The Neuropsychiatry Of Acquired Brain Injury

The psychiatric syndromes derived from acquired brain injury are the behaviouralconsequences of the combination of cognitive,emotional and volitional sequelae. Theirimpact on the quality of life of patients andrelatives is far greater tan the impact ofmotor or sensory deficit. The descriptionof these behavioural presentations and anattempt to understand the formation of thesymptoms will be undertaken. Changes inawareness, empathy, emotional recognitionand regulation are important mediating factors.Behavioural changes mainly take theform of disinhibition or apathy. Psychoticsyndromes, major depression or bipolar disordersare rare. Some delusional ideas respondto changes in the perception of noveltyor to changes in body perception. (AU)

Los síndromes psiquiátricos y los cambios conductuales que se derivan del daño cerebralson las consecuencias de la combinaciónde las alteraciones volitivas, emocionales ycognitivas. El impacto en la calidad de vidade los pacientes y de sus familiares es significativamentemayor que el impacto de las secuelasmotoras o sensoriales. En este artículose aborda la descripción de estos trastornosneuropsiquiátricos y se propone un acercamientoa la comprensión de cómo se gestan.Los cambios en conciencia de situación, empatía,reconocimiento y regulación emocionalson factores mediadores importantes enla formación de los síntomas. Los cambiosconductuales se presentan principalmente enforma de apatía o desinhibición. Los síndromespsicóticos, los trastornos bipolares o ladepresión mayor son muy poco frecuentes.Por otro lado, las ideas delirantes respondena cambios en la percepción de la novedad/familiaridad de los estímulos o a cambios enla percepción del cuerpo que ocurren tras lesionesdel hemisferio derecho. (AU)

Traumatic Brain Injury and Stem Cells: An Overview of Clinical Trials, the Current Treatments and Future Therapeutic Approaches.

Traumatic brain injury represents physical damage to the brain tissue that induces transitory or permanent neurological disabilities. The traumatic injury activates an important inflammatory response, followed by a cascade of events that lead to neuronal loss and further brain damage. Maintaining proper ventilation, a normal level of oxygenation, and adequate blood pressure are the main therapeutic strategies performed after injury. Surgery is often necessary for patients with more serious injuries. However, to date, there are no therapies that completely resolve the brain damage suffered following the trauma. Stem cells, due to their capacity to differentiate into neuronal cells and through releasing neurotrophic factors, seem to be a valid strategy to use in the treatment of traumatic brain injury. The purpose of this review is to provide an overview of clinical trials, aimed to evaluate the use of stem cell-based therapy in traumatic brain injury. These studies aim to assess the safety and efficacy of stem cells in this disease. The results available so far are few; therefore, future studies need in order to evaluate the safety and efficacy of stem cell transplantation in traumatic brain injury.

Effect of horse riding equipment in activity of trunk and lower limb muscles in equine-assisted therapy

Equine-assisted therapy uses the horse in rehabilitation and/or education of people, such as Down syndrome(SD), cerebral palsy(PC)and intellectual disability(DI). In context, the rehabilitation program and horse riding equipment should be usedaccording to the specific characteristics of each individual, becoming an ally in the quest for excellence in equine-assisted therapy programs. The aim was to evaluate the effect of riding equipment used in equine-assisted therapy on the muscular activityof trunk and lower limb of individuals with SD, PC and DI. The study included 15 individuals equally assigned to each group: SD, PC and DIwith a mean age of 16.2 (±1.10), 16 (±1.22)e 16 (±0) years,respectively. The analysis of muscle activity was performed through surface electromyography, using four variations of horse riding equipment: saddle with and without feet supported on the stirrups and blanket with and without feet supported on the stirrups. Sigma Stat 3.5®software was used for statistical analysis.The Shapiro Wilk's test was used for normality of the data, the Bartlett test for homogeneity of the variances and the Kruskal-Wallis test for repeated measures with no normal distribution.Statistically significant differences were observed forp<0.05.The SDgroup presented a greater muscular activity of trunk and lower limbs with blanket equipment without the feet supported in the stirrups (H = 15.078, p = 0.002), as in the DI group (H=8.302, p = 0.040), while inPCgroup was the saddle with feet supported in the stirrups (H=11.137,p = 0.011). The choice of riding equipment used in equine-assisted therapy interferes differently in the pattern of muscular activation of the trunk and the lower limbs, according to the pathological processes of the practitioners. It should be an important aspect to consider when planninga treatment.

