Early-onset neonatal sepsis as a risk factor for peri-intraventricular hemorrhage in premature infants / Sepse precoce como fator de risco para hemorragia peri-intraventricular em prematuros

ABSTRACT Objective: To assess early-onset sepsis as a risk factor of peri-intraventricular hemorrhage in premature infants born at less than or equal to 34 weeks' gestation and admitted to a neonatal intensive care unit (NICU). Methods: This retrospective cohort study included premature patients born at less than or equal to 34 weeks' gestation who were admitted to the NICU of a tertiary hospital in southern Brazil, and born from January 2017 to July 2021. Data were collected from patients' medical records. Early-onset sepsis was measured according to the presence or absence of diagnosis within the first 72 hours of life, whereas the outcome, peri-intraventricular hemorrhage, was described as the presence or absence of hemorrhage, regardless of its grade. Results: Hazard ratios were calculated using Cox regression models. A total of 487 patients were included in the study, of which 169 (34.7%) had some degree of peri-intraventricular hemorrhage. Early-onset sepsis was present in 41.6% of the cases of peri-intraventricular hemorrhage, which revealed a significant association between these variables, with increased risk of the outcome in the presence of sepsis. In the final multivariate model, the hazard ratio for early-onset sepsis was 1.52 (95% confidence interval 1.01-2.27). Conclusion: Early-onset sepsis and the use of surfactants showed to increase the occurrence of the outcome in premature children born at less than or equal to 34 weeks' gestation. Meanwhile, factors such as antenatal corticosteroids and gestational age closer to 34 weeks' gestations were found to reduce the risk of peri-intraventricular hemorrhage.

RESUMO Objetivo: O objetivo do presente trabalho foi avaliar a sepse precoce como fator de risco para hemorragia peri-intraventricular (HPIV) em prematuros com 34 semanas ou menos, admitidos em Unidade de Terapia Intensiva (UTI) Neonatal. Métodos: Este estudo de coorte retrospectivo incluiu pacientes prematuros com 34 semanas ou menos, que receberam alta da UTI Neonatal de hospital terciário, no sul do Brasil, nascidos no período de janeiro de 2017 a julho de 2021. Os dados foram coletados por meio dos prontuários desses pacientes. A sepse precoce foi mensurada conforme a presença ou a ausência do diagnóstico nas primeiras 72 horas de vida. Já o desfecho, hemorragia peri-intraventricular, foi descrito conforme a presença ou ausência da hemorragia, independentemente do grau. Resultados: Hazard ratios (HR) foram calculados por meio de modelos de regressão de Cox. Foram incluídos no estudo 487 pacientes. Destes, 169 (34,7%) apresentaram algum grau de hemorragia peri-intraventricular. A sepse precoce esteve presente em 41,6% dos casos de hemorragia peri-intraventricular e apresentou associação significativa, elevando o risco do desfecho quando presente. No modelo multivariável final, o HR para a sepse precoce foi de 1,52 (intervalo de confiança de 95% — IC95% 1,01-2,27). Conclusão: Sepse precoce e uso de surfactante demonstraram aumentar a ocorrência do desfecho em crianças prematuras até 34 semanas, enquanto fatores como corticoide antenatal e idades gestacionais mais próximas a 34 semanas mostraram reduzir o risco de ocorrência hemorragia peri-intraventricular.

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.

Riesgo de hemorragia cerebral en el traumatismo craneal leve y tratamiento antitrombótico / Risk of cerebral hemorrhage in mild traumatic brain injury and antithrombotic treatment

