Longitudinal changes in brain volumetry and cognitive functions after moderate and severe diffuse axonal injury.

BACKGROUND AND OBJECTIVE: Diffuse axonal injury (DAI) induces a long-term process of brain atrophy and cognitive deficits. The goal of this study was to determine whether there are correlations between brain volume loss, microhaemorrhage load (MHL) and neuropsychological performance during the first year after DAI. METHODS: Twenty-four patients with moderate or severe DAI were evaluated at 2, 6 and 12 months post-injury. MHL was evaluated at 3 months, and brain volumetry was evaluated at 3, 6 and 12 months. The trail making test (TMT) was used to evaluate executive function (EF), and the Hopkins verbal learning test (HVLT) was used to evaluate episodic verbal memory (EVM) at 6 and 12 months. RESULTS: There were significant white matter volume (WMV), subcortical grey matter volume and total brain volume (TBV) reductions during the study period (p < 0.05). MHL was correlated only with WMV reduction. EF and EVM were not correlated with MHL but were, in part, correlated with WMV and TBV reductions. CONCLUSIONS: Our findings suggest that MHL may be a predictor of WMV reduction but cannot predict EF or EVM in DAI. Brain atrophy progresses over time, but patients showed better EF and EVM in some of the tests, which could be due to neuroplasticity.

3D preoperative planning in the ER with OsiriX®: when there is no time for neuronavigation.

The evaluation of patients in the emergency room department (ER) through more accurate imaging methods such as computed tomography (CT) has revolutionized their assistance in the early 80s. However, despite technical improvements seen during the last decade, surgical planning in the ER has not followed the development of image acquisition methods. The authors present their experience with DICOM image processing as a navigation method in the ER. The authors present 18 patients treated in the Emergency Department of the Hospital das Clínicas of the University of Sao Paulo. All patients were submitted to volumetric CT. We present patients with epidural hematomas, acute/subacute subdural hematomas and contusional hematomas. Using a specific program to analyze images in DICOM format (OsiriX(®)), the authors performed the appropriate surgical planning. The use of 3D surgical planning made it possible to perform procedures more accurately and less invasively, enabling better postoperative outcomes. All sorts of neurosurgical emergency pathologies can be treated appropriately with no waste of time. The three-dimensional processing of images in the preoperative evaluation is easy and possible even within the emergency care. It should be used as a tool to reduce the surgical trauma and it may dispense methods of navigation in many cases.

Evaluation of cerebral hemodynamics by transcranial Doppler ultrasonography and its correlation with intracranial pressure in an animal model of intracranial hypertension.

BACKGROUND: Transcranial Doppler has been tested in the evaluation of cerebral hemodynamics as a non-invasive assessment of intracranial pressure (ICP), but there is controversy in the literature about its actual benefit and usefulness in this situation. OBJECTIVE: To investigate cerebral blood flow assessed by Doppler technique and correlate with the variations of the ICP in the acute phase of intracranial hypertension in an animal model. METHODS: An experimental animal model of intracranial hypertension was used. The experiment consisted of two groups of animals in which intracranial balloons were implanted and inflated with 4 mL (A) and 7 mL (B) for controlled simulation of different volumes of hematoma. The values of ICP and Doppler parameters (systolic [FVs], diastolic [FVd], and mean [FVm] cerebral blood flow velocities and pulsatility index [PI]) were collected during the entire procedure (before and during hematoma simulations and venous hypertonic saline infusion intervention). Comparisons between Doppler parameters and ICP monitoring were performed. RESULTS: Twenty pigs were studied, 10 in group A and 10 in group B. A significant correlation between PI and ICP was obtained, especially shortly after abrupt elevation of ICP. There was no correlation between ICP and FVs, FVd or FVm separately. There was also no significant change in ICP after intravenous infusion of hypertonic saline solution. CONCLUSIONS: These results demonstrate the potential of PI as a parameter for the evaluation of patients with suspected ICP elevation.

[The pathophysiological mechanisms following traumatic brain injury]. / Mecanismos de lesão cerebral no traumatismo cranioencefálico.

Traumatic brain injury is the main cause of death and disability in children and adults in Western Countries. The definitive brain injury is a consequence of pathophysiological mechanisms that begin at the moment of an accident and may extend for days or weeks. Traumatic brain injury may be classified as diffuse or focal. These two mechanisms are commonly associated in a patient, however one is generally predominant. Therefore knowledge of the pathophysiological mechanisms of brain injury in head trauma is important to establish the therapeutic, clinical and surgical measures. In this paper the authors present a critical review of the literature on the pathophysiological principles of traumatic brain injury.