Exercise-driven restoration of the alcohol-damaged brain.

There are vast literatures on the neural effects of alcohol and the neural effects of exercise. Simply put, exercise is associated with brain health, alcohol is not, and the mechanisms by which exercise benefits the brain directly counteract the mechanisms by which alcohol damages it. Although a degree of brain recovery naturally occurs upon cessation of alcohol consumption, effective treatments for alcohol-induced brain damage are badly needed, and exercise is an excellent candidate from a mechanistic standpoint. In this chapter, we cover the small but growing literature on the interactive neural effects of alcohol and exercise, and the capacity of exercise to repair alcohol-induced brain damage. Increasingly, exercise is being used as a component of treatment for alcohol use disorders (AUD), not because it reverses alcohol-induced brain damage, but because it represents a rewarding, alcohol-free activity that could reduce alcohol cravings and improve comorbid conditions such as anxiety and depression. It is important to bear in mind, however, that multiple studies attest to a counterintuitive positive relationship between alcohol intake and exercise. We therefore conclude with cautionary notes regarding the use of exercise to repair the brain after alcohol damage.

Uso de bromocriptina en pacientes con alteración de conciencia secundaria a traumatismo craneoencefálico / Bromocriptine in disorders of consciouness due to traumatic brain injury

Introducción: el objetivo de este trabajo es evaluar los resultados y efectos secundarios de la administración de bromocriptina en pacientes con traumatismo craneoencefálico (TCE) en estado de síndrome vigilia sin respuesta (SVSR) o estado de mínima conciencia (EMC). Métodos: revisión retrospectiva de 10 casos clínicos: 6 TCE-SVSR y 4 TCE-EMC. Todos los pacientes recibieron bromocriptina con dosis iniciales de 2,5mg 2 veces al día. Esta fue incrementada progresivamente hasta 7,5 o 12,5mg 2 veces al día según respuesta y mantenida durante al menos 4 semanas. Se emplearon diversas escalas de valoración en los siguientes estadios: previo a la administración de bromocriptina, a las 4 semanas de inicio del tratamiento y previo al alta hospitaria. Las escalas de valoración que se emplearon fueron: Coma Recovery Scale-Revised, Disability Rating Scale, Glasgow Coma Scale, Barthel Scale y Marshall Scale. Resultados: de los 10 pacientes 4 en EMC y 4 en SVSR consiguieron al alta 23 puntos en escala CRS-R, emergiendo por tanto de dichos estados y alcanzando un estado de fuera de mínima conciencia. Dos de los 10 pacientes mejoraron, pero de manera más discreta pasando de SVSR a EMC (8 a 11 y de 5 a 10 puntos en CRS-R). Conclusiones: considerando el mal pronóstico de recuperación de estos pacientes el beneficio-riesgo es positivo con bromocriptina a dosis como mínimo de 7,5mg 2 veces al día durante 4 semanas

