Comparación de la efectividad entre distintas intervenciones en los síntomas posconmoción en adolescentes y jóvenes: una revisión bibliográfica / Comparison of effectiveness between different interventions in postconcussive symptoms in adolescents and young people: A literature review

Introducción: Actualmente la conmoción cerebral se considera un problema de gran magnitud, siendo los adolescentes y jóvenes la población de riesgo, ya que se encuentran en proceso de maduración. Nuestro objetivo ha sido comparar la eficacia de diferentes intervenciones (ejercicio físico terapéutico, terapia vestibular y descanso) en adolescentes y jóvenes con conmoción cerebral.Desarrollo: Se realizó una búsqueda bibliográfica en las principales bases de datos. Una vez aplicados los criterios de inclusión/exclusión y la escala metodológica Physiotherapy Evidence Database PEDro, fueron revisados seis artículos. Los resultados apoyan la utilización del ejercicio y la terapia vestibular en las etapas iniciales para disminuir los síntomas posconmoción. Según la mayoría de los autores, el ejercicio físico terapéutico y la terapia vestibular reportan mayores beneficios, aunque se necesitaría un protocolo que unificara escalas de valoración, variables de estudio y parámetros de análisis para poder realizar la inferencia en la población diana.Conclusión: Desde el momento del alta hospitalaria del paciente, la aplicación combinada de ejercicio físico y terapia vestibular, podría considerarse como la mejor opción para disminuir los síntomas posconmoción.(AU)

Introduction: Currently, concussion considers a problem of great magnitude, adolescents and young people being the population at risk, since it is in the process of maturation. Our goal has been to compare the effectiveness of different interventions (exercise therapy, vestibular rehabilitation and rest) in adolescents and young people with concussion. Development: A bibliographic search was carried out in the main databases. Once the inclusion / exclusion criteria and the PEDro methodological scale were applied, 6 articles were reviewed. The results support the use of exercise and vestibular rehabilitation in the initial stages to reduce post-concussion symptoms. According to most authors, therapeutic physical exercise and vestibular rehabilitation report greater benefits, although a protocol that unifies assessment scales, study variables and analysis parameters would be needed to be able to make the inference in the target population. Conclusión: From the moment of hospital discharge, the combined application of exercise and vestibular rehabilitation could be the best option to reduce post-concussion symptoms.(AU)

Temperature management in acute brain injury: A narrative review.

Temperature management has been used in patients with acute brain injury resulting from different conditions, such as post-cardiac arrest hypoxic-ischaemic insult, acute ischaemic stroke, and severe traumatic brain injury. However, current evidence offers inconsistent and often contradictory results regarding the clinical benefit of this therapeutic strategy on mortality and functional outcomes. Current guidelines have focused mainly on active prevention and treatment of fever, while therapeutic hypothermia (TH) has fallen into disuse, although doubts persist as to its effectiveness according to the method of application and appropriate patient selection. This narrative review presents the most relevant clinical evidence on the effects of TH in patients with acute neurological damage, and the pathophysiological concepts supporting its use.

Fatigue in patients with acquired brain damage.

Fatigue is a complex, multidimensional syndrome that is prevalent in patients with acquired brain damage and has a negative impact on the neurorehabilitation process. It presents from early stages after the injury, and may persist over time, regardless of whether sequelae have resolved. Fatigue is conditioned by upper neuronal circuits, and is defined as an abnormal perception of overexertion. Its prevalence ranges from 29% to 77% after stroke, from 18% to 75% after traumatic brain injury, and from 47% to 97% after brain tumours. Fatigue is associated with factors including female sex, advanced age, dysfunctional families, history of specific health conditions, functional status (eg, fatigue prior to injury), comorbidities, mood, secondary disability, and the use of certain drugs. Assessment of fatigue is fundamentally based on such scales as the Fatigue Severity Scale (FSS). Advances have recently been made in imaging techniques for its diagnosis, such as in functional MRI. Regarding treatment, no specific pharmacological treatment currently exists; however, positive results have been reported for some conventional neurorehabilitation therapies, such as bright light therapy, neurofeedback, electrical stimulation, and transcranial magnetic stimulation. This review aims to assist neurorehabilitation professionals to recognise modifiable factors associated with fatigue and to describe the treatments available to reduce its negative effect on patients.

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)

Relationship between prehospital clinical status intracranial pressure and outcomes in pediatric patients with severe head trauma

Introduction: The prehospital phase of the management of pediatric severe traumatic brain injury may have a direct influence on the results. Objective: To evaluate the influence of prehospital variables on intracranial pressure and the results in pediatric patients with severe TBI. Method: A descriptive study of 41 pediatric patients who were admitted to the medical emergency department and later admitted to the pediatric intensive care unit due to severe head trauma was carried out between January 2003 and December 2018. Results: children aged 5-17 years predominate, and the highest number of cases were received between 0-3h at the neurotrauma center. Of the 41 cases, 27 arrived with a non-expedited airway and hypoxia was verified upon arrival by pulse oximetry. A correlation was observed between arterial hypotension on admission and elevated intracranial pressure in 9 of 15 children (60%) and in the deceased (40%). Discussion: Clinical conditions, oxygenation, arterial hypotension, and treatment in the prehospital phase may influence the state of intracranial pressure and other intracranial variables in pediatric patients with severe head injury.

