Rehabilitación del daño cerebral y unidades de convalecencia / Brain Injury Rehabilitation and Convalescent Units

Existe un consenso generalizado en cuanto que la atención del daño cerebral requiere la existencia de unidades y equipos especializados en dar una atención integral.La realidad es que existe una escasez de recursos para la atención de pacientes con daño cerebral, especialmente en cuanto a laexistencia de unidades específicas de neurorehabilitación o unidades de rehabilitación intensiva. A pesar de que la Congregación de Hermanas Hospitalarias cuenta con la Red Menni de daño cerebral no es suficientepara atender a todos los pacientes. Un número importante de pacientes son atendidos actualmente en unidades de convalecencia (centros afines de la Red Menni), los cuales no todos cuentan con un equipo multidisciplinar ni con la tecnología ni robótica necesaria. (AU)

There is a general consensus that carefor brain damage requires the existence ofunits and teamns specialized in providingcomprehensive care. The reality is that there is a shortage of resources for the care of patients with brain, especially regarding the existence of specific units of neurorehabilitation or intensive rehabilitation units.Even though the Congregation of SistersHospitallers has the Menni Network of brain damage not it is enough to take care of all the patiens.A significant number of patients they are currently cared for in convalescent units (related centers of the Red Menni), nota ll of which have a multidisciplinary tea mor the technology no robotics necessary. (AU)

Impact of COVID-19 on a brain damage unit.

AIM: To report on the impact of COVID-19 on a brain damage unit. METHODS: We reviewed the records of all patients admitted to our brain damage unit. The study included all the significant clinical events from the first positive qualitative real-time reverse-transcriptase-polymerase-chain-reaction assay (April 8th, 2020) for SARS-CoV-2 to the day all patients tested negative (June 8th, 2020). RESULTS: Of the 20 patients (14 men) (age 57.7 ± 14.9; 2-71 months after brain damage; all with a modified Rankin scale score > 4), 16 tested positive for SARS-CoV-2 and remained positive for a mean of 32.3 days (ranging from 26 to 61). One patient died from COVID-19, while 12 patients were asymptomatic and three suffered mild pneumonia without acute respiratory distress syndrome. All patients received prophylactic subcutaneous heparin. Intravenous methylprednisolone was prescribed for three patients with bilateral pneumonia with excellent results. CONCLUSIONS: Most positive cases (93.7%) were not severe. The good outcome was most likely due to the use of prophylactic anticoagulation therapy, the early use of methylprednisolone for pneumonia and the previously reported immunosuppression amid patients with brain damage. This study hopes to encourage further study into brain damage immunity.

EEG reactivity testing for prediction of good outcome in patients after cardiac arrest.

OBJECTIVE: To determine the additional value of EEG reactivity (EEG-R) testing to EEG background pattern for prediction of good outcome in adult patients after cardiac arrest (CA). METHODS: In this post hoc analysis of a prospective cohort study, EEG-R was tested twice a day, using a strict protocol. Good outcome was defined as a Cerebral Performance Category score of 1-2 within 6 months. The additional value of EEG-R per EEG background pattern was evaluated using the diagnostic odds ratio (DOR). Prognostic value (sensitivity and specificity) of EEG-R was investigated in relation to time after CA, sedative medication, different stimuli, and repeated testing. RESULTS: Between 12 and 24 hours after CA, data of 108 patients were available. Patients with a continuous (n = 64) or discontinuous (n = 19) normal voltage background pattern with reactivity were 3 and 8 times more likely to have a good outcome than without reactivity (continuous: DOR, 3.4; 95% confidence interval [CI], 0.97-12.0; p = 0.06; discontinuous: DOR, 8.0; 95% CI, 1.0-63.97; p = 0.0499). EEG-R was not observed in other background patterns within 24 hours after CA. In 119 patients with a normal voltage EEG background pattern, continuous or discontinuous, any time after CA, prognostic value was highest in sedated patients (sensitivity 81.3%, specificity 59.5%), irrespective of time after CA. EEG-R induced by handclapping and sternal rubbing, especially when combined, had highest prognostic value. Repeated EEG-R testing increased prognostic value. CONCLUSION: EEG-R has additional value for prediction of good outcome in patients with discontinuous normal voltage EEG background pattern and possibly with continuous normal voltage. The best stimuli were clapping and sternal rubbing.

Application of the cerebral edema monitor on cardiopulmonary bypass in infants.

A diagnostic accuracy study was adopted to evaluate the ability of Cerebral edema monitor by comparing the index test results with those of the reference standard. The serum levels of astrocyte S100 protein and neuron-specific enolase (NSE) were determined. Changes in the cerebral electrical impedance coefficient (CEIC) was detected with the BORN-BE monitor. The left- and right-sided CEIC values, serum levels of S100, and serum NSE in the CPB group significantly increased from the beginning to the end of the operation (P < .05). Furthermore, left and right-sided CEIC values, serum levels of S100, and serum NSE in the CPB-B group were significantly higher than those of the CPB-A group (P < .05). Detection rates of cerebral edema in the CPB-B group at the 24 h post-operative time point were significantly higher than those in the CPB-A group (P < .05). The degree of brain damage is positively correlated with the CPB and aortic cross-clamping. CEIC is a sensitive index reflecting brain damage during CPB in infants.