Introduction: the aim of this study was to assess the results and adverse effects of bromocriptine in patients with traumatic brain injury-vegetative state (TBI-VS) or traumatic brain injury-minimally conscious state (TBI-MCS). Methods: we conducted a retrospective review of 10 patients, six with TBI-VS and four with TBI-MCS. All patients received bromocriptine at a starting dose of 2.5mg twice daily. Bromocriptine was titrated up to 7.5 or 12.5mg twice daily according to response and was maintained for at least 4 weeks. Various assessment scales were used in the following stages: before bromocriptine administration, at 4 weeks post bromocriptine prescription, and at hospital discharge. The assessment scales used were the Coma Recovery Scale-Revised (CRS-R), Disability Rating Scale, Glasgow Coma Scale, Barthel Scale, and Marshall Scale. Results: of the 10 patients, four with TBI-MCS and four with TBI-VS achieved a score of 23 points at discharge in the CRS-R, thus emerging from VS or MCS and regaining functional status. There were only two patients who emerged from VS but remained in MCS (8 to 11 and 5 to 10 points in CRS-R). Conclusions: considering the poor prognosis for recovery in these patients, bromocriptine use has a positive risk-benefit ratio at a dosage of at least 7.5mg twice daily for 4 weeks

Predictors of Outcome Post Cardiac Arrest.

Early predictors of prognosis in comatose patients post cardiac arrest help inform decisions surrounding continuation or withdrawal of treatment and provide a framework on which to better inform relatives of the likely outcome. Markers defined prior to the widespread use of therapeutic hypothermia post arrest may no longer be reliable and an up-to-date analysis of the literature is presented.

Hematopoietic Stem Cell Gene Therapy for Storage Disease: Current and New Indications.

Lysosomal storage disorders (LSDs) are a broad class of monogenic diseases with an overall incidence of 1:7,000 newborns, due to the defective activity of one or more lysosomal hydrolases or related proteins resulting in storage of un-degraded substrates in the lysosomes. The over 40 different known LSDs share a life-threatening nature, but they are present with extremely variable clinical manifestations, determined by the characteristics and tissue distribution of the material accumulating due to the lysosomal dysfunction. The majority of LSDs lack a curative treatment. This is particularly true for LSDs severely affecting the CNS. Based on current preclinical and clinical evidences, among other treatment modalities, hematopoietic stem cell gene therapy could potentially result in robust therapeutic benefit for LSD patients, with particular indication for those characterized by severe brain damage. Optimization of current approaches and technology, as well as implementation of clinical trials for novel indications, and prolonged and more extensive follow-up of the already treated patients will allow translating this promise into new medicinal products.

Prácticas clínicas al final de la vida en pacientes con daño cerebral catastrófico en España: implicaciones para la donación de órganos / End-of-life practices in patients with devastating brain injury in Spain: implications for organ donation

OBJETIVO: Describir las prácticas clínicas al final de la vida relevantes para la donación de órganos en pacientes con daño cerebral catastrófico en España. DISEÑO: Estudio multicéntrico prospectivo de una cohorte retrospectiva. Periodo: 1 de noviembre de 2014 al 30 de abril de 2015. Ámbito: Sesenta y ocho hospitales autorizados para donación. PACIENTES: Pacientes fallecidos por daño cerebral catastrófico (posibles donantes). Edad: 1 mes-85 años. Variables de interés principales: Cuidado recibido, donación en muerte encefálica, donación en asistolia controlada, intubación/ventilación, notificación al coordinador de trasplantes. RESULTADOS: Se identificaron 1.970 posibles donantes. La mitad recibió tratamiento activo en una Unidad de Críticos (UC) hasta evolucionar a muerte encefálica (27%), sufrir una parada cardiorrespiratoria (5%), o hasta la limitación de tratamiento de soporte vital (19%). Del resto, un 10% ingresó en una UC para facilitar la donación y el 39% nunca ingresó en una UC. De los pacientes que evolucionaron a muerte encefálica (n=695), la mayoría derivaron en una donación eficaz (n=446; 64%). De los pacientes fallecidos tras limitación de tratamiento de soporte vital (n=537), 45 (8%) se convirtieron en donantes en asistolia eficaces. La ausencia de un programa de donación en asistolia controlada fue el motivo más frecuente de no donación. El 37% de los posibles donantes falleció sin intubar/ventilar, fundamentalmente porque el profesional responsable no consideró la donación tras descartar intubación terapéutica. El 36% de los posibles donantes no fue notificado al coordinador de trasplantes. CONCLUSIONES: Aunque el proceso de donación está optimizado en España, existen oportunidades para la mejora en la detección de posibles donantes fuera de UC y en la consideración de la donación en asistolia controlada en pacientes fallecidos tras limitación de tratamiento de soporte vital