Introducción: La fase prehospitalaria del manejo del traumatismo craneoencefálico grave pediátrico puede tener una influencia directa en los resultados. Objetivo: Evaluar la influencia de variables prehospitalarias sobre la presión intracraneal y los resultados en pacientes pediátricos con TCE grave. Metodología: Se realizó un estudio descriptivo de 41 pacientes pediátricos que ingresaron al servicio de urgencias médicas y posteriormente ingresaron a la unidad de cuidados intensivos pediátricos por traumatismo craneoencefálico severo entre enero de 2003 y diciembre de 2018. Resultados: predominan los niños de 5 a 17 años, y el mayor número de casos se recibieron entre las 0-3h en el centro de neurotrauma. De los 41 casos, 27 llegaron con vía aérea no acelerada y se verificó hipoxia al llegar mediante oximetría de pulso. Se observó correlación entre hipotensión arterial al ingreso y presión intracraneal elevada en 9 de 15 niños (60%) y en los fallecidos (40%). Discusión: Las condiciones clínicas, la oxigenación, la hipotensión arterial y el tratamiento en la fase prehospitalaria pueden influir en el estado de la presión intracraneal y otras variables intracraneales en pacientes pediátricos con traumatismo craneoencefálico grave.

Hypopituitarism after traumatic brain injury in adults: Clinical guidelines of the neuroendocrinology area of the Spanish Society of Endocrinology and Nutrition (SEEN).

Traumatic brain injury (TBI) is associated with hypopituitarism with a variable incidence, depending on the time and methods used to diagnosis, and on factors related to the trauma, such as its severity, its anatomical location and the drugs used in the acute phase. The pituitary gland can be damaged directly by the impact or secondary to factors such as ischemia, inflammation, excitotoxicity or immunity. In acute phases ACTH deficiency is the most relevant, since failure to detect and treat it can compromise the patient's life. Clinical manifestations are typical of each hormone deficient axes, although the combination hypopituitarism-trauma has been associated with cognitive deterioration, worse metabolic profile and greater impairment of quality of life. One of the clinical challenges is to determine which patients benefit from a systematic hormonal evaluation, and therefore from hormone replacement, and what is the appropriate time to do so and the most suitable diagnostic methods.

Sinking bone flap due to overdrainage of a ventriculoperitoneal shunt. A case report and review of the literature / Hundimiento de colgajo óseo por sobredrenaje de una derivación ventriculoperitoneal. Caso clínico y revisión de la literatura

The widespread use of decompressive craniectomy and subsequent cranioplasty has led to a better understanding of its complications. However, cases of a sunken bone flap have hardly ever been described. We present the eighth case reported up to date and perform a review of the literature of this sporadic complication. A 40-year-old Caucasian male suffered a traumatic brain injury that required a decompressive craniectomy. One month after initial trauma autologous cranioplasty was performed. A ventriculoperitoneal shunt was also placed. Neurological status progressively improved but his therapist noted cognitive status decline 8 months later. Follow-up computed tomography showed a progressive sinking bone flap. The patient underwent bone flap removal and a custom-made calcium phosphate-based implant was inserted, leading to symptoms resolution. Bone resorption has been described as the main cause of sinking bone flap following cranioplasty. This entity may manifest with symptoms of overdrainage in patients with cerebrospinal fluid shunt devices (AU)

El uso extendido de la craniectomía descompresiva y la consiguiente craneoplastia ha propiciado un mejor conocimiento de sus complicaciones. Sin embargo, esporádicamente se han descrito casos de hundimiento del colgajo óseo. Describimos el octavo caso descrito hasta la fecha y realizamos una revisión de la literatura de esta infrecuente complicación. Un varón de 40 años sufrió un traumatismo craneoencefálico que requirió craniectomía descompresiva. Un mes después se sometió a la reposición de su colgajo óseo, junto con la implantación de una derivación ventriculoperitoneal. Presentó mejoría neurológica progresiva que se frenó y empeoró ocho meses después. La tomografía computarizada de control mostró hundimiento progresivo del colgajo óseo. El paciente se sometió a la retirada del colgajo óseo y cranioplastia con implante a medida, con resolución de los síntomas. La resorción ósea se ha descrito como la principal causa del hundimiento del colgajo óseo tras cranioplastia. Sin embargo, esta entidad puede manifestarse como síntomas de sobredrenaje en pacientes con derivación de líquido cefalorraquídeo (AU)

Fluid therapy and traumatic brain injury: A narrative review / Fluidoterapia y daño cerebral traumático: una revisión narrativa

Traumatic brain injury (TBI) is an important health and social problem. The mechanism of damage of this entity could be divided into two phases: (1) a primary acute injury because of the traumatic event; and (2) a secondary injury due to the hypotension and hypoxia generated by the previous lesion, which leads to ischemia and necrosis of neural cells. Cerebral edema is one of the most important prognosis markers observed in TBI. In the early stages of TBI, the cerebrospinal fluid compensates the cerebral edema. However, if edema increases, this mechanism fails, increasing intracranial pressure. To avoid this chain effect, several treatments are applied in the clinical practice, including elevation of the head of the bed, maintenance of normothermia, pain and sedation drugs, mechanical ventilation, neuromuscular blockade, controlled hyperventilation, and fluid therapy (FT). The goal of FT is to improve the circulatory system to avoid the lack of oxygen to organs. Therefore, rapid and early infusion of large volumes of crystalloids is performed in clinical practice to restore blood volume and blood pressure. Despite the relevance of FT in the early management of TBI, there are few clinical trials regarding which solution is better to apply. The aim of this study is to provide a narrative review about the role of the different types of FT used in the daily clinical practice on the management of TBI. To achieve this objective, a physiopathological approach to this entity will be also performed, summarizing why the different types of FT are used (AU)