Desarrollo y validación externa de un modelo pronóstico precoz para supervivientes de una parada cardiaca extrahospitalaria / Development and external validation of an early prognostic model for survivors of out-of-hospital cardiac arrest

Introducción y objetivos: A pesar del uso de la hipotermia terapéutica, los pacientes recuperados tras sufrir una parada cardiaca extrahospitalaria tienen un elevado riesgo de muerte o deterioro neurológico grave. Se analizaron la utilidad de diversas variables disponibles al ingreso hospitalario para predecir su evolución a los 6 meses. Métodos: Se desarrolló un estudio multicéntrico en 3 unidades de cuidados intensivos cardiacos. El análisis se realizó sobre 153 pacientes ingresados en dos centros tras sufrir una parada cardiaca extrahospitalaria recuperada y que se trataron con control de temperatura, entre enero de 2007 y julio de 2015. Se consideraron secuelas neurológicas significativas si la Cerebral Performance Categories Scale > 2 a los 6 meses. Los resultados se validaron externamente con los datos procedentes de otros 91 pacientes ingresados en un tercer hospital, durante el mismo periodo de tiempo. Resultados: Del total de 244 pacientes (mediana de edad, 60 años; 77,1% varones; 50,0% en el contexto de isquemia miocárdica aguda), 107 (43,8%) sobrevivieron a los 6 meses con una evolución neurológica favorable. Se calculó un modelo predictivo que incluyó 5 variables (primer ritmo, edad, lactato al ingreso, tiempo hasta recuperación de circulación espontánea y diabetes), con un área bajo la curva de 0,90 (IC95%, 0,85-0,95). Cuando se realizó la validación externa del modelo, la sensibilidad fue de 73,5%, con una especificidad de 78,6% y un área bajo la curva de 0,82 (IC95%, 0,73-0,91). Conclusiones: Un modelo predictivo que incluye cinco variables disponibles en el momento de ingreso de pacientes recuperados tras sufrir una parada cardiaca extrahospitalaria puede ayudar a predecir la probabilidad de supervivencia libre de secuelas neurológicas graves en el seguimiento

Introduction and objectives: Despite therapeutic hypothermia, unconscious survivors of out-of-hospital cardiac arrest have a high risk of death or poor neurologic function. Our objective was to assess the usefulness of the variables obtained in the early moments after resuscitation in the prediction of 6-month prognosis. Methods: A multicenter study was performed in 3 intensive cardiac care units. The analysis was done in 153 consecutive survivors of out-of-hospital cardiac arrest who underwent targeted temperature management between January 2007 and July 2015. Significant neurological sequelae at 6 months were considered to be present in patients with Cerebral Performance Categories Scale > 2. An external validation was performed with data from 91 patients admitted to a third hospital in the same time interval. Results: Among the 244 analyzed patients (median age, 60 years; 77.1% male; 50.0% in the context of acute myocardial ischemia), 107 patients (43.8%) survived with good neurological status at 6 months. The prediction model included 5 variables (Shockable rhythm, Age, Lactate levels, Time Elapsed to return of spontaneous circulation, and Diabetes - SALTED) and provided an area under the curve of 0.90 (95%CI, 0.85-0.95). When external validation was performed, the predictive model showed a sensitivity of 73.5%, specificity of 78.6%, and area under the curve of 0.82 (95%CI, 0.73-0.91). Conclusions: A predictive model that includes 5 clinical and easily accessible variables at admission can help to predict the probability of survival without major neurological damage following out-of-hospital cardiac arrest

Neurological Complications Occurring After Liver Transplantation: Role of Risk Factors, Hepatic Encephalopathy, and Acute (on Chronic) Brain Injury.

Orthotopic liver transplantation (LT) remains the only way to definitively cure patients with the most severe liver diseases. Because the survival rate is now fairly high, important questions about neurological sequelae or quality of life after LT have emerged. Indeed, LT represents a peculiar situation because up to 30% of patients present with neurological symptoms after LT compared with only 4% after cardiac transplant and 0.5% after renal transplant. These postoperative neurological symptoms have long been interpreted as sequelae of hepatic encephalopathy (HE). However, postoperative decompensation of an unknown cerebral condition due to the pathophysiology of cirrhosis or undiagnosed neurodegenerative disorders or aging constitute other possibilities that are underrecognized. Some patients who undergo LT for acute liver failure and patients with cirrhosis without episodes of HE and without any previous cerebral alteration also display post-LT neurological symptoms. This latter situation speaks in favor of a direct adverse effect of either general anesthesia, the surgical procedure, or factors related to the postoperative intensive care unit (ICU) environment. The role of inflammation, which has been described in the ICU setting, could also be a crucial determinant. In this review, we will discuss the neurological complications associated with LT, the neurocognitive complications after LT, and how to assess the LT-related neurological or neurocognitive complications. Furthermore, we will review the various hypotheses surrounding post-LT neurocognitive impairment and will conclude with recommendations for future directions.

