El Futuro del monitoreo no invasivo de la presión intracraneal

Letter to the Editor (without abstract)Carta al Editor (sin resumen

Satisfacción del Paciente en el Servicio de Emergencia

Carta al Editor (Sin resumen

Hemorragia alveolar pulmonar como presentación inicial de leptospirosis

Introducción: La leptospirosis es una enfermedad zoonotica de amplia distribución mundial en especial en países con alto índice fluvial. El compromiso respiratorio de la enfermedad tiene una incidencia del 20% al 70% y frecuentemente es leve y subdiagnosticada, la hemorragia alveolar pulmonar es la forma severa de compromiso respiratorio y tiene una mortalidad mayor al 50%. Reporte de Caso: Paciente de 16 años, procedente de Piura, estuvo en contacto con aguas contaminadas días previos debido al Fenómeno El Niño Costero. Ingresó por un cuadro clínico de 3 días de evolución caracterizado por fiebre, mialgias, disnea y expectoración hemoptoica. En radiografía de tórax se evidencia infiltrado alveolar reticulonodular bilateral y difuso, más acentuado en el sector periférico e inferior. Conclusión: La variedad de presentación de la enfermedad involucra un alto nivel de sospecha para identificar esta enfermedad que puede ser letal, principalmente debido a que el compromiso pulmonar puede pasar desapercibido

Rescatando al RescueICP: ¿Quién decide que es favorable o no?

Tipo de Estudio: Internacional, multicéntrico, controlado y randomizado, Objetivo: Evaluar efectividad de la craniectomía descompresiva (CD) en el manejo de la hipertensión intracraneal refractaria en pacientes con lesión cerebral traumática. Material y Métodos: Incluyó 408 pacientes entre 10 y 65 años desde el 2004 hasta 2014. 202 pacientes en el grupo quirúrgico y 196 en el grupo de manejo médico fueron enrolados, 10 pacientes fueron excluidos por falta de consentimiento informado válido y retiro voluntario. Una vez enrolados se randomizó en 02 grupos: 1) craniectomía descompresiva (CD), debía realizarse 4 a 6 horas después de la randomización (hemicraniectomía frontotémporoparietal o craniectomía bifrontal) y 2) tratamiento médico, la cual dentro sus medidas de manejo (línea 1 y línea 2) incluía también el uso de barbitúricos e hipotermia. Resultados: La mortalidad en grupo quirúrgico fue 26,9% vs 48,9% en el grupo médico, estado vegetativo 8,5% vs 2,1%, dependencia completa de otros 21,9% vs 14,4%, buena recuperación sin déficit 4% vs 6,9% a los 6 meses. Mortalidad en grupo quirúrgico a 12 meses fue 30,% vs 52% en el grupo médico, estado vegetativo 6,2% vs 1,7%, dependencia completa de otros 18% vs 14%, buena recuperación sin déficit 9,8% vs 8,4%. Conclusión: La CD como tratamiento de la hipertensión endocraneana grave y refractaria, disminuyó la mortalidad en un 22%, comparado con el grupo de tratamiento médico (p< 0,001), pero se asoció con mayores casos de pacientes en estado vegetativo y discapacidad severa. Las tasas de discapacidad moderada y buena recuperación, fueron similares en ambos grupos

Incidencia y pronóstico del ictus minor y ataque isquémico transitorio de alto riesgo en Nordictus: estudio IMMINENT