Objetivo El tiempo de observación en el traumatismo craneoencefálico leve (TCEL) es controvertido. Nuestro objetivo se basó en evaluar el riesgo de complicaciones neurológicas en el TCEL con y sin tratamiento antitrombótico. Método Evaluamos retrospectivamente los pacientes con TCEL atendidos en urgencias durante 3 años. Consideramos TCEL aquellos con Glasgow ≥13 al ingreso. Se realizó una TC craneal en todos los casos con >1 factor de riesgo al ingreso y a las 24h en aquellos con deterioro neurológico o TC craneal inicial patológica. Se revisó retrospectivamente las complicaciones en los siguientes 3 meses. Resultados Evaluamos 907 pacientes con una edad media de 73±19 años. El 91% presentaron factores de riesgo, con un 60% en tratamiento antitrombótico. Detectamos un 11% de hemorragia cerebral inicial, 0,4% a las 24h y ningún caso a los 3 meses. El tratamiento antitrombótico no se asoció con incremento de riesgo de hemorragia cerebral (9,9 con vs. 11,9% sin tratamiento; p=0,3). El 39% de las hemorragias presentaron síntomas neurológicos (18% amnesia postraumática, 12% cefalea, 8% vómitos, 1% convulsiones), siendo en un 78,4% síntomas leves. De las 4 hemorragias detectadas a las 24h, 3 fueron asintomáticas y un caso emporó la cefalea inicial. Ningún paciente asintomático sin lesión en la TC craneal inicial presentó clínica a las 24h. Conclusiones Nuestro estudio sugiere que los pacientes con TCEL asintomáticos, sin lesión en la TC craneal inicial no precisarían periodo de observación ni TC craneal de control, independientemente del tratamiento antitrombótico o nivel de INR (AU)

Introduction The observation time in mild traumatic brain injury (mTBI) is controversial. Our aim was to assess the risk of neurological complications in mTBI with and without antithrombotic treatment. Method We retrospectively evaluated patients with mTBI seen in the emergency room for 3 years. We considered MTBI those with Glasgow ≥13 at admission. A cranial CT was performed in all cases with >1 risk factor at admission and at 24h in those with neurological impairment or initial pathological cranial CT. Complications in the following 3 months were retrospectively reviewed. Results We evaluated 907 patients with a mean age of 73±19 years. Ninety-one percent presented risk factors, with 60% on antithrombotic treatment. We detected 11% of initial brain hemorrhage, 0.4% at 24h, and no cases at 3 months. Antithrombotic treatment was not associated with an increased risk of brain hemorrhage (9.9% with vs. 11.9% without treatment, P=.3). 39% of the hemorrhages presented neurological symptoms (18% post-traumatic amnesia, 12% headache, 8% vomiting, 1% seizures), with 78.4% having mild symptoms. Of the 4 hemorrhages detected at 24h, 3 were asymptomatic and one case that worsened the initial headache. No asymptomatic patient without lesion on initial clinical cranial CT presented at 24h. Conclusions Our study suggests that patients with asymptomatic mTBI, without a lesion on the initial cranial CT, would not require the observation period or CT control regardless of antithrombotic treatment or INR level (AU)

Perfil clínico y abuso de metanfetamina no recreativa (shabú) entre los pacientes con ictus en la población filipina / Clinical profile and non-recreational methamphetamine abuse (shabu) among stroke patients in the Philippine population

Introducción En la población filipina de Barcelona está aumentando el consumo crónico no recreativo de metanfetaminas (shabú). La población asiática presenta un patrón de ictus diferente, con mayor incidencia de hemorragias, y diferentes factores de riesgo vascular y conductas de salud. El objetivo es describir el perfil de ictus e incidencia de consumo de metanfetaminas en pacientes de origen filipino ingresados en nuestro centro. Pacientes y métodos Se registraron datos demográficos, factores de riesgo vascular, datos clínicos y pronóstico. Se analizó la exposición a metanfetamina en muestras de plasma recogidas en el ingreso, que se analizaron por cromatografía líquida-espectrometría de masas. Resultados Del total de 6.418 pacientes con ictus, se identificó a 73 pacientes filipinos (1,1%). La edad media era de 54,4 ± 12,1 años, el 54% eran hombres y el ictus era isquémico en el 64,4%. La hipertensión arterial fue el principal factor de riesgo. Diez (13,7%) pacientes dieron positivo a metanfetamina y anfetamina. Estos resultados confirman un consumo reciente de sustancias previo al ictus, principalmente en hombres (80%). En pacientes consumidores, un 60% presentaba un ictus hemorrágico, con mal pronóstico funcional a tres meses en el 55,6% de los pacientes. Conclusiones En nuestro medio, los pacientes de etnia filipina ingresados por ictus en relación con consumo de shabú presentaron un perfil de edad más joven, con menor prevalencia de factores de riesgo vascular y predominio del subtipo hemorrágico. Se recomienda la determinación de metanfetamina en los pacientes filipinos con ictus debido a la alta prevalencia del consumo de metanfetamina en nuestro país. (AU)