OBJECTIVE: To describe end-of-life care practices relevant to organ donation in patients with devastating brain injury in Spain. DESIGN: A multicenter prospective study of a retrospective cohort. Period: 1 November 2014 to 30 April 2015. SETTING: Sixty-eight hospitals authorized for organ procurement. PATIENTS: Patients dying from devastating brain injury (possible donors). Age: 1 month-85 years. Primary endpoints: Type of care, donation after brain death, donation after circulatory death, intubation/ventilation, referral to the donor coordinator. RESULTS: A total of 1,970 possible donors were identified, of which half received active treatment in an Intensive Care Unit (ICU) until brain death (27%), cardiac arrest (5%) or the withdrawal of life-sustaining therapy (19%). Of the rest, 10% were admitted to the ICU to facilitate organ donation, while 39% were not admitted to the ICU. Of those patients who evolved to a brain death condition (n=695), most transitioned to actual donation (n=446; 64%). Of those who died following the withdrawal of life-sustaining therapy (n=537), 45 (8%) were converted into actual donation after circulatory death donors. The lack of a dedicated donation after circulatory death program was the main reason for non-donation. Thirty-seven percent of the possible donors were not intubated/ventilated at death, mainly because the professional in charge did not consider donation alter discarding therapeutic intubation. Thirty-six percent of the possible donors were never referred to the donor coordinator. CONCLUSIONS: Although deceased donation is optimized in Spain, there are still opportunities for improvement in the identification of possible donors outside the ICU and in the consideration of donation after circulatory death in patients who die following the withdrawal of life-sustaining therapy

Cerebral plasticity: Windows of opportunity in the developing brain.

BACKGROUND: Neuroplasticity refers to the inherently dynamic biological capacity of the central nervous system (CNS) to undergo maturation, change structurally and functionally in response to experience and to adapt following injury. This malleability is achieved by modulating subsets of genetic, molecular and cellular mechanisms that influence the dynamics of synaptic connections and neural circuitry formation culminating in gain or loss of behavior or function. Neuroplasticity in the healthy developing brain exhibits a heterochronus cortex-specific developmental profile and is heightened during "critical and sensitive periods" of pre and postnatal brain development that enable the construction and consolidation of experience-dependent structural and functional brain connections. PURPOSE: In this review, our primary goal is to highlight the essential role of neuroplasticity in brain development, and to draw attention to the complex relationship between different levels of the developing nervous system that are subjected to plasticity in health and disease. Another goal of this review is to explore the relationship between plasticity responses of the developing brain and how they are influenced by critical and sensitive periods of brain development. Finally, we aim to motivate researchers in the pediatric neuromodulation field to build on the current knowledge of normal and abnormal neuroplasticity, especially synaptic plasticity, and their dependence on "critical or sensitive periods" of neural development to inform the design, timing and sequencing of neuromodulatory interventions in order to enhance and optimize their translational applications in childhood disorders of the brain. METHODS: literature review. RESULTS: We discuss in details five patterns of neuroplasticity expressed by the developing brain: 1) developmental plasticity which is further classified into normal and impaired developmental plasticity as seen in syndromic autism spectrum disorders, 2) adaptive (experience-dependent) plasticity following intense motor skill training, 3) reactive plasticity to pre and post natal CNS injury or sensory deprivation, 4) excessive plasticity (loss of homeostatic regulation) as seen in dystonia and refractory epilepsy, 6) and finally, plasticity as the brain's "Achilles tendon" which induces brain vulnerability under certain conditions such as hypoxic ischemic encephalopathy and epileptic encephalopathy syndromes. We then explore the unique feature of "time-sensitive heightened plasticity responses" in the developing brain in the in the context of neuromodulation. CONCLUSION: The different patterns of neuroplasticity and the unique feature of heightened plasticity during critical and sensitive periods are important concepts for researchers and clinicians in the field of pediatric neurology and neurodevelopmental disabilities. These concepts need to be examined systematically in the context of pediatric neuromodulation. We propose that critical and sensitive periods of brain development in health and disease can create "windows of opportunity" for neuromodulatory interventions that are not commonly seen in adult brain and probably augment plasticity responses and improve clinical outcomes.