Pterional, Pretemporal, and Orbitozygomatic Approaches: Anatomic and Comparative Study.

OBJECTIVE: Although pterional craniotomy and its variants are the most used approaches in neurosurgery, few studies have evaluated their precise indications. We evaluate the pterional (PT), pretemporal (PreT), and orbitozygomatic (OZ) approaches through quantitative measurements of area, linear, and angular exposures of the major intracranial vascular structures. METHODS: Eight fresh, adult cadavers were operated with the PT, followed by the PreT, and ending with the OZ approach. The working area, angular exposure of vascular structures and linear exposure of the basilar artery were measured. RESULTS: The OZ approach presented a wider area (1301.3 ± 215.9 mm2) with an increase of 456.7 mm2 compared with the PT and of 167.4 mm2 to the PreT (P = 0.011). The extension from PT to PreT and OZ increases linear exposure of the basilar artery. When comparing the PreT and OZ, we found an increase in the horizontal and vertical angle to the bifurcation of the ipsilateral middle cerebral artery (P = 0.005 and P = 0.032, respectively), horizontal angle to the basilar artery tip (P = 0.02), and horizontal angle to the contralateral ICA bifurcation (P = 0.048). CONCLUSIONS: The OZ approach offered notable surgical advantages compared with the traditional PT and PreT regarding to the area of exposure and linear exposure to basilar artery. Regarding angle of attack, the orbital rim and zygomatic arch removal provided quantitatively wider exposure and increased surgical freedom. A detailed anatomic study for each patient and surgeon experience must be considered for individualized surgical approach indication.

Evaluation of cerebral hemodynamics by transcranial Doppler ultrasonography and its correlation with intracranial pressure in an animal model of intracranial hypertension / Avaliação da hemodinâmica encefálica utilizando Doppler transcraniano e sua correlação com a pressão intracraniana em um modelo animal de hipertensão intracraniana

ABSTRACT Background: Transcranial Doppler has been tested in the evaluation of cerebral hemodynamics as a non-invasive assessment of intracranial pressure (ICP), but there is controversy in the literature about its actual benefit and usefulness in this situation. Objective: To investigate cerebral blood flow assessed by Doppler technique and correlate with the variations of the ICP in the acute phase of intracranial hypertension in an animal model. Methods: An experimental animal model of intracranial hypertension was used. The experiment consisted of two groups of animals in which intracranial balloons were implanted and inflated with 4 mL (A) and 7 mL (B) for controlled simulation of different volumes of hematoma. The values of ICP and Doppler parameters (systolic [FVs], diastolic [FVd], and mean [FVm] cerebral blood flow velocities and pulsatility index [PI]) were collected during the entire procedure (before and during hematoma simulations and venous hypertonic saline infusion intervention). Comparisons between Doppler parameters and ICP monitoring were performed. Results: Twenty pigs were studied, 10 in group A and 10 in group B. A significant correlation between PI and ICP was obtained, especially shortly after abrupt elevation of ICP. There was no correlation between ICP and FVs, FVd or FVm separately. There was also no significant change in ICP after intravenous infusion of hypertonic saline solution. Conclusions: These results demonstrate the potential of PI as a parameter for the evaluation of patients with suspected ICP elevation.

RESUMO Antecedentes: O Doppler transcraniano (DTC) é uma técnica não invasiva para a avaliação da hemodinâmica cerebral, porém existem controvérsias na literatura sobre sua aplicabilidade preditiva em situações de elevada pressão intracraniana (PIC). Objetivo: Investigar o fluxo sanguíneo cerebral pelo DTC e correlacioná-lo com as variações da PIC na fase aguda da hipertensão intracraniana em modelo animal. Métodos: Dois grupos de animais (suínos) foram submetidos a hipertensão intracraniana secundária à indução de diferentes volumes de hematoma, por meio da insuflação de balão intracraniano controlado com 4 e 7 mL de solução salina fisiológica (grupos A e B, respectivamente). Em seguida, administrou-se infusão venosa de solução salina hipertônica (SSH 3%). Foram coletados os valores dos parâmetros de PIC e DTC (velocidade sistólica [FVs], diastólica [FVd] e média [FVm] do fluxo sanguíneo cerebral), bem como o índice de pulsatilidade (IP). Comparações entre os parâmetros do DTC e o monitoramento da PIC foram realizadas. Resultados: Vinte porcos foram estudados, dez no grupo A e dez no grupo B. Correlação significativa entre IP e PIC foi obtida, principalmente logo após a elevação abrupta da PIC. Não houve correlação entre PIC e FVs, FVd ou FVm separadamente. Também não houve alteração significativa na PIC após a infusão de SSH. Conclusões: Esses resultados demonstram o potencial do IP como um bom parâmetro para a avaliação de pacientes com suspeita de elevação da PIC.