El traumatismo craneoencefálico (TCE) es un importante problema sanitario y social. El mecanismo de daño de esta entidad se podría dividir en dos fases: 1) una lesión aguda primaria a causa del evento traumático, y 2) una lesión secundaria por la hipotensión e hipoxia generada por la lesión anterior, que conduce a la isquemia y necrosis de las células neurales. El edema cerebral es uno de los marcadores pronósticos más importantes observados en el TCE. En las primeras etapas de TCE, el líquido cefalorraquídeo compensa el edema cerebral. Sin embargo, si aumenta el edema, este mecanismo falla, aumentando la presión intracraneal. Para evitar este efecto en cadena, en la práctica clínica se aplican varios tratamientos, entre ellos la elevación de la cabecera de la cama, el mantenimiento de la normotermia, los fármacos para el dolor y la sedación, la ventilación mecánica, el bloqueo neuromuscular, la hiperventilación controlada y la fluidoterapia (FT). El objetivo de la FT es mejorar el sistema circulatorio para evitar la falta de oxígeno a los órganos. Por lo tanto, en la práctica clínica se realiza una infusión rápida y temprana de grandes volúmenes de cristaloides para restablecer el volumen sanguíneo y la presión arterial. A pesar de la relevancia de la FT en el manejo temprano del TCE, existen pocos ensayos clínicos sobre qué solución es mejor aplicar. El objetivo de este estudio es proporcionar una revisión narrativa sobre el papel de los diferentes tipos de FT utilizados en la práctica clínica diaria en el manejo del TCE. Para lograr este objetivo, también se realizará un abordaje fisiopatológico de esta entidad, resumiendo por qué se utilizan los diferentes tipos de FT (AU)

Implantación de una unidad pediátrica de daño cerebral adquirido en fase subaguda en el sistema público de salud. Características epidemiológicas, clínicas y de evolución inicial de los pacientes atendidos / Implementation of a pediatric unit of acquired brain injury in subacute phase in the public health system. Epidemiological, clinical and initial evolution characteristics of the patients attended

Introducción: El daño cerebral adquirido (DCA) se define como una lesión neurológica, acaecida de forma aguda, en algún momento de la vida provocando deficiencia o pérdida de capacidad funcional. En el año 2019 se crea un documento específico por parte del defensor del pueblo señalando la relevancia de la atención a esta entidad en la edad pediátrica. Pacientes y método: Se presenta el proceso de creación y la casuística de atención de una de las primeras unidades de atención integral al DCA en fase subaguda en edad pediátrica dentro del sistema público de salud.Resultados: Se han elaborado diferentes guías clínicas sobre el proceso de admisión y atención dentro de la unidad, tanto al paciente como a sus familiares. Se han atendido 24 pacientes ≤18 años, ingresados en la unidad de DCA en fase subaguda desde noviembre de 2019 hasta julio de 2021, 12 provenientes de la Comunidad de Madrid. La mediana de edad fue de 6,97 años. El mecanismo traumático fue el más frecuente predominando las causas iatrogénicas, seguido de la precipitación y los accidentes relacionados con vehículos. A su ingreso en la unidad, 8 mantenían un estado de mínima conciencia/vegetativo. Se requirió la colaboración de hasta 14 especialistas diferentes dada la complejidad de los pacientes. La evolución fue globalmente favorable en 23 casos, con secuelas en todos ellos. Conclusión: Es de vital importancia la creación de unidades especializadas en la atención al DCA en edad pediátrica con protocolos de actuación específicos y un trabajo coordinado trans- y multidisciplinar.(AU)

Introduction: Acquired brain injury (ABI) is defined as a neurological injury, acutely occurred, at some point in life causing impairment or loss of functional capacity. In 2019, a specific document was created by the Ombudsman pointing out the relevance of attention to this entity in the pediatric age. Patients and method: The process of creation and the casuistry of care of one of the first comprehensive care units for subacute ACD in pediatric age within the public health system is presented. Results: Different clinical guidelines have been prepared on the admission and care process within the unit, both for patients and their relatives. Twenty-four patients ≤18 years old, admitted to the subacute phase ACD unit from November 2019 to July 2021, 12 coming from the Community of Madrid, were attended. The median age was 6.97 years. Traumatic mechanism was the most frequent, with iatrogenic causes predominating, followed by precipitation and vehicle-related accidents. On admission to the unit, 8 maintained a minimally conscious/vegetative state. The collaboration of up to 14 different specialists was required due to the complexity of the patients. The overall evolution was favorable in 23 cases, with sequelae in all of them. Conclusion: The creation of units specialized in pediatric ACD care with specific action protocols and coordinated trans- and multidisciplinary work is of vital importance.(AU)

Estado actual y perspectivas futuras en el manejo de la hipertensión intracraneal posterior a traumatismo craneoencefálico: craniectomía descompresiva, hipotermia terapéutica y barbitúricos / Current status and outlook for the management of intracranial hypertension after traumatic brain injury: decompressive craniectomy, therapeutic hypothermia, and barbiturates