Cranial grafting of stem cell-derived microvesicles improves cognition and reduces neuropathology in the irradiated brain.

Cancer survivors face a variety of challenges as they cope with disease recurrence and a myriad of normal tissue complications brought on by radio- and chemotherapeutic treatment regimens. For patients subjected to cranial irradiation for the control of CNS malignancy, progressive and debilitating cognitive dysfunction remains a pressing unmet medical need. Although this problem has been recognized for decades, few if any satisfactory long-term solutions exist to resolve this serious unintended side effect of radiotherapy. Past work from our laboratory has demonstrated the neurocognitive benefits of human neural stem cell (hNSC) grafting in the irradiated brain, where intrahippocampal transplantation of hNSC ameliorated radiation-induced cognitive deficits. Using a similar strategy, we now provide, to our knowledge, the first evidence that cranial grafting of microvesicles secreted from hNSC affords similar neuroprotective phenotypes after head-only irradiation. Cortical- and hippocampal-based deficits found 1 mo after irradiation were completely resolved in animals cranially grafted with microvesicles. Microvesicle treatment was found to attenuate neuroinflammation and preserve host neuronal morphology in distinct regions of the brain. These data suggest that the neuroprotective properties of microvesicles act through a trophic support mechanism that reduces inflammation and preserves the structural integrity of the irradiated microenvironment.

[Neurological diseases after lightning strike : Lightning strikes twice]. / Neurologische Erkrankungen nach Blitzschlag : Lightning strikes twice.

Lightning strikes rarely occur but 85 % of patients have lightning-related neurological complications. This report provides an overview about different modes of energy transfer and neurological conditions related to lightning strikes. Moreover, two case reports demonstrate the importance of interdisciplinary treatment and the spectrum of neurological complications after lightning strikes.

Rehabilitación cognitiva en daño cerebral adquirido: variables que median en la respuesta al tratamiento / Cognitive rehabilitation in acquired brain injury: variables mediating treatment response

Objetivo. Identificar qué variables se relacionaban con la respuesta a un programa de rehabilitación cognitiva en una población de pacientes con daño cerebral adquirido. Material y métodos. En este estudio retrospectivo participaron 528 pacientes con daño cerebral adquirido que recibieron rehabilitación cognitiva en nuestro centro entre febrero de 2008 y enero de 2013. Mediante análisis de regresión logística se analizó la respuesta al tratamiento (variable dependiente). La respuesta al tratamiento se calculó a partir de las diferencias entre las exploraciones neuropsicológicas pre- y post-tratamiento para las variables atención, memoria y funciones ejecutivas. Resultados. La edad en el momento de la lesión (OR = 0,97; 95% CI: 0,96-0,98) y el lugar donde se realizó el tratamiento (OR = 0,45; 95% CI: 0,27-0,73) se asociaron positivamente con una mejor respuesta al tratamiento para el índice atencional. En el caso del índice mnésico fueron la edad (OR = 0,98; 95% CI: 0,96-0,99), etiología (OR = 0,63; 95% CI: 0,39-1) y lugar de realización del tratamiento (OR = 0,48; 95% CI: 0,29-0,79); tales variables también resultaron significativas para el índice ejecutivo. Conclusiones. Los resultados sugieren que parte de las diferencias interindividuales observadas en la respuesta al tratamiento cognitivo en pacientes con daño cerebral adquirido podrían ser explicadas por las variables edad, etiología y lugar de realización del tratamiento (AU)