Evaluation of stereotactic radiosurgery for cerebral dural arteriovenous fistulas in a multicenter international consortium.

OBJECTIVE: In this multicenter study, the authors reviewed the results obtained in patients who underwent Gamma Knife radiosurgery (GKRS) for dural arteriovenous fistulas (dAVFs) and determined predictors of outcome. METHODS: Data from a cohort of 114 patients who underwent GKRS for cerebral dAVFs were compiled from the International Gamma Knife Research Foundation. Favorable outcome was defined as dAVF obliteration and no posttreatment hemorrhage or permanent symptomatic radiation-induced complications. Patient and dAVF characteristics were assessed to determine predictors of outcome in a multivariate logistic regression analysis; dAVF-free obliteration was calculated in a competing-risk survival analysis; and Youden indices were used to determine optimal radiosurgical dose. RESULTS: A mean margin dose of 21.8 Gy was delivered. The mean follow-up duration was 4 years (range 0.5-18 years). The overall obliteration rate was 68.4%. The postradiosurgery actuarial rates of obliteration at 3, 5, 7, and 10 years were 41.3%, 61.1%, 70.1%, and 82.0%, respectively. Post-GRKS hemorrhage occurred in 4 patients (annual risk of 0.9%). Radiation-induced imaging changes occurred in 10.4% of patients; 5.2% were symptomatic, and 3.5% had permanent deficits. Favorable outcome was achieved in 63.2% of patients. Patients with middle fossa and tentorial dAVFs (OR 2.4, p = 0.048) and those receiving a margin dose greater than 23 Gy (OR 2.6, p = 0.030) were less likely to achieve a favorable outcome. Commonly used grading scales (e.g., Borden and Cognard) were not predictive of outcome. Female sex (OR 1.7, p = 0.03), absent venous ectasia (OR 3.4, p < 0.001), and cavernous carotid location (OR 2.1, p = 0.019) were predictors of GKRS-induced dAVF obliteration. CONCLUSIONS: GKRS for cerebral dAVFs achieved obliteration and avoided permanent complications in the majority of patients. Those with cavernous carotid location and no venous ectasia were more likely to have fistula obliteration following radiosurgery. Commonly used grading scales were not reliable predictors of outcome following radiosurgery.

Out-of-hospital cardiac arrest at place of residence is associated with worse outcomes in patients admitted to intensive care. A post-hoc analysis of the targeted temperature management trial.

BACKGROUND: The majority of out-of-hospital cardiac arrests (OHCAs) occur at place of residence, which is associated with worse outcomes in unselected prehospital populations. Our aim was to investigate whether location of arrest was associated with outcome in a selected group of initial survivors admitted to intensive care. METHODS: This is a post-hoc analysis of the Targeted Temperature Management After Cardiac Arrest (TTM) trial, a multicenter controlled trial, randomizing 950 OHCA patients to an intervention of 33 °C or 36 °C. The location of cardiac arrest was defined as place of residence versus public place or other. The outcome measures were mortality and neurological outcome, as defined by the Cerebral Performance Category Scale, at 180 days. RESULTS: Approximately half of 938 included patients arrested at place of residence (53%). Location groups did not differ with respect to age (P=0.11) or witnessed arrests (P=0.48) but bystander CPR was less common (P=0.02) at place of residence. OHCA at place of residence was associated with higher 180-day mortality (55% vs. 38%, P<0.001) and worse neurological outcome (61% vs. 43%, P<0.001) compared with a public place or other. After adjusting for known confounders, OHCA at place of residence remained an independent predictor of mortality (P=0.007). CONCLUSIONS: Half of all initial survivors after OHCA admitted to intensive care had an arrest at place of residence which was independently associated with poor outcomes. Actions to improve outcomes after OHCA at place of residence should be addressed in future trials.

[A systematic review of the characteristics and prognosis of subjects who suffer an embolic stroke of undetermined source]. / Revision sistematica de las caracteristicas y pronostico de los sujetos que sufren un ictus criptogenico no lacunar de mecanismo embolico.

INTRODUCTION: The concept of embolic stroke of undetermined source (ESUS) has recently appeared to better characterise patients with cryptogenic stroke. PATIENTS AND METHODS: A systematic review of studies published since 2014 was performed to evaluate the epidemiology, clinical features and prognosis of patients with ESUS and their proportion among patients with cryptogenic stroke. RESULTS: Ten studies were identified with a total of 14,810 patients. The frequency of ESUS varied between 6% and 42%. We observed a high percentage of patients with cryptogenic stroke who met ESUS criteria (37-82%). The mean age of these patients was 65-68 years. The mean severity of the stroke, as measured using the National Institutes of Health Stroke Scale, was found to be 3-7 points. A high degree of variability was seen in the proportion of atrial fibrillation (detected during follow-up) related to the electrocardiogram monitoring technique. In five studies, some minor source of cardioembolism was observed in one out of every two patients, the most frequent being the persistence of patent foramen ovale. The risk of recurrence was 5-14.5%. CONCLUSION: The application of the new ESUS criteria provides a better definition of patients with cryptogenic stroke. Applying the concept of ESUS requires not only adequate electrocardiogram monitoring, but also routine complementary examinations to rule out the presence of minor sources of cardioembolism and other sources of embolism other than atrial fibrillation.