Introducción: El aumento de la presión intracraneal se ha asociado a un pronóstico neurológicodesfavorable y a un incremento en la mortalidad en pacientes con traumatismo craneoencefálico grave. Tradicionalmente, las terapias para disminuir la presión intracraneal se administranutilizando un enfoque progresivo, reservando el uso de opciones más agresivas para los casossin respuesta a intervenciones de primer nivel, o de hipertensión intracraneal refractaria. Desarrollo: El valor terapéutico de las intervenciones de rescate para la hipertensión intracraneal, así como el momento adecuado para su uso ha sido debatido constantemente en laliteratura. En esta revisión, discutiremos las principales opciones de tratamiento para la hipertensión intracraneal refractaria posterior a un traumatismo craneoencefálico grave en adultos.Tenemos la intención de llevar a cabo una revisión en profundidad de los ensayos controladosaleatorios más representativos sobre las diferentes intervenciones terapéuticas de rescate,incluyendo la craniectomía descompresiva, hipotermia terapéutica y barbitúricos. Además,discutiremos las perspectivas futuras de estas opciones de tratamiento. Conclusiones: La evidencia parece mostrar que se puede reducir la mortalidad al utilizar estasintervenciones de rescate como terapia de último nivel, sin embargo, este beneficio vieneacompanado de una discapacidad severa. La decisión de realizar o no estas intervencionesdebe ser individualizada y centrada en el paciente. El desarrollo e integración de diferentesvariables fisiológicas a través de monitorización multimodal es de suma importancia para poderproporcionar información pronóstica más sólida a los pacientes que enfrentan este tipo dedecisiones.(AU)

Introduction: Increased intracranial pressure has been associated with poor neurological out-comes and increased mortality in patients with severe traumatic brain injury. Traditionally,intracranial pressure-lowering therapies are administered using an escalating approach, withmore aggressive options reserved for patients showing no response to first-tier interventions,or with refractory intracranial hypertension. Development: The therapeutic value and the appropriate timing for the use of rescue treat-ments for intracranial hypertension have been a subject of constant debate in literature. Inthis review, we discuss the main management options for refractory intracranial hypertensionafter severe traumatic brain injury in adults. We intend to conduct an in-depth revision of themost representative randomised controlled trials on the different rescue treatments, includingdecompressive craniectomy, therapeutic hypothermia, and barbiturates. We also discuss futureperspectives for these management options. Conclusions: The available evidence appears to show that mortality can be reduced whenrescue interventions are used as last-tier therapy; however, this benefit comes at the cost ofsevere disability. The decision of whether to perform these interventions should always bepatient-centred and made on an individual basis. The development and integration of differentphysiological variables through multimodality monitoring is of the utmost importance to providemore robust prognostic information to patients facing these challenging decisions.(AU)

Ecografía de nervio óptico para estimar hipertensión intracraneal en pacientes adultos con neurotrauma

Introducción: El neurotrauma es una condición que puede dar paso a una hipertensión intracraneana, situación que es muy grave. Los métodos diagnósticos de elección son los invasivos, aun así, los no invasivos y entre ellos la ecografía del nervio óptico, ofrecen muchísimas ventajas. Objetivo: Describir elementos esenciales de la ecografía de nervio óptico como método para diagnosticar hipertensión intracraneal en pacientes adultos con neurotrauma. Métodos: Se hizo una revisión de la literatura más reciente sin restricción lingüística o geográfica en las bases de datos PubMed y SciELO, se usaron términos afines al tema del artículo y se realizó una valoración crítica sobre la bibliografía consultada. Resultados: La literatura disponible sobre la ecografía del nervio óptico en la determinación de la hipertensión intracraneal es abundante y la mayoría apunta a sus beneficios como método no invasivo. La principal debilidad del mismo es que no es capaz de dar un valor exacto y esto se debe a que el valor normal del diámetro de la vaina del nervio óptico por cada persona puede variar significativamente. La proporción directa entre el diámetro de la vaina del nervio óptico y la presión intracraneal es un hecho que ningún autor intenta invalidar. Conclusiones: La ecografía del nervio óptico es un método seguro, accesible económicamente, no invasivo, fácil de usar y con un valor predictivo confiable para determinar la hipertensión intracraneal.

Introduction: Neurotrauma is a condition that can lead to intracranial hypertension, which is a very serious situation. The diagnostic methods of choice are the invasive ones, even so, the non-invasive ones offer many advantages, the ultrasound of the optic nerve is among them. Objective: To describe essential elements of optic nerve ultrasound as a method to diagnose intracranial hypertension in adult patients with neurotrauma. Methods: A review of the most recent literature was made without linguistic or geographical restrictions in databases such as PubMed and SciELO, terms related to the theme of the manuscript were used. A critical assessment of the consulted bibliography was made. Results: The available literature on optic nerve ultrasound in the determination of intracranial hypertension is abundant and most points to the benefits as a non-invasive method. However, its main weakness lies in the fact that it is not capable of giving an exact value, due to the fact that the normal value of the diameter of the optic nerve sheath for each person can vary significantly. The direct relationship between optic nerve sheath diameter and intracranial pressure is a fact that no author attempts to invalidate. Conclusions: Optic nerve ultrasound is a safe, affordable, non-invasive, easy-to-use method with a reliable predictive value to determine intracranial hypertension.

Evolução clínica e sobrevida de pacientes vítimas de traumatismo cranioencefálico / Clinical evolution and survival of patients victims of head trauma / Evolución clínica y supervivencia de pacientes víctimas de trauma cerebral