[Abstract] Background. Our primary aim was to investigate the incidence of non-cardioembolic minor acute ischemic stroke (AIS) and high-risk transient ischemic attack (TIA) and to identify predictors of stroke recurrence/death and severe bleeding. We also evaluated the rates of TIA, major vascular events, therapeutic management and predictors of poor functional outcome at 3 months in these patients. Methods. We retrospectively reviewed data from all stroke patients evaluated at the emergency department of 19 hospitals belonging to the NORDICTUS stroke network between July and December 2019. Consecutive patients with non-cardioembolic minor AIS (NIHSS ≤5) and high-risk TIA (ABCD2 ≥6 or ipsilateral stenosis ≥50%) were included. We recorded clinical, neuroimaging and therapeutic variables. Follow-up was performed at 30 and 90 days. Functional prognosis was assessed with the modified Rankin scale score (mRS). Results. Of 8275 patients, 1679 (20%) fulfilled IMMINENT criteria (1524 AIS/155 TIA), resulting in a global incidence of 48/100,000 inhabitants per-year. Recurrent stroke/death occurred in 73 (4.3%) patients. Extracranial ipsilateral stenosis (>50%): HR 1.999 (95% CI: 1.115–3.585, p = 0.020) and lack of hyperacute cerebral arterial assessment: HR 1.631 (95% CI: 1.009–2.636, p = 0.046) were associated with recurrent stroke/death at 90 days. Intracranial stenosis was associated with poor prognosis (p = 0.044). Reperfusion therapy was given to 147 (9%) and urgent double antiplatelet therapy (DAPT) to 320 (21%) patients. Conclusion. Twenty percent of our stroke patients presented as non-cardioembolic high-risk TIA or minor AIS. Extracranial ipsilateral stenosis and lack of hyperacute cerebral arterial assessment were predictors of stroke recurrence/death; intracranial stenosis was associated with poor outcome. Despite current recommendations there was a low penetrance of DAPT.[Resumen] Introducción. Nuestro objetivo principal fue investigar la incidencia de ictus minor no cardioembólico y ataque isquémico transitorio (AIT) de alto riesgo, además de identificar predictores de recurrencia de ictus/muerte y sangrado grave. Evaluamos los porcentajes de AIT, eventos vasculares mayores, manejo terapéutico y predictores de mal pronóstico funcional. Métodos. Estudio retrospectivo de todos los pacientes con ictus evaluados en urgencias de 19 hospitales de la RED NORDICTUS entre julio-diciembre de 2019. Se incluyeron pacientes consecutivos con ictus minor no cardioembólico (National Institute of Health Stroke Scale [NIHSS] ≤ 5) y AIT de alto riesgo (ABCD2 ≥ 6 o estenosis ipsilateral ≥ 50%). Registramos variables clínicas, de neuroimagen y terapéuticas. Se realizó seguimiento a los 30 y 90 días. El pronóstico funcional se determinó mediante la escala de Rankin modificada (mRS). Resultados. De 8.275 pacientes, 1.679 (20%) cumplieron criterios del estudio IMMINENT (1.524 ictus/155 AIT), la incidencia global fue 48/100.000 h habitantes-año. Hubo recurrencias de ictus/muerte en 73 (4,3%) pacientes. La estenosis extracraneal ipsilateral (>50%): HR 1.999 (IC 95%: 1.115-3.585); p = 0,020 y la ausencia de estudio cerebrovascular hiperagudo: HR 1.631 (IC 95%: 1.009-2.636); p = 0.046, fueron predictores de ictus/muerte a 90 días. La estenosis intracraneal se asoció a mal pronóstico (p = 0,044). Se administró terapia de reperfusión a 147 (9%) y doble antiagregación a 320 (21%) pacientes. Conclusión. Un 20% de los pacientes se presentó como ictus minor o AIT de alto riesgo. La estenosis extracraneal ipsilateral y la ausencia de estudio neurovascular hiperagudo fueron predictores de ictus/muerte; la estenosis intracraneal se asoció con mal pronóstico. A pesar de las recomendaciones actuales hay baja penetrancia de doble antiagregación.This study was sponsored by AstraZeneca, funder had no involvement in the analysis or interpretation of the data, or the writing of the manuscript. MER-A was funded by the Instituto de Salud Carlos III (ISCIII) JR19/00020, co-funded by ERDF/ESF, “A way to make Europe”/“Investing in your future”). Investigators of this study belong to the RETICS-RICORS ICTUS financed by ISCIII (RD21/0006/0005-RD21/0006/0016-RD21/0006/0017-RD21/0006/0020-RD21/0006/0022).Instituto de Salud Carlos III; JR19/0002

Table_1_High vs. low tidal volume and pulmonary complications in patients with cervical spinal cord injury on mechanical ventilation: systematic review.docx