INTRODUCTION Chronic non-recreational use of methamphetamine (shabú) is increasing among the Filipino population in Barcelona. The Asian population presents a different stroke pattern, with a higher incidence of haemorrhage, and different vascular risk factors and health behaviours. The objective of this study is to describe the stroke profile and incidence of methamphetamine use in patients of Filipino origin admitted to our centre. PATIENTS AND METHODS Demographic data, vascular risk factors, clinical data and prognosis were recorded. Methamphetamine exposure was analysed in plasma samples collected on admission, which were then analysed by liquid chromatography-mass spectrometry. RESULTS Of a total of 6,418 stroke patients, 73 (1.1%) were identified as being of Filipino origin. The mean age was 54.4 ± 12.1 years, 54% were male and the stroke was ischaemic in 64.4% of cases. Arterial hypertension was the main risk factor. Ten (13.7%) patients tested positive for methamphetamine and amphetamine. These results confirm recent substance use prior to the stroke, mostly in men (80%). In patients who were consumers, 60% had a haemorrhagic stroke, with a poor functional prognosis at three months in 55.6% of patients. CONCLUSIONS In our setting, patients of Filipino ethnicity admitted for stroke related to the consumption of shabú belonged a younger age bracket, with a lower prevalence of vascular risk factors and a predominance of the haemorrhagic subtype. Methamphetamine testing in Filipino stroke patients is recommended due to the high prevalence of methamphetamine use in our country. (AU)

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.

Risk of cerebral hemorrhage in mild traumatic brain injury and antithrombotic treatment.

INTRODUCTION: The observation time in mild traumatic brain injury (mTBI) is controversial. Our aim was to assess the risk of neurological complications in mTBI with and without antithrombotic treatment. METHOD: We retrospectively evaluated patients with mTBI seen in the emergency room for 3 years. We considered MTBI those with Glasgow ≥13 at admission. A cranial CT was performed in all cases with ≥1 risk factor at admission and at 24 h in those with neurological impairment or initial pathological cranial CT. Complications in the following 3 months were retrospectively reviewed. RESULTS: We evaluated 907 patients with a mean age of 73 ±â€¯19 years. Ninety-one percent presented risk factors, with 60% on antithrombotic treatment. We detected 11% of initial brain hemorrhage, 0.4% at 24 h, and no cases at 3 months. Antithrombotic treatment was not associated with an increased risk of brain hemorrhage (9.9% with vs 11.9% without treatment, p = 0.3). 39% of the hemorrhages presented neurological symptoms (18% post-traumatic amnesia, 12% headache, 8% vomiting, 1% seizures), with 78.4% having mild symptoms. Of the 4 hemorrhages detected at 24 h, 3 were asymptomatic and one case that worsened the initial headache. No asymptomatic patient without lesion on initial clinical cranial CT presented at 24 h. CONCLUSIONS: Our study suggests that patients with asymptomatic mTBI, without a lesion on the initial cranial CT, would not require the observation period or CT control regardless of antithrombotic treatment or INR level.

Microhemorragias cerebrales. Utilidad de las secuencias de susceptibilidad magnética (SWI) / Cerebral microbleeds. Utility of SWI sequences

Objetivo: Definir el concepto de microhemorragia cerebral y revisar las secuencias de resonancia magnética (RM) utilizadas para su valoración. Revisar cuáles son las patologías que presentan microhemorragias y que pueden beneficiarse del uso de secuencias de susceptibilidad magnética (SWI). Conclusión: Las SWI son útiles en la detección y caracterización de microhemorragias, venas y otras fuentes de susceptibilidad. La secuencia SWI mejora la sensibilidad diagnóstica con respecto a las secuencias convencionales potenciadas en T2* (eco de gradiente T2* [2D-GRE]). Las microhemorragias cerebrales pueden asociarse a diversas enfermedades, aparecer en contextos clínicos menos conocidos o servir como biomarcador tumoral en gliomas (ITTS) y como marcador de actividad inflamatoria en las placas de esclerosis múltiple (EM).(AU)