Introdução: Trauma cranioencefálico é causa importante de morbimortalidade e incapacidades, principalmente em indivíduos com idade inferior a 45 anos. Doenças neurológicas possuem um processo de recuperação lenta, requerem internação prolongada e, consequentemente, predispõem os pacientes a complicações. Objetivo: Descrever a evolução clínica e a sobrevida de pacientes vítimas de traumatismo crânioencefálico internados em uma Unidade de Terapia Intensiva. Método: Estudo transversal com delineamento descritivo e abordagem quantitativa. Resultados: No período do estudo, foram internadas 33 pessoas diagnosticadas com traumatismo cranioencefálico numa Unidade de Terapia Intensiva Neurológica Adulta de um hospital de ensino no Noroeste Paulista. Em relação ao perfil, 75,7% dos pacientes eram do sexo masculino e a faixa etária predominante de 31 a 59 anos (51,5%). Quanto à causa do trauma, o principal motivo foi a queda, com valor equivalente a 57,58%. Quanto à classificação da lesão, 57,58% foram traumas graves e 66,67% receberam tratamento cirúrgico. O tempo médio de permanência na Unidade de Terapia Intensiva foi superior a 7 dias (42,4%). Sobre a evolução clínica, 42,42% necessitaram de cateter para monitoração da pressão intracraniana, 63,64% foram submetidos à ventilação mecânica invasiva e 78,79% fizeram uso de drogas vasoativas sendo a mais utilizada a Noradrenalina em 67,65% dos casos, seguida do Nitroprussiato de sódio (Nipride®) em 17,65% e a Vasopressina em 14,70%, associada a Noradrenalina. Complicações ocorreram em 54,5% dos pacientes, sendo mais frequente a pneumonia, com 47,83%. O desfecho clínico foi a alta hospitalar para 75,76%, enquanto 12% apresentaram sequelas neurológicas. Conclusão: A maioria dos pacientes necessitou de monitoração da pressão intracraniana, ventilação mecânica e drogas vasoativas. Por ocasião da alta hospitalar, se observou uma pequena porcentagem de pacientes com sequelas neurológicas, reforçando a importância, expertise e competência da equipe multiprofissional no trabalho assistencial em unidades de neurointensivismo.

Introduction: Cranioencephalic trauma is an important cause of morbidity, mortality and disability, especially in individuals under the age of 45. Neurological diseases have a slow recovery process, require prolonged hospitalization and, consequently, predispose patients to complications. Objective: To describe the clinical evolution and survival of patients suffering from traumatic brain injury admitted to an Intensive Care Unit. Method: Cross-sectional study with a descriptive design and quantitative approach. Results: During the study period, 33 people diagnosed with traumatic brain injury were admitted to an Adult Neurological Intensive Care Unit of a teaching hospital in the Northwest of São Paulo. Regarding the profile, 75.7% of patients were male and the predominant age range was 31 to 59 years old (51.5%). As for the cause of the trauma, the main reason was the fall, with a value equivalent to 57.58%. Regarding the classification of the injury, 57.58% were severe traumas and 66.67% received surgical treatment. The average length of stay in the Intensive Care Unit was more than 7 days (42.4%). Regarding clinical evolution, 42.42% required an catheter to monitor intracranial pressure, 63.64% underwent invasive mechanical ventilation and 78.79% used vasoactive drugs, with Noradrenaline being the most used in 67.65% of cases, followed by sodium nitroprusside (Nipride®) in 17.65% and vasopressin in 14.70%, associated with noradrenaline. Complications occurred in 54.5% of patients, with pneumonia being the most common, with 47.83%. The clinical outcome was hospital discharge for 75.76%, while 12% had neurological sequelae. Conclusion: Most patients required intracranial pressure monitoring, mechanical ventilation and vasoactive drugs. At the time of hospital discharge, a small percentage of patients with neurological sequelae were observed, reinforcing the importance, expertise and competence of the multidisciplinary team in care work in neurointensive care units

Introducción: El trauma craneoencefálico es una causa importante de morbilidad, mortalidad y discapacidad, especialmente en individuos menores de 45 años. Las enfermedades neurológicas tienen un proceso de recuperación lento, requieren hospitalización prolongada y, en consecuencia, predisponen a los pacientes a sufrir complicaciones. Objetivo: Describir la evolución clínica y supervivencia de pacientes con traumatismo craneoencefálico ingresados en una Unidad de Cuidados Intensivos. Método: Estudio transversal con diseño descriptivo y enfoque cuantitativo. Resultados: Durante el período de estudio, 33 personas diagnosticadas con lesión cerebral traumática fueron internadas en una Unidad de Cuidados Intensivos Neurológicos de Adultos de un hospital universitario del Noroeste de São Paulo. En cuanto al perfil, el 75,7% de los pacientes fueron del sexo masculino y el rango de edad predominante fue de 31 a 59 años (51,5%). En cuanto a la causa del traumatismo, el motivo principal fue la caída, con un valor equivalente al 57,58%. En cuanto a la clasificación de la lesión, el 57,58% fueron traumatismos graves y el 66,67% recibió tratamiento quirúrgico. La estancia media en la Unidad de Cuidados Intensivos fue superior a 7 días (42,4%). En cuanto a la evolución clínica, el 42,42% requirió catéter para monitorizar la presión intracraneal, el 63,64% recibió ventilación mecánica invasiva y el 78,79% utilizó fármacos vasoactivos, siendo la noradrenalina la más utilizada en el 67,65% de los casos, seguida del nitroprusiato de sodio (Nipride®) en 17,65% y vasopresina en 14,70%, asociada a noradrenalina. Las complicaciones ocurrieron en el 54,5% de los pacientes, siendo la neumonía la más común, con el 47,83%. El resultado clínico fue el alta hospitalaria para el 75,76%, mientras que el 12% tuvo secuelas neurológicas. Conclusión: La mayoría de los pacientes requirieron monitorización de la presión intracraneal, ventilación mecánica y fármacos vasoactivos. Al momento del alta hospitalaria se observó un pequeño porcentaje de pacientes con secuelas neurológicas, lo que refuerza la importancia, experiencia y competencia del equipo multidisciplinario en el trabajo asistencial en las unidades de cuidados neurointensivos

Fluid therapy and traumatic brain injury: A narrative review.