Objective. To identify the variables related to response to a cognitive rehabilitation program in a population of patients with acquired brain injury. Material and methods. This retrospective study included 528 patients with acquired brain injury who received cognitive rehabilitation at our center between February 2008 and January 2013. We used logistic regression analysis to examine the impact of predictive variables on treatment response (dependent variable). Differences between pre- and post-treatment neuropsychological assessment were used to calculate treatment response in the domains of attention, memory, and executive function. Results. For the attention index, the variables positively associated with better treatment response were age at the time of injury (OR = 0.97, 95% CI: 0.96-0.98) and place of treatment (OR = 0.45, 95% CI: 0.27-0.73). For the memory index, the variables positively associated with better treatment response were age (OR = 0.98, 95% CI: 0.96 to 0.99), etiology (OR = 0.63, 95% CI: 0.39 to 1) and place of treatment (OR = 0.48, 95% CI: 0.29 to 0.79); these variables were also significant for the executive index. Conclusions. These findings suggest that part of the inter-individual differences in response to cognitive rehabilitation in patients with acquired brain injury could be explained by age, etiology and place of treatment (AU)

Realidade virtual como possibilidade terapêutica para adolescentes com encefalopatia crônica não progressiva da infância / Virtual reality as a therapeutic possibility for teenagers with chronic not-progressive encephalopathy of childhood

INTRODUÇÃO: A aprendizagem motora surge de um processo complexo de percepção/cognição/ação. Para a Fisioterapia, o conhecimento sobre aprendizado motor fornece bases neurofisiológicas que sustentam a intervenção terapêutica. Na área de ensino de Ciências, a realidade virtual pode se apresentar como um instrumental pelo qual possam ser alcançadas as adolescentes com paralisia cerebral, com déficit no desempenho motor. OBJETIVOS: O presente estudo propôs a inserção de conhecimentos do ensino de ciências por meio de recursos tecnológicos na prática fisioterapêutica direcionada a adolescentes portadores de paralisia cerebral. Essa abordagem foi mediada pela realidade virtual, visando ao incremento do aprendizado motor. MÉTODOS: O desenho experimental utilizado no presente estudo foi o de abordagem qualitativa participante, utilizando-se como instrumento de coleta de dados as oficinas pedagógicas que tratavam de conceitos da ciência para o aprendizado motor aliado à realidade virtual. A amostra analisada foi constituída de quatro adolescentes, entre 11 e 18 anos, portadores de paralisia cerebral, matriculados no ensino fundamental da rede de ensino do município de Teresópolis (RJ), em tratamento fisioterapêutico na Clínica-Escola de Fisioterapia do Unifeso. Foi utilizada, também, a escala de função motora grossa (GMFM) como escala avaliativa pré e pós-intervenção. RESULTADOS: Os sujeitos/pacientes apresentaram melhora em seu desempenho neuromotor associado com o ensino de ciências, demonstrando ser possível a potencialização do aprendizado motor com a aproximação do aprendizado científico. Em relação à escala GMFM, pode-se perceber aumento de 4% na média geral, confirmando o avanço motor dos participantes, percebido nessa análise qualitativa. CONCLUSÃO: A criação de subsídios para a construção do conhecimento científico por meio dos recursos do ambiente virtual aponta para o incremento do desempenho motor e para a formação de sujeitos histórico-sociais.