Objectives: Define the concept of cerebral microbleeds (CMB) and describe the most useful MRI sequences for detecting this finding. Review the entities that most frequently present with CMB and that may benefit from the use of susceptibility-weighted imaging (SWI) sequences. Conclusions: SWI is a useful MRI sequence for the detection and characterization of microhemorrhages, venous structures and other sources of susceptibility in imaging. SWI is particularly sensitive to local magnetic field inhomogeneities generated by certain substances and is superior to T2* GRE sequences for this assessment. CMB may be seen in different neurologic conditions, in certain infrequent clinical contexts and have a key role as a biomarker status in gliomas (ITTS) and as a marker of inflammatory activity in multiple sclerosis.(AU)

Cerebral microbleeds. Utility of SWI sequences.

OBJECTIVES: Define the concept of cerebral microbleeds (CMBs) and describe the most useful MRI sequences for detecting this finding. Review the entities that most frequently present with CMBs and that may benefit from the use of susceptibility-weighted imaging (SWI) sequences. CONCLUSIONS: SWI is a useful MRI sequence for the detection and characterization of microhemorrhages, venous structures and other sources of susceptibility in imaging. SWI is particularly sensitive to local magnetic field inhomogeneities generated by certain substances and is superior to T2* GRE sequences for this assessment. CMBs may be seen in different neurologic conditions, in certain infrequent clinical contexts and have a key role as a biomarker status in gliomas (ITTS) and as a marker of inflammatory activity in multiple sclerosis.

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.

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.

Accidente Cerebrovascular en tallo cerebral, presentación inusual con evolución tórpida en paciente renal

La tercera causa de morbi-mortalidad en muchos países, es el accidente cerebrovascular (ACV), la incidencia es mayor en los pacientes con hemodiálisis. La presencia del ACV hemorrágico se vincula con peores resultados; el diagnóstico y tratamiento precoces son primordiales por la rápida expansión de la misma, que provoca un detrimento neurológico, hasta un desenlace fatal. Se presenta el caso de una mujer de 52 años, ingresa por servicio de emergencia en fecha 23/05/23 con antecedente de terapia de reemplazo renal tri-semanal, hipertensión arterial, diabetes mellitus; cuadro clínico con cefalea súbita, de moderada intensidad, acompañado de somnolencia, entumecimiento a nivel de columna cervicodorsal, paraparesia en extremidades inferiores e hipertensión; tomografía de cráneo con ACV hemorrágico pre tallo cerebral; ingresa a la Unidad de Terapia Intensiva (UTI) para monitorización y manejo, sin embargo a pesar del tratamiento evoluciono de manera tórpida y fallece en fecha 11/06/2023.

The third cause of morbidity and mortality in many countries is cerebrovascular accident (CVA), the incidence is higher in hemodialysis patients. The presence of hemorrhagic stroke is associated with worse results; early diagnosis and treatment are essential due to its rapid expansion, which causes neurological detriment, up to a fatal outcome. The case of a 52-year-old woman is presented, admitted for emergency service on 05/23/23 with a history of three-weekly renal replacement therapy, arterial hypertension, diabetes mellitus; clinical picture with sudden headache of moderate intensity, accompanied by drowsiness, numbness at the level of the cervicodorsal spine, paraparesis in the lower extremities and hypertension; skull tomography with pre-brain stem hemorrhagic stroke; he was admitted to the Intensive Care Unit (ICU) for monitoring and management, however despite the treatment he evolved torpidly and died on 06/11/2023.

Dilated optic nerve sheath by ultrasound predicts mortality among patients with acute intracerebral hemorrhage / A bainha do nervo óptico dilatada na ultrassonografia prediz mortalidade na hemorragia intraparenquimatosa aguda