Traumatic brain injury (TBI) is an important health and social problem. The mechanism of damage of this entity could be divided into two phases: (1) a primary acute injury because of the traumatic event; and (2) a secondary injury due to the hypotension and hypoxia generated by the previous lesion, which leads to ischemia and necrosis of neural cells. Cerebral edema is one of the most important prognosis markers observed in TBI. In the early stages of TBI, the cerebrospinal fluid compensates the cerebral edema. However, if edema increases, this mechanism fails, increasing intracranial pressure. To avoid this chain effect, several treatments are applied in the clinical practice, including elevation of the head of the bed, maintenance of normothermia, pain and sedation drugs, mechanical ventilation, neuromuscular blockade, controlled hyperventilation, and fluid therapy (FT). The goal of FT is to improve the circulatory system to avoid the lack of oxygen to organs. Therefore, rapid and early infusion of large volumes of crystalloids is performed in clinical practice to restore blood volume and blood pressure. Despite the relevance of FT in the early management of TBI, there are few clinical trials regarding which solution is better to apply. The aim of this study is to provide a narrative review about the role of the different types of FT used in the daily clinical practice on the management of TBI. To achieve this objective, a physiopathological approach to this entity will be also performed, summarizing why the different types of FT are used.

Current status and outlook for the management of intracranial hypertension after traumatic brain injury: decompressive craniectomy, therapeutic hypothermia, and barbiturates.

INTRODUCTION: Increased intracranial pressure (ICP) has been associated with poor neurological outcomes and increased mortality in patients with severe traumatic brain injury (TBI). Traditionally, ICP-lowering therapies are administered using an escalating approach, with more aggressive options reserved for patients showing no response to first-tier interventions, or with refractory intracranial hypertension. DEVELOPMENT: The therapeutic value and the appropriate timing for the use of rescue treatments for intracranial hypertension have been a subject of constant debate in literature. In this review, we discuss the main management options for refractory intracranial hypertension after severe TBI in adults. We intend to conduct an in-depth revision of the most representative randomised controlled trials on the different rescue treatments, including decompressive craniectomy, therapeutic hypothermia, and barbiturates. We also discuss future perspectives for these management options. CONCLUSIONS: The available evidence appears to show that mortality can be reduced when rescue interventions are used as last-tier therapy; however, this benefit comes at the cost of severe disability. The decision of whether to perform these interventions should always be patient-centred and made on an individual basis. The development and integration of different physiological variables through multimodality monitoring is of the utmost importance to provide more robust prognostic information to patients facing these challenging decisions.

Comparison of effectiveness between different interventions in postconcussive symptoms in adolescents and young people: a literature review.

INTRODUCTION: Currently, concussion considers a problem of great magnitude, adolescents and young people being the population at risk, since it is in the process of maturation. Our goal has been to compare the effectiveness of different interventions (exercise therapy, vestibular rehabilitation and rest) in adolescents and young people with concussion. DEVELOPMENT: A bibliographic search was carried out in the main databases. Once the inclusion/exclusion criteria and the PEDro methodological scale were applied, 6 articles were reviewed. The results support the use of exercise and vestibular rehabilitation in the initial stages to reduce post-concussion symptoms. According to most authors, therapeutic physical exercise and vestibular rehabilitation report greater benefits, although a protocol that unifies assessment scales, study variables and analysis parameters would be needed to be able to make the inference in the target population. CONCLUSIóN: From the moment of hospital discharge, the combined application of exercise and vestibular rehabilitation could be the best option to reduce post-concussion symptoms.

Actualización en el manejo de la hipertensión intracraneal tras un traumatismo craneoencefálico / Update in management of intracraneial hypertensión after traumatic brain injury

El traumatismo craneoencefálico es una entidad heterogénea y dinámica cuya característica común, cualquiera que sea su etiología, es la disminución de la perfusión cerebral en las horas siguientes al impacto. Dado que las lesiones cerebrales por hipoxia,pueden producirse en momentos variables tras el traumatismo, la monitorización de la hipoxia, la disfunción metabólica, la hipertensión intracraneal y la actividad comicial deben detectarse de forma precoz para evitar secuelas. La neuromonitorización va a permitir detectar esas posibles anomalías que pueda comprometer el adecuado aporte de oxígeno y sustrato metabólico a las células cerebrales. A pesar de que, en los últimos años, se han incrementado las herramientas de medición de oximetría cerebral, en nuestro país su uso sigue siendo todavía muy limitado y la monitorización se basa, fundamentalmente, en la observación de la presión intracraneal y la presión de perfusión cerebral, insuficiente para garantizar una adecuada oxigenación cerebral. El objetivo de esta revisión pretende integrar la fisiopatología del traumatismo craneoencefálico con las distintas técnicas de neuromonitorización, proporcionando así un manejo actualizado y más individualizado que mejore el pronóstico del enfermo neurocrítico. (AU)

Trauma brain injury is a heterogeneous and dynamic entity characterized, whatever its etiology, by a decrease in cerebral perfusion the first hours after the impact. Brain injury due to hypoxia can occur after trauma, so monitoring brain hypoxia, metabolic dysfunction, intracranial hypertension and seizure activity must be detected early to prevent brain sequelae. Neuromonitoring will detect those anomalies that could compromise the adequate oxygen supply and substrates of cerebral metabolism. Despite cerebral oximetry monitoring has increased in recent years, unfortunately very limited in our country, neuromonitoring is often based on intracranial pressure and cerebral perfusion pressure, insufficient to measure cerebral oxygenation. The objective of this review is to integrate the pathophysiology of trauma brain injury with the different neuromonitoring techniques to provide an updated and more individualized management that improves the prognosis of neurocritical patients. (AU)

Sinking bone flap due to overdrainage of a ventriculoperitoneal shunt. A case report and review of the literature.