INTRODUCTION: Motor learning arises from a complex process of perception/cognition/action. For Physiotherapy, knowledge of motor learning provides neurophysiological bases that support therapeutic intervention. In the area of science education, virtual reality may represent an instrument by which adolescents with cerebral palsy and deficit in motor performance can be reached. OBJETIVES: The present study has as purpose the inclusion of knowledge of science education through technology in physical therapy practice directed at adolescents with cerebral palsy. This approach was mediated by virtual reality, aiming to increase motor learning. METHODS: The experimental design used was a qualitative participant study, using as instrument to collect data pedagogical workshops, which dealt with science concepts for motor learning combined with virtual reality. The sample consisted of four subjects, aged 11 and 18 years, with cerebral palsy, enrolled in primary schools in the municipality of Teresopolis (RJ), and on physiotherapy in the School of Physiotherapy Clinic Unifeso. The scale of motor function (GMFM) as pre- and post-intervention was also used for evaluation. RESULTS: Subjects/patients showed improvement in their neuromotor performance associated with the teaching of science, demonstrating the feasibility of the enhancement of motor learning with the scientific learning approach. Regarding the GMFM scale it could be perceived an increase of 4% in the overall average, confirming the motor progress of the participants, perceived by this qualitative analysis. CONCLUSION: The creation of subsidies for the construction of scientific knowledge, by means of virtual resources environment, point to the enhancement of the motor performance and for the formation of social-historical subjects.

Complications and follow up of subarachnoid hemorrhages.

Complications of subarachnoid hemorrhage are the major life threatening and functional components of the follow up of a ruptured aneurysm. Knowing how to identify these is a key challenge. They vary in type throughout the postoperative follow up period. The aim of this article is firstly to list the main complications of the acute phase (rebleeding, acute hydrocephalus, acute ischemic injury and non-neurological complications), the subacute phase (vasospasm) and the chronic phase of subarachnoid hemorrhages: (chronic hydrocephalus and cognitive disorders) and to describe their major clinical and radiological features. Secondly, we describe the long-term follow up strategy for patients who have suffered a subarachnoid hemorrhage and have been treated endovascularly or by surgery. This follow up involves a combination of clinical consultations, cerebral MRI and at least one review angiogram.

Isolated linear skull fractures in children with blunt head trauma.

BACKGROUND AND OBJECTIVE: Children and adolescents with minor blunt head trauma and isolated skull fractures are often admitted to the hospital. The objective of this study was to describe the injury circumstances and frequency of clinically important neurologic complications among children with minor blunt head trauma and isolated linear skull fractures. METHODS: This study was a planned secondary analysis of a large prospective cohort study in children <18 years old with blunt head trauma. Data were collected in 25 emergency departments. We analyzed patients with Glasgow Coma Scale scores of 14 or 15 and isolated linear skull fractures. We ascertained acute neurologic outcomes through clinical information collected during admission or via telephone or mail at least 1 week after the emergency department visit. RESULTS: In the parent study, we enrolled 43,904 children (11,035 [25%] <2 years old). Of those with imaging studies, 350 had isolated linear skull fractures. Falls were the most common injury mechanism, accounting for 70% (81% for ages <2 years old). Of 201 hospitalized children, 42 had computed tomography or MRI repeated; 5 had new findings but none required neurosurgical intervention. Of 149 patients discharged from the hospital, 20 had repeated imaging, and none had new findings. CONCLUSIONS: Children with minor blunt head trauma and isolated linear skull fractures are at very low risk of evolving other traumatic findings noted in subsequent imaging studies or requiring neurosurgical intervention. Hospital admission for neurologically normal children with isolated linear skull fractures after minor blunt head trauma for monitoring is typically unnecessary.

[Acute treatment of patients with severe traumatic brain injury]. / Akutversorgung des Patienten mit schwerem Schädel-Hirn-Trauma.