Abstract Background Intracerebral hemorrhage (ICH) is a deadly disease and increased intracranial pressure (ICP) is associated with worse outcomes in this context. Objective We evaluated whether dilated optic nerve sheath diameter (ONSD) depicted by optic nerve ultrasound (ONUS) at hospital admission has prognostic value as a predictor of mortality at 90 days. Methods Prospective multicenter study of acute supratentorial primary ICH patients consecutively recruited from two tertiary stroke centers. Optic nerve ultrasound and cranial computed tomography (CT) scans were performed at hospital admission and blindly reviewed. The primary outcome was mortality at 90-days. Multivariate logistic regression, ROC curve, and C-statistics were used to identify independent predictors of mortality. Results Between July 2014 and July 2016, 57 patients were evaluated. Among those, 13 were excluded and 44 were recruited into the trial. Their mean age was 62.3 ± 13.1 years and 12 (27.3%) were female. On univariate analysis, ICH volume on cranial CT scan, ICH ipsilateral ONSD, Glasgow coma scale, National Institute of Health Stroke Scale (NIHSS) and glucose on admission, and also diabetes mellitus and current nonsmoking were predictors of mortality. After multivariate analysis, ipsilateral ONSD (odds ratio [OR]: 6.24; 95% confidence interval [CI]: 1.18-33.01; p = 0.03) was an independent predictor of mortality, even after adjustment for other relevant prognostic factors. The best ipsilateral ONSD cutoff was 5.6mm (sensitivity 72% and specificity 83%) with an AUC of 0.71 (p = 0.02) for predicting mortality at 90 days. Conclusion Optic nerve ultrasound is a noninvasive, bedside, low-cost technique that can be used to identify increased ICP in acute supratentorial primary ICH patients. Among these patients, dilated ONSD is an independent predictor of mortality at 90 days.

Resumo Antecedentes A hemorragia intraparenquimatosa (HIP) aguda apresenta elevada morbimortalidade e a presença de hipertensão intracraniana (HIC) confere um pior prognóstico. Objetivo Avaliamos se a dilatação do diâmetro da bainha do nervo óptico (DBNO) através do ultrassom do nervo óptico (USNO) na admissão hospitalar seria preditora de mortalidade. Métodos Estudo multicêntrico e prospectivo de pacientes consecutivos com HIP supratentorial primária aguda admitidos em dois centros terciários. Ultrassom do nervo óptico e tomografia computadorizada (TC) de crânio foram realizados na admissão e revisados de forma cega. O desfecho primário do estudo foi a mortalidade em 3 meses. Análises de regressão logística, curva de característica de operação do receptor (ROC, na sigla em inglês) e estatística-C foram utilizadas para identificação dos preditores independentes de mortalidade. Resultados Entre julho de 2014 e julho de 2016, 44 pacientes foram incluídos. A idade média foi 62,3 (±13,1) anos e 12 (27,3%) eram mulheres. Na análise univariada, o volume da HIP na TC de crânio, DBNO ipsilateral à HIP, glicemia, escala de coma de Glasgow (ECG) e NIHSS na admissão hospitalar, e também diabetes mellitus e não-tabagista foram preditores de mortalidade. Após análise multivariada, o DBNO ipsilateral à HIP permaneceu como preditor independente de mortalidade (odds ratio [OR]: 6,24; intervalo de confiança [IC] de 95%: 1,18-33,01; p = 0,03). O melhor ponto de corte do DBNO ipsilateral como preditor de mortalidade em 3 meses foi 5,6mm (sensibilidade 72% e especificidade 83%) e área sob a curva (AUC, na sigla em inglês) 0,71 (p = 0,02). Conclusão O USNO é um método não-invasivo, beira-leito, de baixo custo, que pode ser empregado para estimar a presença de HIC em pacientes com HIP supratentorial primária aguda. A presença de DBNO dilatada é um preditor independente de mortalidade em 3 meses nesses pacientes.

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.

Neuroimagen en pacientes con infección por COVID-19 descripción de hallazgos y revisión de la literatura / Neuroimaging in patients with COVID-19: findings description and review of the literature

El síndrome respiratorio agudo severo causado por coronavirus 2 (SARS-CoV-2) es responsable de la propagación mundial de la enfermedad por coronavirus (COVID-19). Nuestro conocimiento hasta el momento del impacto de este virus en el sistema nervioso es limitado. El propósito de este artículo es revisar el espectro de los diversos hallazgos en neuroimágenes asi como la fisiopatología en los pacientes con COVID-19. Se necesitan estudios futuros que examinen el impacto de los síntomas y su correlación con las neuroimágenes durante el curso de la enfermedad, para aclarar y evaluar aún más el vínculo entre las complicaciones neurológicas y el resultado clínico, así como limitar las consecuencias a largo plazo.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the global spread of coronavirus disease (COVID-19). Our understanding, so far, of the impact this virus has on the nervous system is limited. Our article aims to review the spectrum of neuroimaging findings in patients with COVID 19, as well as, their underlying pathophysiology. Future studies examining the impact of symptoms and their correlation with neuroimaging findings duirng the course of the disease are needed to further clarify and evaluate the association between neurological complications and clinical outcome, as well as to limit long-term consequences.