TITLE: Revision sistematica de las caracteristicas y pronostico de los sujetos que sufren un ictus criptogenico no lacunar de mecanismo embolico.Introduccion. Recientemente ha surgido el concepto de ictus criptogenico no lacunar de mecanismo embolico ­del ingles embolic stroke of undetermined source (ESUS)­ para caracterizar mejor a los pacientes con ictus criptogenico. Pacientes y metodos. Se realiza una revision sistematica de los estudios publicados desde 2014 hasta la actualidad, valorando la epidemiologia, las caracteristicas clinicas y el pronostico de los pacientes con ESUS y su proporcion entre los pacientes con ictus criptogenico. Resultados. Se identificaron 10 estudios con un total de 14.810 pacientes. La frecuencia de ESUS vario entre el 6 y el 42%. Se observo un porcentaje elevado de pacientes con ictus criptogenico que cumplian los criterios de ESUS (37-82%). La edad media de estos pacientes era de 65-68 años. La gravedad media del ictus, medida por la National Institutes of Health Stroke Scale, se establecio en 3-7 puntos. Se observo una alta variabilidad en la proporcion de fibrilacion auricular (detectada durante el seguimiento) relacionada con la tecnica de monitorizacion del electrocardiograma. En cinco estudios, hasta en uno de cada dos pacientes se observo alguna fuente de cardioembolismo menor, la mas frecuente, la persistencia del foramen oval permeable. El riesgo de recurrencia fue del 5-14,5%. Conclusion. La aplicacion de los nuevos criterios de ESUS define mejor a los pacientes con ictus criptogenico. La aplicacion del concepto de ESUS exige no solo una monitorizacion de electrocardiograma adecuada, sino exploraciones complementarias de rutina para descartar la presencia de fuentes de cardioembolismo menor y de otras fuentes de embolismo diferentes a la fibrilacion auricular.

Work ability score of solvent-exposed workers.

PURPOSE: Occupational chronic solvent encephalopathy (CSE), characterized by neurocognitive dysfunction, often leads to early retirement. However, only the more severe cases are diagnosed with CSE, and little is known about the work ability of solvent-exposed workers in general. The aim was to study memory and concentration symptoms, work ability and the effect of both solvent-related and non-occupational factors on work ability, in an actively working solvent-exposed population. METHODS: A questionnaire on exposure and health was sent to 3640 workers in four solvent-exposed fields, i.e. painters and floor-layers, boat builders, printers, and metal workers. The total number of responses was 1730. We determined the work ability score (WAS), a single question item of the Work Ability Index, and studied solvent exposure, demographic factors, Euroquest memory and concentration symptoms, chronic diseases, and employment status using univariate and multivariate analyses. The findings were compared to those of a corresponding national blue-collar reference population (n = 221), and a small cohort of workers with CSE (n = 18). RESULTS: The proportion of workers with memory and concentration symptoms was significantly associated with solvent exposure. The WAS of solvent-exposed workers was lower than that of the national blue-collar reference group, and the difference was significant in the oldest age group (those aged over 60). Solvent-exposed worker's WAS were higher than those of workers diagnosed with CSE. The WAS were lowest among painters and floor-layers, followed by metal workers and printers, and highest among boat builders. The strongest explanatory factors for poor work ability were the number of chronic diseases, age and employment status. Solvent exposure was a weak independent risk factor for reduced WAS, comparable to a level of high alcohol consumption. CONCLUSIONS: Even if memory and concentration symptoms were associated with higher solvent exposure, the effect of solvents on self-experienced work ability was relatively weak. This in line with the improved occupational hygiene and reduced solvent exposure levels in industrialized countries, thus the effect may be stronger in high-level exposure environments. As a single question, WAS is easily included, applicable, and recommendable in occupational screening questionnaires.

Life After the Neurosurgical Ward in Sub-Saharan Africa: Neurosurgical Treatment and Outpatient Outcomes in Uganda.

BACKGROUND: In the past decade, neurosurgery in Uganda experienced increasing surgical volume and a new residency training program. Although research has examined surgical capacity, minimal data exist on the patient population treated by neurosurgery and their eventual outcomes in sub-Saharan Africa. METHODS: Patients admitted to Mulago National Referral Hospital neurosurgical ward over 2 years (2014 and 2015) were documented in a prospective database. In total, 1167 were discharged with documented phone numbers and thus eligible for follow-up. Phone surveys were developed and conducted in the participant's language to assess mortality, neurologic outcomes, and follow-up health care. RESULTS: During the study period, 2032 patients were admitted to the neurosurgical ward, 80% for traumatic brain injury. A total of 7.8% received surgical intervention. The in-hospital mortality rate was 18%. A total of 870 patients were reached for phone follow-up, a 75% response rate, and 30-day and 1-year mortality were 4% and 8%, respectively. Almost one-half of patients had not had subsequent health care after the initial encounter. Most patients had Glasgow Outcome Scale-Extended scores consistent with good recovery and mild disability, with patients experiencing trauma faring best and patients with tumor faring worst. A total of 85% felt they returned to baseline work performance, and 76% of guardians felt that children returned to baseline school performance. CONCLUSIONS: The neurosurgical service provided health care to a large proportion of nonoperative patients. Phone surveys captured data on patients in whom nearly one-half would be lost to subsequent health care. Although mortality during initial hospitalization was high, more than 90% of those discharged survived at 1-year follow up, and the vast majority returned to work and school.