The widespread use of decompressive craniectomy and subsequent cranioplasty has led to a better understanding of its complications. However, cases of a sunken bone flap have hardly ever been described. We present the eighth case reported up to date and perform a review of the literature of this sporadic complication. A 40-year-old Caucasian male suffered a traumatic brain injury that required a decompressive craniectomy. One month after initial trauma autologous cranioplasty was performed. A ventriculoperitoneal shunt was also placed. Neurological status progressively improved but his therapist noted cognitive status decline 8 months later. Follow-up computed tomography showed a progressive sinking bone flap. The patient underwent bone flap removal and a custom-made calcium phosphate-based implant was inserted, leading to symptoms resolution. Bone resorption has been described as the main cause of sinking bone flap following cranioplasty. This entity may manifest with symptoms of overdrainage in patients with cerebrospinal fluid shunt devices.

External validation of the Glasgow Coma Scale-Pupils in patients with severe head injury. / Validación externa de la Escala de Coma de Glasgow con valoración pupilar en pacientes con traumatismo craneoencefálico grave.

OBJECTIVES: To compare the ability of the Glasgow Coma Scale (GCS) score, the GCS Pupils (GCS-P) score, and the Pupil Reactivity Score (PRS) to predict mortality in patients with severe head injury. MATERIAL AND METHODS: Retrospective analysis of all patients with severe head injury and initial GCS scores of 8 or lower on initial evaluation for whom records included pupil dilation information and clinical course after admission to intensive care units of participating hospitals. We assessed the ability of each of the 3 scores (GCS, GCS-P, and PRS) to predict mortality using discrimination analysis. Discrimination was estimated by calculating the areas under the receiver operating characteristic curves (AUC) and 95% CIs. RESULTS: A total of 1551 patients with severe head injury and pupil dilation records were studied. The mean age was 50 years, 1190 (76.7%) were males, and 592 (38.2%) died. No pupil dilation was observed in 905 patients (58.3%), 362 (23.3%) had unilateral mydriasis, and 284 (18.3%) had bilateral mydriasis. The GCS-P score was significantly better at predicting mortality, with an AUC of 0.77 (95% CI, 0.74-0.79), versus 0.69 (95% CI, 0.67-0.72) for the GCS, and 0.75 (95% CI, 0.72-0.77) for the PRS. As the GCS-P score decreased, mortality increased. CONCLUSION: The GCS-P was more useful than the GCS for predicting death after severe head injury.

OBJETIVO: Analizar la capacidad para predecir la mortalidad hospitalaria de la Escala de Coma de Glasgow con valoración pupilar (GCS-P) comparado con la Escala de Coma de Glasgow (GCS) y con la escala de reactividad pupilar (PRS) en pacientes con traumatismo craneoencefálico (TCE) grave. METODO: Análisis retrospectivo de cohortes de todos los pacientes con TCE, puntuación en la GCS # 8 en la atención inicial, datos de exploración pupilar inicial y del desenlace hospitalario ingresados en las unidades de cuidados intensivos participantes. Se determinó la capacidad predictiva de mortalidad de la GCS, PRS y la GCS-P mediante un análisis de discriminación. La discriminación se analizó empleando curvas operativas del receptor (COR), el área bajo la curva (ABC) y su intervalo de confianza del 95% (IC 95%). RESULTADOS: Se analizaron 1.551 pacientes con TCE grave y datos sobre exploración pupilar. La edad media fue de 50 años, 1.190 (76,7%) eran hombres, y hubo 592 (38,2%) defunciones. Hubo 905 (58,3%) pacientes sin alteraciones pupilares, 362 (23,3%) con midriasis unilateral y 284 (18,3%) pacientes con midriasis bilateral. El análisis del ABCCOR para predecir la mortalidad hospitalaria mostró de forma significativa una mejor capacidad predictiva del GCS-P con ABC = 0,77 (IC 95% 0,74-0,79) respecto al GCS con ABC = 0,69 (IC 95% 0,67-0,72). La reactividad pupilar mostró un ABC = 0,75 (IC 95% 0,72-0,77). Se observó un incremento de mortalidad con la disminución del GCS-P. CONCLUSIONES: La escala GCS-P presentó mejor rendimiento que la GCS para predecir mortalidad en el TCE grave.

Validación externa de la Escala de Coma de Glasgow con valoración pupilar en pacientes con traumatismo craneoencefálico grave / External validation of the Glasgow Coma Scale-Pupils in patients with severe head injury

Objetivos. Analizar la capacidad para predecir la mortalidad hospitalaria de la Escala de Coma de Glasgow con valoración pupilar (GCS-P) comparado con la Escala de Coma de Glasgow (GCS) y con la escala de reactividad pupilar (PRS) en pacientes con traumatismo craneoencefálico (TCE) grave. Métodos. Análisis retrospectivo de cohortes de todos los pacientes con TCE, puntuación en la GCS # 8 en la atención inicial, datos de exploración pupilar inicial y del desenlace hospitalario ingresados en las unidades de cuidados intensivos participantes. Se determinó la capacidad predictiva de mortalidad de la GCS, PRS y la GCS-P mediante un análisis de discriminación. La discriminación se analizó empleando curvas operativas del receptor (COR), el área bajo la curva (ABC) y su intervalo de confianza del 95% (IC 95%). Resultados. Se analizaron 1.551 pacientes con TCE grave y datos sobre exploración pupilar. La edad media fue de 50 años, 1.190 (76,7%) eran hombres, y hubo 592 (38,2%) defunciones. Hubo 905 (58,3%) pacientes sin alteraciones pupilares, 362 (23,3%) con midriasis unilateral y 284 (18,3%) pacientes con midriasis bilateral. El análisis del ABCCOR para predecir la mortalidad hospitalaria mostró de forma significativa una mejor capacidad predictiva del GCS-P con ABC = 0,77 (IC 95% 0,74-0,79) respecto al GCS con ABC = 0,69 (IC 95% 0,67-0,72). La reactividad pupilar mostró un ABC = 0,75 (IC 95% 0,72-0,77). Se observó un incremento de mortalidad con la disminución del GCS-P. Conclusiones. La escala GCS-P presentó mejor rendimiento que la GCS para predecir mortalidad en el TCE grave. (AU)