BACKGROUND: Traumatic brain injury (TBI) is a leading cause of death and permanent disability and a common and important global problem. The contribution of secondary posttraumatic brain damage to overall disability in TBI is significant, underlining the importance of prompt and comprehensive treatment for affected patients. METHODS: This article focuses on current concepts of prehospital and emergency room management of patients with severe TBI to prevent secondary brain injuries. RESULTS AND DISCUSSION: Preclinical prevention and treatment of hypoxia, hypotension and hypercarbia are essential, as they affect the long-term outcome in TBI patients. Prehospital intubation should be critically weighed and in the context of an individual decision. In general, prehospital intubation is more difficult than in the clinical setting. The combination of ketamine and benzodiazepines are commonly used to induce anesthesia before intubation in hemodynamic instable patients. The choice of a muscle relaxant for anesthesia induction is either a non-depolarizing neuromuscular blocking agent or succinylcholine. Administration of mannitol or hypertonic saline is effective to rapidly decrease intracranial pressure. Whenever possible the final destination for transport of TBI patients should be a level I center with round the clock neurosurgical expertise. Trauma-induced coagulopathy should be recognized and immediately treated using a point-of-care testing. CONCLUSION: Hypoxia, hypotension and hypercarbia should strictly be avoided to improve survival and neurological outcome in patients with severe TBI. The prehospital decision to intubate must be made on a case by case basis at the accident site. A level I trauma center should be the destination for this patient group.

Déficits neuropsicológicos asociados a la relación entre abuso de cocaína y violencia: mecanismos neuronales facilitadores / Neuropsychological impairments associated with the relation between cocaine abuse and violence: neurological facilitation mechanisms

Introducción. El abuso de la cocaína, así como la exposición prenatal a la misma parece ser un factor relevante en el desencadenamiento de comportamientos violentos. Los déficits neuropsicológicos, así como el género y la combinación con el alcohol, serían los posibles mecanismos facilitadores. Objetivo. Revisar y recapitular los resultados obtenidos sobre los déficits neuropsicológicos debidos al abuso o a la exposición prenatal a la cocaína y relacionarlos con la expresión de la violencia. Además, se enfatiza el papel del género y el abuso del alcohol junto a la cocaína, así como la posible existencia de daño orgánico cerebral como mecanismos facilitadores. Desarrollo. Se ha revisado la bibliografía científica usando los buscadores Google Scholar, PsycINFO, PubMed, Medline e ISI Web of Knowledge. Conclusiones. La cocaína facilitaría la expresión de la violencia debido a los déficits en la decodificación emocional, la capacidad de abstracción e inhibición, así como en las habilidades verbales y mnémicas. Esto explicaría, además, los problemas en la toma de decisiones. Los déficits y la expresión de la violencia parecen ser más evidentes en los hombres. Sin embargo, a pesar de que la combinación de la cocaína con el alcohol incrementaría el riesgo de reaccionar de forma violenta, los déficits no serían mayores que el consumo de cada una de ellas por separado. Estos déficits podrían ser producto de un funcionamiento anormal de algunas áreas del lóbulo frontal (especialmente el prefrontal) y el parietal, así como estructuras subcorticales como la amígdala. Todo ello permitiría planificar estrategias de intervención cuyos objetivos serían estos dominios cognitivos

Introduction. Cocaine abuse, as well as prenatal exposure to cocaine, could be key factors in the expression of violent behaviour. Neuropsychological impairments, sex differences and the concurrent abuse of cocaine and alcohol have been suggested as facilitation mechanisms. Aims. To review and recapitulate the results obtained on the relationship between neuropsychological deficits due to cocaine abuse and/or prenatal exposure and the expression of violence. Furthermore, we analyze the roles of sex, concurrent alcohol abuse and possible brain damage as risk markers in this relationship. Development. The scientific literature was reviewed using Google Scholar, PsycINFO, PubMed, Medline and ISI Web of Knowledge. Conclusions. Cocaine facilitates the expression of violence due to neuropsychological deficits in emotional decoding, abstract reasoning and inhibitory control, as well as in mnemonic and verbal skills, and such impairments might also explain problems in decisionmaking. Both the deficits and the expression of violence appear to be more pronounced in men than in women. However, despite the fact that the combination of cocaine and alcohol use may increase the risk of violent reactions, the deficits would not be greater than those resulting from the separate use of each substance. The impairments might be caused by functional abnormalities of certain regions of the frontal (especially the prefrontal) and parietal lobes and some subcortical structures, such as the amygdala. All of this would provide a basis for the development of intervention strategies focusing on these cognitive domains