Current clinical approach to patients with disorders of consciousness.

In clinical practice, hospital admission of patients with altered level of consciousness, sleepy or in a non-responsive state is extremely common. This clinical condition requires an effective investigation and early treatment. Performing a focused and objective evaluation is critical, with quality history taking and physical examination capable to locate the lesion and define conducts. Imaging and laboratory exams have played an increasingly important role in supporting clinical research. In this review, the main types of changes in consciousness are discussed as well as the essential points that should be evaluated in the clinical management of these patients.

Epidural hematomas of the posterior cranial fossa.

OBJECT: The authors present their experience in the management of posterior fossa epidural hematoma (PFEDH), which involved an aggressive diagnostic approach with the extensive use of head computerized tomography (CT) scanning. METHODS: The authors treated 43 cases of PFEDH in one of the largest health centers in Brazil. Diagnosis was established in all patients with the aid of CT scanning because the clinical manifestations were frequently nonspecific. Cases were stratified by clinical course, Glasgow Coma Scale score, and their radiological status. Based on clinical and radiological parameters the patients underwent surgical or conservative management. CONCLUSIONS: Compared with outcomes reported in the available literature, good outcome was found in this series. This is primarily due to the broad use of CT scanning for diagnostic and observational purposes, which, in the authors' opinion, led to early diagnosis and prompt treatment.

Transcranial doppler sonography in two patients who underwent decompressive craniectomy for traumatic brain swelling: report of two cases.

The role of decompressive craniectomy in the treatment of severe posttraumatic cerebral swelling remains quite a controversial issue. To the best of our knowledge, there is no study demonstrating the effect of decompressive craniectomy on cerebral blood flow (CBF) velocity by means of transcranial Doppler sonography (TCD). We present two patients who developed traumatic brain swelling and uncontrollable intracranial hypertension with coma and signs of transtentorial herniation. One patient underwent bifrontal, while the second, unilateral, frontotemporoparietal decompressive craniectomy with dural expansion. In both patients, TCD examinations were performed immediately before and after surgery to study the cerebral hemodynamic changes related to the operations. Pre and postoperative TCD examinations demonstrated a significant increase in blood flow velocity in the intracranial arteries in both subjects. In conclusion, our cases suggest that decompressive craniectomy with dural expansion may result in elevation of CBF velocity in patients with massive brain swelling. The increase in CBF velocity appears to occur not only in the decompressed hemisphere, but also on the opposite side.

Gunshot wound to the upper cervical spine leading to instability.

Gunshot wounds (GSW) to the cervical spine leading to instability are rare. Also, the presence of vital vascular and neurological structures in the surround area lead to death or severe disability in the vast majority of cases. In this brief report, we present a rare case of C1 fracture due to GSW leading to instability of the atlanto-occipital joint in a neurologically intact patient.

Bilateral acute epidural hematoma with good outcome.

Epidural haematomas are one of the most common complicated closed-head injuries, but they, rarely show any bilateral localization. We are reporting here a case of a man found unconscious with Glasgow Coma Scale score; 8/15. Computed tomography of skull revealed bilateral epidural hematoma. Two emergency craniotomies were performed simultaneously, with satisfactory radiological control and neurological outcome. We discussed the aspects of a etiology and treatment about this unusual condition.

Experimental model of intracranial hypertension with continuous multiparametric monitoring in swine.

OBJECTIVE: Intracranial hypertension (IH) develops in approximately 50% of all patients with severe traumatic brain injury (TBI). Therefore, it is very important to identify a suitable animal model to study and understand the pathophysiology of refractory IH to develop effective treatments. METHODS: We describe a new experimental porcine model designed to simulate expansive brain hematoma causing IH. Under anesthesia, IH was simulated with a balloon insufflation. The IH variables were measured with intracranial pressure (ICP) parenchymal monitoring, epidural, cerebral oximetry, and transcranial Doppler (TCD). RESULTS: None of the animals died during the experiment. The ICP epidural showed a slower rise compared with parenchymal ICP. We found a correlation between ICP and cerebral oximetry. CONCLUSION: The model described here seems useful to understand some of the pathophysiological characteristics of acute IH.

Current clinical approach to patients with disorders of consciousness / Abordagem clínica atual do paciente com distúrbios de consciência

Summary In clinical practice, hospital admission of patients with altered level of consciousness, sleepy or in a non-responsive state is extremely common. This clinical condition requires an effective investigation and early treatment. Performing a focused and objective evaluation is critical, with quality history taking and physical examination capable to locate the lesion and define conducts. Imaging and laboratory exams have played an increasingly important role in supporting clinical research. In this review, the main types of changes in consciousness are discussed as well as the essential points that should be evaluated in the clinical management of these patients.