Association Between Neurological Outcomes Related to Aneurysmal Subarachnoid Hemorrhage and Onsite Access to Neurointerventional Radiology.

OBJECTIVE: An onsite access to neurointerventional radiology (NIR) may be useful for managing patients with aneurysmal subarachnoid hemorrhage (aSAH) after the aneurysm-securing procedure. We aimed to assess the association between neurological outcomes related to aSAH and onsite access to NIR service. METHODS: This was a sequential period study of 47 patients with aSAH admitted consecutively during the pre-NIR period (January 2010 to June 2012) compared with 81 patients with aSAH admitted consecutively during the post-NIR period (January 2013 to June 2015) at an academic tertiary referral intensive care unit (ICU). The primary end point was the incidence of poor neurological outcome, defined as modified Rankin scale of ≥3 at 6 months from ictus. Secondary outcomes included incidence of symptomatic vasospasm (SV) and length of stay in ICU/hospital. RESULTS: The primary end point was observed in 18 of 47 (38%) patients during the pre-NIR period versus 25 of 81 (31%) patients during the post-NIR period (P = 0.39). The post-NIR period did not have an independent impact on neurological outcomes (adjusted odds ratio = 0.8, 95% confidence interval 0.3-2.1; P = 0.66). Of the patients who developed SV, 10 of 47 (21%) were during the pre-NIR period versus 33 of 81 (41%) during the post-NIR period (P = 0.02). The post-NIR period and higher Fisher grade were independent predictors of SV. Patients with SV had similar outcomes, but with longer stay in ICU during the post-NIR period compared with the pre-NIR period. CONCLUSIONS: Among patients with aSAH, the post-NIR period was associated with more frequent detection of SV, more endovascular procedures, longer hospital stay, but with no appreciable improvement in neurological outcomes either overall or in the subset of patients with SV. STUDY REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12616000201471.

The Results of Neuroendoscopic Surgery in Patients with Posttraumatic and Posthemorrhagic Hydrocephalus.

BACKGROUND: Posttraumatic hydrocephalus (PTH) and posthemorrhagic hydrocephalus (PHH) were previously considered not suitable for neuroendoscopic treatment. New hydrocephalus theories support possible successful neuroendoscopy in such patients. METHODS: This study presents the results of neuroendoscopy in PTH and PHH with a background analysis. From 130 hydrocephalic patients after neuroendoscopic surgeries, 35 cases with PTH (n = 11) or PHH (n = 24; acute: n = 9, subacute: n = 10, chronic: n = 5) were found. The success rate (Glasgow Outcome Scale [GOS] score 4 or 5 without shunt) and clinical outcome (GOS score) of endoscopic third ventriculostomy (ETV) were analyzed. During the study period, 34 patients had ventriculoperitoneal shunts implanted, including 2 PTH and 5 PHH patients (all chronic). RESULTS: The success rate of ETV in PTH was 54.5%. In acute PHH, the success rate was 33.3%, 42.8% after excluding devastating hematomas. A post-ETV shunt was implanted in 1 patient (massive subarachnoid hemorrhage [SAH]) with final GOS score of 5. In subacute cases, the ETV success rate was 40% (no post-ETV shunts). In chronic PHH, only 1 patient with a GOS score of 5 was shunt-free (20%). The cause of ETV failure was massive SAH. Low final GOS score was caused by the extent of intracerebral bleeding or extracranial problems. The main indications for primary shunt implantation in PTH and PHH were infectious complications. The rate of good outcomes was 0% in PTH and 40% in PHH. CONCLUSIONS: The best results of neuroendoscopy were achieved in PTH and acute PHH. ETV failures were associated with massive SAH; arachnoid cistern blockage and scarring precludes ETV success.

Conocimiento sobre daño cerebral adquirido en familiares de pacientes neuroquirúrgicos / Brain injury knowledge in family members of neurosurgical patients

