Craniectomía descompresiva, una alternativa de tratamiento. Caso clínico / Decompressive craniectomy, an alternative treatment. Clinical case

Introducción: El Trauma Cráneo Encefálico Grave (TCE), continúa siendo un problema de preocupación para las autoridades sanitarias a nivel mundial. A pesar de las diferentes publicaciones existen divergencias en la toma de desición en aplicar la Craniectomía descompresiva (Cd). En el presente trabajo se describe caso clínico portador de Hematoma Epidural (HE), Hipertensión Endocraneana (HE), intervenido quirúrgicamente donde la información fue tomada de la historia clínica realizada en la Unidad de Cuidados Intensivos del Hospital Andino del Chimborazo, Riobamba, Ecuador, previa obtención del consentimiento informado. Presentación del caso: Paciente femenina de 18 años de edad que sufre Trauma craneoencefálico grave, hematoma epidural con efecto de masa y edema cerebral. Sometida a craniectomía descompresiva y tratamiento neurointensivo. Estadía en Unidad de Cuidados Intensivos de seis días, evolución favorable, ausencia de secuelas neurológicas. Conclusiones: La Craniectomía descompresiva mejora la Hipertensión endocraneana, disminuye la estadía UCI, y los días de ventilación mecánica, sin embargo los estudios actuales demuestran que esta intervención no mejora resultados finales. La Craniectomía Descompresiva primaria, en centros de escasos recursos de neuromonitoreo, puede constituir un proceder salvador. La craniectomía descompresiva está indicada en la segunda línea de tratamiento según la American Association of Neurological Surgeons.

Introduction: Serious Skull Trauma (SST), continues to be a problem of concern for health authorities worldwide. Despite the different publications there are divergences in the decision making in applying decompressive craniectomy (dc). In the present work, a clinical case of Epidural Hematoma (EH), Endocranial Hypertension (EH), surgically intervened was described, where the information was taken from the clinical history carried out in the Intensive Care Unit of the Andino del Chimborazo Hospital, Riobamba, Ecuador, after obtaining the informed consent. Presentation of the case: An 18-year-old female patient suffering from severe head trauma, epidural hematoma with mass effect and cerebral edema. Subjected to decompressive craniectomy and neurointensive treatment. Stay in the Intensive Care Unit for six days, favorable evolution, absence of neurological sequelae. Conclusions: Decompressive craniectomy improves intracranial hypertension, decreases ICU stay, and days of mechanical ventilation, however current studies show that this intervention does not improve final results. Primary Decompressive Craniectomy, in centers with scarce resources of neuromonitoring, can be a saving procedure. Decompressive craniectomy is indicated in the second line of treatment according to the American Association of Neurological Surgeons.

Linguagem, memória e escrita / Language, memory and writing / El lenguaje, la memoria y la escritura

Este texto apresenta resultados do acompanhamento longitudinal da linguagem de um sujeito após um traumatismo craneoencefálico. Para tanto, partimos dos pressupostos teórico-metodológicos da neurolinguística discursiva. Os resultados apontam que a leitura e a escrita podem ser eficazes na reestruturação da oralidade do sujeito, na reconstituição da sua identidade e na reinserção social.

This paper presents results of language intervention of a brain damaged subject. The theoretical and methodological basis is the neurolinguistic. The results show that reading and writing are effective in the restructuring of the subject and the social reintegration of the subject.

Early levels in blood of immunoglobulin M and natural killer cells predict outcome in nonseptic critically ill patients.

PURPOSE: Critical illness results in derangements of all components of the immune response. Nonetheless, most of the efforts evaluating immune status in critically ill patients have been done in the field of sepsis. Here we have evaluated the immunity status at intensive care unit (ICU) admission in a cohort of nonseptic critically ill patients and its influence on their outcome. MATERIAL AND METHODS: Ninety patients 18 years and older admitted to our ICU were studied for levels of immunoglobulin (Ig) G, IgM, IgA, CD3(+)CD4(+) T cells, CD3(+)CD8(+) T cells, B cells, natural killer (NK) cells, and C3 and C4 complement factors in peripheral blood in the next 24 hours after admission to the ICU. Patients with infection, sepsis, immunodeficiency, or concomitant immunosuppressive therapy were excluded. RESULTS: Levels of IgM, CD3(+) T cells, CD4(+) T cells, CD8(+) T cells, and B lymphocytes correlated inversely with age. In turn, levels of CD3(+) T cells, CD4(+) T cells, CD8(+) T cells, and C3 factor of the complement system correlated inversely with Acute Physiology and Chronic Health Evaluation II score. Multivariate Cox regression analysis censored at 28 days evidenced that levels of IgM played a protective role, whereas levels of NK cells behaved as a risk factor for mortality. Kaplan-Meier curves showed a cutoff of 58 mg/dL for IgM and 140 cells/mm(3) for NK cells. CONCLUSIONS: In conclusion, our results demonstrate that IgM plays a protective role in critically ill patients with no sepsis, whereas NK cell counts seem to play a deleterious one. Aging and severity at admission affect levels of key factors of the immune system in the blood of these patients.

El examen de las pupilas en el neuromonitoreo clínico del paciente con trauma craneoencefálico / The examination of the pupils in the clinical neuromonitoring of the patient with trauma cranioencephalic

El neuromonitoreo clínico intensivo de los pacientes con trauma craneoencefálico, asociado a novedosas tecnologías imagenológicas y funcionales, facilita la detección precoz de complicaciones intracraneales para disminuir la mortalidad y la discapacidad. En los casos graves, la mayoría de los aspectos del examen neurológico está afectado por el uso de analgésicos, sedantes y relajantes musculares necesarios para aliviar los síntomas y permitir una ventilación mecánica adecuada. El examen de las pupilas, junto a la escala del coma de Glasgow, constituye una de las armas clínicas más valiosas utilizadas para el seguimiento clínico intensivo de estos enfermos. En el siguiente artículo se realiza una revisión sobre las principales alteraciones pupilares que pueden encontrarse en los pacientes con trauma craneoencefálico y facilitar su interpretación, en ocasiones compleja.(AU)

Clinical intensive neuromonitoring of patients with craneoencephalic trauma, along with novel images and functional technologies, facilitates the early detection of intracranial complications to decrease mortality and disabilities. In severe cases, most of the neurological exam is bias because of the use of analgesic, sedatives and muscle relaxant drugs needed for relieving the symptoms and mechanical ventilation. Pupillary examination along with the Glasgow coma scale is one of the most valuable clinical resources used for the intensive clinical following of these patients. In the following article a review of the main alterations of the pupillary response that can be found in the acute injured patient to help in its interpretation is performed.(AU)