Resumo Abordagem Na prática clínica é extremamente comum a admissão hospitalar de pacientes com nível de consciência alterado, sonolentos ou em estado não responsivo. Essa condição clínica demanda uma investigação eficaz e um tratamento precoce. É fundamental a realização de uma avaliação focada e objetiva, com a realização de anamnese e exame físico de qualidade para localizar a lesão e definir condutas. Exames de imagem e laboratoriais têm desempenhado papéis cada vez mais relevantes no suporte à investigação clínica. Nesta revisão, são discutidos os principais tipos de alterações de consciência e os pontos imprescindíveis que devem ser avaliados na abordagem clínica desses pacientes.

Traumatic Brain Injury Research in Brazil: A Bibliometric Study

Traumatic brain injury (TBI) is responsible for high rates of morbidity and mortality, constituting an important public health problem throughout the world. Improving medical research on systemic trauma is a critical issue to understand its impact and develop strategies for prevention and treatment. This paper presents an overview of medical research performed in Brazil about TBI comparing it with the production on the same topic with other countries and with publications about different neurological and non-neurological diseases. It is possible to notice that Brazil has a deficiency in the scientific production on TBI given its importance. Greater integration between the research centers could help meliorate the production and quality of the papers and encourage further studies on the theme, in the quest to minimize the shortage of publications that can be seen today.

O trauma cranioencefálico (TCE) é responsável por altas taxas de morbidade e mortalidade, constituindo um importante problema de saúde pública em todo o mundo. Melhorar a investigação médica sobre trauma sistêmico é uma questão crítica para compreender seu impacto e desenvolver estratégias para a sua prevenção e tratamento. Este artigo apresenta uma visão geral da pesquisa médica realizada no Brasil sobre TCE comparando-a com a produção sobre o mesmo tema com outros países e com publicações sobre diferentes doenças neurológicas e não neurológicas. É possível notar que o Brasil tem uma deficiência na produção científica sobre TCE dada a sua importância. Maior integração entre os centros de pesquisa poderia ajudar a aperfeiçoar a produção e a qualidade dos trabalhos e incentivar novos estudos sobre o tema, na busca de minimizar a escassez de publicações vista atualmente.

Continuous ventricular cerebrospinal fluid drainage with intracranial pressure monitoring for management of posttraumatic diffuse brain swelling.

BACKGROUND: Ventricular drainage has played an important role in the management of traumatic brain-injured patients. The aim of the present study was describe outcomes in a series of 57 patients with diffuse brain swelling underwent to intracranial pressure (ICP) monitoring. METHOD: Fifty-eight patients with diffuse posttraumatic brain swelling, were evaluated prospectively. The Glasgow Coma Scale (GCS) scores of patients varied from 4 to 12. Patients groups divided according to GCS and age. Patient neurological assessment was classified as favorable, unfavorable, and death. RESULTS: Mechanisms of injury were vehicle accidents in 72.4% and falls in 15.6%. 54% of patients had GCS scores between 6 and 8. There were no statistical differences, regarding outcome, between groups separated by age. In the adults group (n=47), 44.7% evolved favorably. CONCLUSION: Our results indicate a poor prognosis in patients with brain swelling. We believe that continuous ventricular CSF drainage with ICP monitoring is a simple method as an adjunct in the management of these patients.

Management of supratentorial epidural hematoma in children: report on 49 patients.

UNLABELLED: Traumatic head injury is a common cause of mortality and acquired neurological impairment in children. However, pediatric epidural hematomas (EDHs) are not common and few series have studied the evolution of these patients. In this study, we present the results from a sample of patients with EDH with long-term follow-up. METHOD: Between January 2006 and December 2008, 49 patients with traumatic EDH were treated at our unit. Clinical course, radiological findings and outcomes were evaluated. Neurological status was assessed using the Glasgow Coma Scale (GCS). The patients' ages ranged from one day to 16 years. The mean follow-up was six months. RESULTS: On admission, most of the patients presented mild trauma and 57% had a GCS of 13-15. The most common symptom was irritability. The most frequent mechanisms of injury were: falling from a height in 29 cases and motor vehicle accidents in 16 cases. Three of these patients presented GCS 3, but only one died. We found a late neurological deficit in nine patients. CONCLUSION: These lesions may occur following mild head trauma and in alert children with nonfocal neurological examinations. However, in children presenting irritability with subgaleal hematomas and a history of loss of consciousness, skull computed tomography must be performed.