Antecedentes y objetivos: Diversos estudios han puesto de manifiesto las creencias erróneas sobre el daño cerebral en diferentes poblaciones. Nuestro objetivo consiste en valorar el conocimiento que poseen los familiares de los pacientes neuroquirúrgicos sobre el daño cerebral adquirido. Material y métodos: Participaron 81 familiares de pacientes ingresados durante el periodo comprendido entre febrero y agosto de 2016. Se utilizó la traducción de un cuestionario aplicado en estudios anteriores en múltiples países (EE. UU., Canadá, Reino Unido, Irlanda y Nueva Zelanda). Se registraron algunos datos sociodemográficos (edad, sexo, nivel educativo y patología del paciente) así como las respuestas a los 19 ítems verdadero/falso que constituyen el cuestionario sobre daño cerebral adquirido. El análisis de datos se ha desarrollado mediante una modelización gráfica con parámetro de regularización configurando así una red que muestra el nivel de asociación de los ítems del cuestionario a partir del patrón de respuestas de los participantes. Resultados: El análisis de los datos muestra dos áreas conceptuales con una elevada tasa de error en los ítems asociados: el comportamiento y el manejo de los pacientes, y las expectativas sobre la recuperación en daño cerebral adquirido. Conclusiones: Con este estudio podemos objetivar las áreas de falsas creencias sobre el daño cerebral que poseen los familiares de los pacientes atendidos en el servicio de neurocirugía. Este desconocimiento puede suponer un obstáculo en el proceso de recuperación de los pacientes. Por lo tanto, proponemos hacer hincapié en la información sobre el daño cerebral a los familiares de estos pacientes, sobre todo sus síntomas y su evolución

Background and objectives: Several studies have shown misconceptions about brain injury in different populations. The aim of this study was to assess the knowledge and perceptions about brain injury of family members of neurosurgical patients in our hospital. Material and methods: The participants (n=81) were relatives of patients admitted to the neurosurgery department between February and August 2016. They voluntarily completed a 19-item true-false format survey about brain injury based on a translation of other questionnaires used in previous studies from other countries (USA, Canada, UK, Ireland and New Zealand). Also, some sociodemographic data were collected (age, sex, education level and the patient's pathology). Data analysis was developed through graphical modelling with a regularisation parameter plotted on a network representing the association of the items of the questionnaire from the response pattern of participants. Results: Data analysis showed two conceptual areas with a high rate of wrong answers: behaviour and management of patients, and expectations about acquired brain injury recovery. Conclusions: The results obtained in this study would enable us to objectify misconceptions about acquired brain injury in patients' relatives attended in the neurosurgery department. This lack of knowledge could be a great obstacle in patients' recovery process. Therefore, we suggest placing the emphasis on the provision of information on brain injury to patients' families, especially with regard to its symptoms and course of development

Tendencias en el tratamiento de los aneurismas cerebrales: análisis de una serie hospitalaria / Tendencies in cerebral aneurism treatment: Analysis of a hospital series

Introducción y objetivo: Conocer, en nuestro medio, si ha habido variaciones en el tiempo en la atención a la HSA. Material y métodos: Análisis de 571 pacientes con HSA tratados en el Hospital Universitario La Fe. Comparación de 2 periodos: HSA-VIEJA: 462 pacientes consecutivos atendidos entre abril del 1997 y marzo de l2005; HSA-NUEVA: 109 pacientes consecutivos atendidos entre marzo del 2007 y abril del 2010. Se analizaron las características demográficas, los factores de riesgo, la gravedad al ingreso, los tiempos hasta la arteriografía, el diagnóstico de aneurisma, el tratamiento quirúrgico o intravascular y sus tiempos, frecuencia de complicaciones neurológicas, la mortalidad durante el ingreso y escala de Rankin modificada (mRS) al alta. Resultados: Media hasta la realización de la arteriografía: HSA-VIEJA: 2,18 ± 2,5 días, HSA-NUEVA: 2,37 ± 2,23 días, p = 0,49. Mortalidad: HSA-VIEJA 30% frente al 18,3% en HSA-NUEVA, p = 0,01. Entre los supervivientes al alta hospitalaria, un 13,3% en HSA-VIEJA tenía mRS > 3 frente a un 21,3% en HSA-NUEVA, p = 0,06. HSA-VIEJA: 245 pacientes tenían aneurisma cerebral, se trataron 208 (45% del total de los pacientes); HSA-NUEVA: reciben tratamiento 65 (60% del total de los pacientes), p = 0,007. HSA-VIEJA: se embolizaron 62,9%, HSA-NUEVA: 74,6%, p = 0,08. HSA-VIEJA: cirugía 22%, HSA-NUEVA: 25,4%, p = 0,62. Conclusiones: En nuestro hospital ha mejorado la atención a la HSA: menor mortalidad, mayor número de tratamientos a expensas del tratamiento intravascular y menor tiempo hasta el tratamiento. El tiempo hasta la arteriografía ha permanecido estable (AU)