Objectives. To compare the ability of the Glasgow Coma Scale (GCS) score, the GCS Pupils (GCS-P) score, and the Pupil Reactivity Score (PRS) to predict mortality in patients with severe head injury. Methods. Retrospective analysis of all patients with severe head injury and initial GCS scores of 8 or lower on initial evaluation for whom records included pupil dilation information and clinical course after admission to intensive care units of participating hospitals. We assessed the ability of each of the 3 scores (GCS, GCS-P, and PRS) to predict mortality using discrimination analysis. Discrimination was estimated by calculating the areas under the receiver operating characteristic curves (AUC) and 95% CIs. Results. A total of 1551 patients with severe head injury and pupil dilation records were studied. The mean age was 50 years, 1190 (76.7%) were males, and 592 (38.2%) died. No pupil dilation was observed in 905 patients (58.3%), 362 (23.3%) had unilateral mydriasis, and 284 (18.3%) had bilateral mydriasis. The GCS-P score was significantly better at predicting mortality, with an AUC of 0.77 (95% CI, 0.74-0.79), versus 0.69 (95% CI, 0.67-0.72) for the GCS, and 0.75 (95% CI, 0.72-0.77) for the PRS. As the GCS-P score decreased, mortality increased. Conclusion. The GCS-P was more useful than the GCS for predicting death after severe head injury. (AU)

Atlanto-occipital dislocation with concomitant severe traumatic brain injury: A retrospective study at a level 1 trauma center / Luxación atlantooccipital con traumatismo craneoencefálico grave concomitante: estudio retrospectivo en un centro de trauma de nivel 1

Background: Traumatic atlanto-occipital dislocation (AOD) is a life-threatening injury. Although traumatic brain injury (TBI) is associated with increased mortality in AOD patients, a detailed individual analysis of these patients is lacking in the literature. Methods: Patients ≥16 years old who were diagnosed of AOD with concomitant severe TBI from 2010 to 2020 were included in this retrospective study. We examined the epidemiology, injury mechanisms, associated injuries, and outcomes of these patients. Results: Eight patients were included. Six patients died before any intervention could be performed, and two patients underwent an occipito-cervical fixation, showing a notorious neurologic improvement on follow-up. Cardiorespiratory arrest (CRA) was a strong predictor of subsequent death. CT signs of diffuse axonal injury (DAI) were present in most patients and were confirmed by magnetic resonance imaging (MRI) in survivors. Although TBI was not the main cause of death, it was responsible for the delayed neurological improvement and deferred stabilization. The average sensitivity of the different used methodologies for AOD diagnosis ranged from 0.50 to 1.00, being the Basion Dens Interval (BDI) and the Condyle-C1 interval (CCI) sum the most reliable criteria. Non-survivors tended to show greater distraction measurements. The high incidence of condylar avulsion fractures suggests that their visualization on the initial CT study should heighten the suspicion for AOD. Conclusions: Our data suggest that patients with AOD and concomitant severe TBI might be salvageable patients. In those who survive beyond the first hospital days and show neurological improvement, surgical treatment should be performed as they can achieve an important neurologic recovery. (AU)

Antecedentes: La luxación atlantooccipital (AOD) traumática es una lesión potencialmente mortal. Aunque el traumatismo craneoencefálico (TCE) se asocia con un aumento de la mortalidad en los pacientes con AOD, no existe en la literatura un análisis individual detallado de estos pacientes. Métodos: En este estudio retrospectivo se incluyeron pacientes mayores de 16 años que fueron diagnosticados de AOD con TCE grave concomitante durante el periodo 2010-2020. Estudiamos la epidemiología, los mecanismos lesionales, así como las lesiones asociadas y los resultados de estos pacientes. Resultados: Se incluyeron ocho pacientes. Seis pacientes fallecieron antes de que se pudiera realizar cualquier intervención y dos pacientes fueron sometidos a una fijación occipitocervical, mostrando una notoria mejoría neurológica durante el seguimiento. La parada cardiorrespiratoria fue un predictor de muerte. En la TC inicial, signos de lesión axonal difusa estaban presentes en la mayoría de los pacientes y se confirmaron mediante imágenes de resonancia magnética en los supervivientes. Aunque el TCE no fue la principal causa de muerte, fue responsable de una mejoría neurológica tardía y por ello una estabilización diferida. La sensibilidad de las diferentes metodologías utilizadas para el diagnóstico de AOD osciló entre 0,50 y 1,00, siendo el intervalo Basion Dens y la suma del intervalo Condylo-C1 los criterios más fiables. Además, los no supervivientes presentaban mayores medidas de distracción. La alta incidencia de fracturas de cóndilo por avulsión sugiere que su visualización en el estudio de TC inicial debería aumentar la sospecha de AOD. Conclusiones: Nuestros datos sugieren que los pacientes con AOD y TCE grave concomitante podrían ser pacientes salvables. En aquellos que sobreviven más allá de los primeros días de...(AU)Palabras clave:Luxación atlantooccipitalColumna cervicalUnión craneocervicalFusión occipitocervicalTraumatismo craneoencefálico