Moyamoya disease in Mexico: our experience.

INTRODUCTION: Moyamoya disease (MD) is a progressive, occlusive disease of the arteries of the anterior cerebral circulation that may cause ischaemia or haemorrhage. Patient management aims to prevent new cerebrovascular events through surgical revascularisation and/or pharmacological treatment. MATERIALS AND METHODS: We studied a series of 17 patients with MD (n = 14) or moyamoya syndrome (MS; n = 3), who were evaluated between January 1989 and December 2016; 11 patients were women and 6 were men. Thirteen patients had definitive MD (76%), one had unilateral MD (5.2%), and 3 had MS (18%). The condition manifested as intraparenchymal haemorrhage (in 35.2% of patients), brain ischaemia (29.4%), subarachnoid haemorrhage (17.6%), seizures (11.7%), and headache with no associated haemorrhage (1 patient). RESULTS: Ten patients (58.8%) underwent revascularisation and 7 (41.2%) received pharmacological treatment. All patients were evaluated with the modified Rankin Scale (mRs) at admission and at the last consultation; mRs scores were significantly lower in the group undergoing surgery (P <  .04). During follow-up, none of the patients undergoing revascularisation experienced recurrences, whereas 2 patients receiving pharmacological treatment did experience a new vascular event (one ischaemic and one haemorrhagic) (P <  .05). No significant differences were observed between the treatment outcomes of different revascularisation techniques. CONCLUSIONS: Although our population has different demographic characteristics from those of other non-Asian populations, ours is the largest published series of Hispanic individuals with MD. Our results support the use of revascularisation procedures to improve these patients' neurological status and to prevent new cerebrovascular events.

Enfermedad moyamoya en México. Experiencia institucional / Moyamoya disease in Mexico: Our experience

Introducción: La enfermedad moyamoya (EM) es una arteriopatía oclusiva y progresiva de la circulación cerebral anterior que puede producir eventos isquémicos o hemorrágicos. El objetivo terapéutico es la prevención de nuevos eventos a través de tratamiento médico o cirugía de revascularización.MétodosSe estudió a 17 pacientes con EM y síndrome de moyamoya, atendidos de enero de 1989 a diciembre del 2016. Trece pacientes tenían EM definitiva (76%), un paciente EM unilateral (5,2%) y 3 pacientes síndrome de moyamoya (18%). Once pertenecían al sexo femenino y 6 al masculino. Su forma de presentación fue hemorragia intraparenquimatosa (35,2%), isquemia cerebral (29,4%), hemorragia subaracnoidea (17,6%), crisis convulsivas (11,7%) y un paciente empezó con cefalea sin hemorragia.ResultadosEn 10 pacientes se realizó una cirugía de revascularización (58,8%) y 7 se manejaron médicamente (41,2%). La valoración neurológica, empleando la escala modificada de Rankin al ingreso y en su última consulta, mostró una diferencia significativa (p < 0,04) a favor del grupo quirúrgico. Ningún paciente del grupo quirúrgico presentó nuevos eventos vasculares, mientras que 2 pacientes del grupo médico desarrollaron uno nuevo (uno isquémico y otro hemorrágico). En nuestro estudio no hubo una diferencia significativa entre los métodos de revascularización, pero sí en comparación con los pacientes que se trataron médicamente (p < 0,05).ConclusionesSi bien nuestra población muestra diferencias con otras series reportadas fuera de Asia, esta es la serie reportada más numerosa para una población hispana. Nuestros resultados indican que los procedimientos de revascularización son útiles para prevenir nuevos eventos vasculares isquémicos o hemorrágicos. (AU)