Introduction and objective: To discover if there have been changes in the treatment time for SAH in our hospital environment. Material and methods: Comparative analysis of 571 patients treated at Hospital Universitari la Fe during 2 different time periods. The SAH-OLD group consisted of 462 patients attended consecutively between April 1997 and March 2005, while SAH-NEW comprised 109 patients attended consecutively between March 2007 and April 2010. We analysed demographic factors, risk factors, severity at time of admission, time to arteriography, diagnosis of aneurysm, use of surgical or endovascular treatment and time to treatment, frequency of neurological complications, in-hospital deaths, and modified Rankin Scale (mRS) at discharge. Results: Mean time to arteriography was 2.18 ± 2.5 days for the SAH-OLD group and 2.37 ± 2.23 days, for the SAH-NEW group (P=.49). Mortality rates for SAH-OLD patients were calculated at 30%, compared to 18.3% in SAH-NEW patients (P=.01). Among patients surviving the hospital stay in the SAH-OLD group, 13.3% had an mRS > 3, compared to 21.3% of survivors in the SAH-NEW group (P=.06). Two hundred forty-five patients in the SAH-OLD group had cerebral aneurysms and 208 were treated (45% of the patient total). Sixty-five of the SAH-NEW patients received treatment (60% of the patient total, P=.007). In the SAH-OLD group, 62.9% of the patients underwent embolisation vs 74.6% in the SAH-NEW group (P=.08). Time to embolisation was 4.7 ± 8.2 days for SAH-OLD patients and 2.12 ± 2.2 days for SAH-NEW patients (P=.01). Twenty-two percent of SAH-OLD patients underwent surgery, compared to 25.4% in the SAH-NEW group (P=.62). Conclusions: Care for SAH patients has improved in this hospital: results include fewer mortalities, a higher number of treatments with a smaller proportion of endovascular treatments, and shorter times to treatment. Elapsed time to arteriography remains stable (AU)

Clinical Characteristics and Outcome in Elderly Patients with Traumatic Brain Injury: For Establishment of Management Strategy.

In recent years, instances of neurotrauma in the elderly have been increasing. This article addresses the clinical characteristics, management strategy, and outcome in elderly patients with traumatic brain injury (TBI). Falls to the ground either from standing or from heights are the most common causes of TBI in the elderly, since both motor and physiological functions are degraded in the elderly. Subdural, contusional and intracerebral hematomas are more common in the elderly than the young as the acute traumatic intracranial lesion. High frequency of those lesions has been proposed to be associated with increased volume of the subdural space resulting from the atrophy of the brain in the elderly. The delayed aggravation of intracranial hematomas has been also explained by such anatomical and physiological changes present in the elderly. Delayed hyperemia/hyperperfusion may also be a characteristic of the elderly TBI, although its mechanisms are not fully understood. In addition, widely used pre-injury anticoagulant and antiplatelet therapies may be associated with delayed aggravation, making the management difficult for elderly TBI. It is an urgent issue to establish preventions and treatments for elderly TBI, since its outcome has been remained poor for more than 40 years.

Diagnosis and Treatment of Traumatic Cerebrovascular Injury: Pitfalls in the Management of Neurotrauma.

Traumatic cerebrovascular injury (TCVI) is an uncommon clinical entity in traumatic brain injury (TBI), yet it may cause devastating brain injury with high morbidity and mortality. Early recognition and prioritized strategic treatment are of paramount importance. A total of 1966 TBI patients admitted between 1999 and 2015 in our tertiary critical care center were reviewed. Screening of TCVI was based on the Guidelines for the Management of Severe Head Injury in Japan. TCVI was confirmed in 33 (1.7%) patients; 29 blunt and 4 penetrating injuries. The primary location of the injury included 16 cervical, 6 craniofacial, and 11 intracranial lesions. On arrival, 15 patients presented with hemorrhage, 5 of these arrived in shock status with massive hemorrhage. Ten presented with ischemic symptoms. Sixteen patients underwent surgical or endovascular intervention, 13 of whom required immediate treatment upon arrival. Surgical procedures included clipping or trapping for traumatic aneurysms, superficial temporal artery - middle cerebral artery bypass, carotid endarterectomy, and direct suture of the injured vessels. Endovascular intervention was undertaken in 7 patients; embolization with Gelfoam (Pharmacia and Upjohn Company, Kalamazoo, MI, USA) or coil for 6 hemorrhagic lesions and stent placement for 1 lesion causing ischemia. Patients' outcome assessed by the Glasgow Outcome Scale at 3 months were good recovery in 8, moderate disability in 3, severe disability in 9, persistent vegetative state in 1, and death in 12, respectively. In order to rescue potentially salvageable TCVI patients, neurosurgeons in charge should be aware of TCVI and master basic skills of cerebrovascular surgical and endovascular procedures to utilize in an emergency setting.

Ictus isquémico presumiblemente perinatal: factores de riesgo, hallazgos clínicos y radiológicos / Presumed perinatal ischemic stroke: risk factors and clinical and radiological findings

Introducción. El ictus isquémico presumiblemente perinatal es una causa frecuente de secuelas neurológicas importantes. Los objetivos del estudio son describir las características clínicas y los factores de riesgo implicados, y analizar las diferencias según su origen vascular. Pacientes y métodos. Estudio descriptivo retrospectivo que incluye pacientes con diagnóstico de ictus isquémico presumiblemente perinatal atendidos en un hospital terciario entre 1990-2015. Resultados. Se incluyeron 44 pacientes: 24 (55%) fueron de origen arterial, frente a 20 (45%) de origen venoso. El diagnóstico fue significativamente más tardío en los de origen venoso que en los de origen arterial (14 y 8 meses respectivamente; p = 0,025). La mayoría comenzó con un déficit motor (90%), y las crisis epilépticas y el retraso psicomotor global fueron menos frecuentes en ambos grupos (< 5%). La prevalencia de epilepsia posterior fue significativamente más frecuente entre los de origen arterial (p = 0,020). Se analizaron los factores de riesgo teóricamente implicados en su patogenia: prenatales, obstétricos, perinatales, protrombóticos y cardíacos, sin hallarse diferencias significativas en la presencia de éstos entre los infartos arteriales y los venosos. Encontramos la presencia de al menos una alteración en el estudio de hipercoagulabilidad en el 48,3% de los pacientes. Conclusión. Es preciso investigar el papel que desempeñan los factores de riesgo implicados en el ictus isquémico presumiblemente perinatal para establecer medidas preventivas. Su diagnóstico es más tardío si el origen es venoso (AU)

