased the neurological score, alleviated brain edema, decreased the levels of the inflammatory cytokines tumor necrosis factor-α (TNF-α), interleukin-1ß (IL-1ß), IL-6, and NF-κB, decreased the levels of reactive oxygen species (ROS) and malondialdehyde (MDA), and upregulated the levels of glutathione (GSH), superoxide dismutase (SOD), and Nrf2. This finding indicated that UTI-mediated inhibition of neuroinflammation and oxidative stress alleviated neuronal damage after ICH. The neuroprotective capacity of UTI is partly dependent on the ROS/MAPK/Nrf2 signaling pathway. Conclusions: UTI improves neurological outcomes in mice and reduces neuronal death by protecting against neural neuroinflammation and oxidative stress.

AISYF: first national, prospective, multicenter study of young patients with stroke in Argentina.

Up to 15% of all strokes affect young patients and the incidence of ischemic stroke in this population is rising. Nevertheless, there is limited information of cerebrovascular events in this population both in our country and in Latin America. The aim of our study was to evaluate the clinical characteristics and risk factors of young adults with stroke in Argentina. This is a prospective, multicenter study of stroke in young adults (18 - 55 years) in Argentina. Patients presenting with a cerebrovascular event within 180 days were included. Stroke subtypes were classified according to TOAST criteria. A total number of 311 patients were enrolled (men 53.9%, mean age: 43.3 years). Ischemic strokes occurred in 91.8% (brain infarcts 82.6%, transient ischemic attack 9.2%) and hemorrhagic strokes in 8.2%. The most frequent vascular risk factors (including ischemic and hemorrhagic strokes) were: hypertension 120 (41%), smoking 92 (31.4%), dyslipidemia 81 (27.6%) and, overweight/obesity: 74 (25.3%). Stroke subtypes were: large artery disease 12.3%, cardioembolism 7.5%, small artery occlusion 11.5%, other defined etiology 27.1%, and undetermined etiology 41.6%. Our study demonstrates that vascular risk factors are very frequent in young adults with stroke. Our findings underline that urgent strategies are required for primary and secondary stroke prevention in this group of patients.

Aproximadamente un 15% de todos los ataques cerebrovasculares afectan a pacientes jóvenes y su incidencia estaría en aumento. Existe escasa información sobre el ataque cerebral en esta población tanto en nuestro país como en Latinoamérica. El objetivo de nuestro estudio fue evaluar las características clínicas y los factores de riesgo de los adultos jóvenes con ictus en Argentina. Realizamos un estudio prospectivo y multicéntrico en adultos jóvenes (18-55 años) en Argentina, que presentaron un evento cerebrovascular dentro de los 180 días previos. Los subtipos de ictus se clasificaron según los criterios de TOAST. Se incluyeron un total de 311 pacientes (hombres 53.9%, edad media: 43,3 años). Los ataques cerebrovasculares isquémicos ocurrieron en el 91.8% (infartos cerebrales 82.6%, ataque isquémico transitorio 9.2%) y los eventos hemorrágicos correspondieron al 8.2%. Los factores de riesgo vascular más frecuentes (incluyendo los eventos isquémicos y hemorrágicos) fueron: hipertensión 120 (41%), tabaquismo 92 (31.4%), dislipidemia 81 (27.6%) y sobrepeso/obesidad: 74 (25.3%). Los subtipos de ictus isquémicos fueron: arteriopatía de gran vaso 12.3%, cardioembolismo 7.5%, oclusión de pequeña arteria 11.5%, otra etiología definida 27.1% y etiología indeterminada 41.6%. Los factores de riesgo vascular son muy frecuentes en los adultos jóvenes con ictus. Nuestros hallazgos subrayan que se requieren estrategias urgentes para la prevención primaria y secundaria del ictus en este grupo particular de pacientes en nuestro país.