Introduction: Moyamoya disease (MD) is a progressive, occlusive disease of the arteries of the anterior cerebral circulation that may cause ischaemia or haemorrhage. Patient management aims to prevent new cerebrovascular events through surgical revascularisation and/or pharmacological treatment.MethodsWe studied a series of 17 patients with MD (n = 14) or moyamoya syndrome (n = 3), who were evaluated between January 1989 and December 2016; 11 patients were women and 6 were men. Thirteen patients had definitive MD (76%), one had unilateral MD (5.2%), and 3 had moyamoya syndrome (18%). The condition manifested as intraparenchymal haemorrhage (in 35.2% of patients), brain ischaemia (29.4%), subarachnoid haemorrhage (17.6%), seizures (11.7%), and headache with no associated haemorrhage (one patient).ResultsTen patients (58.8%) underwent revascularisation and 7 (41.2%) received pharmacological treatment. All patients were evaluated with the modified Rankin Scale (mRs) at admission and at the last consultation; mRs scores were significantly lower in the group undergoing surgery (P < .04). During follow-up, none of the patients undergoing revascularisation experienced recurrences, whereas 2 patients receiving pharmacological treatment did experience a new vascular event (one ischaemic and one haemorrhagic) (P < .05). No significant differences were observed between the treatment outcomes of different revascularisation techniques.ConclusionsAlthough our population has different demographic characteristics from those of other non-Asian populations, ours is the largest published series of Hispanic individuals with MD. Our results support the use of revascularisation procedures to improve these patients’ neurological status and to prevent new cerebrovascular events. (AU)

Hemorrhagic stroke associated to COVID-19 infection in Mexico General Hospital.

INTRODUCCIÓN: en la actual pandemia de COVID-19, existe evidencia creciente que ha identificado el neurotropismo del virus SARS-CoV-2 y sus complicaciones neurológicas, incluida la enfermedad cerebrovascular isquémica y escasamente hemorragia cerebral (HC). OBJETIVO: describir las características clínicas, radiológicas, de laboratorio y pronósticas de los pacientes con HC asociada al SARS-CoV-2. MÉTODOS: se incluyeron pacientes consecutivos con prueba de PCR confirmatoria para infección por SARS-CoV-2 y HC. RESULTADOS: en un período de 90 días, en un centro de referencia COVID-19 en México, de 1108 pacientes con infección por SARS-CoV-2, se encontraron 4 pacientes (0.36%) con HC. Tenían una edad de 71(±12.2) años, 2 eran mujeres. Se encontró que dos tenían factores de riesgo cardiovascular previos. En dos casos se encontró el origen en el núcleo dentado mientras que los otros dos correspondieron al tálamo. Tres de los cuatro pacientes murieron. Postulamos que el descontrol hipertensivo, coagulopatía, trombocitopenia y la respuesta inmune inducida por el virus SARS-CoV-2 podrían desencadenar HC en un paciente con riesgo previo. CONCLUSIONES: la HC se asocia a la infección por SARS-CoV-2 con mal pronóstico cuando se presenta. Los equipos de neurocirugía deben estar preparados para el tratamiento oportuno de estos pacientes. INTRODUCTION: In the current COVID-19 pandemic, there is a growing body of evidence that has identified the neurotropism of the SARS-CoV-2 virus and its neurological complications, including cerebrovascular disease, focusing mainly in ischemic and scarcely about hemorrhagic stroke (HS). OBJECTIVE: The objective of the study was to describe clinical, radiological, laboratory tests, and prognostic characteristics of patients with SARS-CoV-2 associated HS. METHODS: Consecutive patients with a confirmatory PCR test for SARS-CoV-2 infection and a HS demonstrated by head CT were included in the study. RESULTS: Over a period of 90 days, in a COVID-19 reference center in Mexico, out of a total of 1108 patients with SARS-CoV-2 infection, it found 4 patients (0.36%) who meet criteria. They had an age of 71 (±12.2) years, 2 were women. It was found that two had prior cardiovascular risk factors. Two of the HS originated in the dentate nucleus while the other two corresponded to the thalamus. Three of the four patients died. We suggest that catastrophic uncontrolled blood pressure, coagulopathy, thrombocytopenia, and immune response induced by SARS-CoV-2 could in a specific patient trigger HS. CONCLUSIONS: HS is associated to SARS-CoV-2 infection with poor prognosis when it presented. Neurosurgery teams should prepare for the timely and appropriate treatment of this patients.