Introduction. Presumed perinatal ischemic stroke is a frequent cause of neurological sequelae. We aimed to describe the different clinical findings and risk factors and to analyse the differences according the vascular origin. Patients and methods. Retrospective, descriptive study of patients diagnosed with presumed perinatal ischemic stroke attended at a tertiary pediatric hospital from 1990 to 2015. Results. 44 patients were included. A total of 24 patients (55%) had arterial ischemic stroke and 20 (45%) had periventricular venous infarction. Delay in diagnosis was significantly higher in patients with periventricular venous infarction compared to those with arterial ischemic stroke (14 and 8 months respectively; p = 0.025). Most patients presented with asymmetrical motor development (90%), only < 5% with seizures or non motor delays. Subsequent epilepsy at follow-up was significantly more prevalent in arterial ischemic stroke group (p = 0.020). We determined risk factors theoretically involved in the pathogenesis of presumed perinatal ischemic stroke: prenatal, obstetrical, perinatal, prothrombotic and cardiac. No significant differences between risk factors and vascular origin were found. Prothrombotic abnormalities were common (48.3%). Conclusions. Investigation in risk factors implicated in presumed perinatal ischemic stroke is required to develop prevention strategies. Delay in diagnosis is higher in periventricular venous infarction group (AU)

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[Disability after stroke: a longitudinal study in moderate and severe stroke patients included in a multidisciplinary rehabilitation program]. / Ictus y discapacidad: estudio longitudinal en pacientes con discapacidad moderada-grave tras un ictus incluidos en un programa de rehabilitacion multidisciplinar.

INTRODUCTION: Stroke is a recognized cause of disability among adults. However the impact that the deficits that occur after a moderate/severe stroke have on long-term disability, as well as the response of the resultant deficits to rehabilitation, are not completely understood. PATIENTS AND METHODS: A total of 396 patients with a modified Rankin score >= 3 after an ischemic (n = 221) or hemorrhagic (n = 175) stroke were included in this study. All patients were assessed with cognitive, behavior, emotional, motor and functional domains. All patients were assessed at baseline and six months after inclusion in a multidisciplinary rehabilitation program. RESULTS: Risk of falling (Berg Balance Scale < 45 in 83.1% of the sample at baseline and 49.5% at follow-up) and functional problems (82.8% with a Barthel Index < 75 at baseline and 53% at follow-up) were the most prevalent deficits. Emotional disturbances were those that most improved while behavioral problems were those that did less. Although global disability improved during treatment among most patients, only 11% of our patients, especially those with preserved cognitive function at baseline, could be classified as patients with mild disability at follow-up. CONCLUSIONS: Stroke consequences are multidimensional. The symptoms that the stroke can cause in multiple domains, as well as the pattern of recovery are widely diverse, with prevalence of behavioral long-term disturbances.

TITLE: Ictus y discapacidad: estudio longitudinal en pacientes con discapacidad moderada-grave tras un ictus incluidos en un programa de rehabilitacion multidisciplinar.Introduccion. Los ictus son causa frecuente de discapacidad en el adulto; sin embargo, la repercusion que los deficits que acontecen tras un ictus moderado-grave tiene sobre el grado de discapacidad final, asi como la respuesta de estos a programas de rehabilitacion, no se ha estudiado por completo. Pacientes y metodos. Se incluyeron 396 pacientes con Rankin modificado >= 3 despues de un ictus isquemico (n = 221) o hemorragico (n = 175). En todos los pacientes se evaluo su situacion cognitiva, conductual, emocional, motora y funcional. Todos los pacientes fueron incluidos en un programa de rehabilitacion multidisciplinar y reevaluados tras seis meses de tratamiento. Resultados. El riesgo de caida (escala de equilibrio de Berg < 45 en el 83,1% de la muestra) y los deficits funcionales (indice de Barthel < 75 en el 82,8% de la muestra) fueron los problemas mas prevalentes en el momento del ingreso, mientras que los conductuales lo fueron en el del alta (55,1% de la muestra). Los problemas emocionales fueron los que mas mejoraron, mientras que los conductuales fueron los que menos lo hicieron. El nivel de discapacidad global mejoro tras el tratamiento, aunque solo un 11% de los pacientes, especialmente los que tenian buena situacion cognitiva en el ingreso, lograron alcanzar una discapacidad leve. Conclusiones. Las consecuencias del ictus son multidimensionales. La afectacion de las distintas esferas y el patron de recuperacion son diferenciales, con predominio a largo plazo de los problemas conductuales.