IntroductionCervical spinal cord injury (CSCI) patients on mechanical ventilation often lack standardized guidelines for optimal ventilatory support. This study reviews existing literature to compare outcomes between high tidal volume (HTV) and low tidal volume (LTV) strategies in this unique patient population.MethodsWe searched for studies published up to August 30, 2023, in five databases, following a PECO/PICO strategy. We found six studies for quantitative analysis and meta-analyzed five studies.ResultsThis meta-analysis included 396 patients with CSCI and mechanical ventilation (MV), 119 patients treated with high tidal volume (HTV), and 277 with low tidal volume (LTV). This first meta-analysis incorporates the few studies that show contradictory findings. Our meta-analysis shows that there is no significant statistical difference in developing VAP between both comparison groups (HTV vs. LTV) (OR 0.46; 95% CI 0.13 to 1.66; p > 0.05; I2: 0%), nor are there differences between the presence of other pulmonary complications when treating with HTV such as acute respiratory distress syndrome (ARDS), atelectasis, onset of weaning.ConclusionIn patients with CSCI in MV, the use of HTV does not carry a greater risk of pneumonia compared to LTV; in turn, it is shown as a safe ventilatory strategy as it does not establish an increase in other pulmonary complications such as ARDS, atelectasis, the onset of weaning nor others associated with volutrauma. It is necessary to evaluate the role of HTV ventilation in this group of patients in primary RCT-type studies.</p

Oral Anticoagulation and Risk of Symptomatic Hemorrhagic Transformation in Stroke Patients Treated With Mechanical Thrombectomy: Data From the Nordictus Registry

Introduction: We aimed to evaluate if prior oral anticoagulation (OAC) and its type determines a greater risk of symptomatic hemorrhagic transformation in patients with acute ischemic stroke (AIS) subjected to mechanical thrombectomy. Materials and Methods: Consecutive patients with AIS included in the prospective reperfusion registry NORDICTUS, a network of tertiary stroke centers in Northern Spain, from January 2017 to December 2019 were included. Prior use of oral anticoagulants, baseline variables, and international normalized ratio (INR) on admission were recorded. Symptomatic intracranial hemorrhage (sICH) was the primary outcome measure. Secondary outcome was the relation between INR and sICH, and we evaluated mortality and functional outcome at 3 months by modified Rankin scale. We compared patients with and without previous OAC and also considered the type of oral anticoagulants. Results: About 1.455 AIS patients were included, of whom 274 (19%) were on OAC, 193 (70%) on vitamin K antagonists (VKA), and 81 (30%) on direct oral anticoagulants (DOACs). Anticoagulated patients were older and had more comorbidities. Eighty-one (5.6%) developed sICH, which was more frequent in the VKA group, but not in DOAC group. OAC with VKA emerged as a predictor of sICH in a multivariate regression model (OR, 1.89 [95% CI, 1.01-3.51], p = 0.04) and was not related to INR level on admission. Prior VKA use was not associated with worse outcome in the multivariate regression model nor with mortality at 3 months. Conclusions: OAC with VKA, but not with DOACs, was an independent predictor of sICH after mechanical thrombectomy. This excess risk was associated neither with INR value by the time thrombectomy was performed, nor with a worse functional outcome or mortality at 3 months

Treatments for intracranial hypertension in acute brain-injured patients: grading, timing, and association with outcome. Data from the SYNAPSE-ICU study

Purpose: Uncertainties remain about the safety and efficacy of therapies for managing intracranial hypertension in acute brain injured (ABI) patients. This study aims to describe the therapeutical approaches used in ABI, with/without intracranial pressure (ICP) monitoring, among different pathologies and across different countries, and their association with six&nbsp;months mortality and neurological outcome. Methods: A preplanned subanalysis of the SYNAPSE-ICU study, a multicentre, prospective, international, observational cohort study, describing the ICP treatment, graded according to Therapy Intensity Level (TIL) scale, in patients with ABI during the first week of intensive care unit (ICU) admission. Results: 2320 patients were included in the analysis. The median age was 55 (I-III quartiles = 39-69) years, and 800 (34.5%) were female. During the first week from ICU admission, no-basic TIL was used in 382 (16.5%) patients, mild-moderate in 1643 (70.8%), and extreme in 295 cases (eTIL, 12.7%). Patients who received eTIL were younger (median age 49 (I-III quartiles = 35-62) vs 56 (40-69) years, p &lt; 0.001), with less cardiovascular pre-injury comorbidities (859 (44%) vs 90 (31.4%), p &lt; 0.001), with more episodes of neuroworsening (160 (56.1%) vs 653 (33.3%), p &lt; 0.001), and were more frequently monitored with an ICP device (221 (74.9%) vs 1037 (51.2%), p &lt; 0.001). Considerable variability in the frequency of use and type of eTIL adopted was observed between centres and countries. At six&nbsp;months, patients who received no-basic TIL had an increased risk of mortality (Hazard ratio, HR = 1.612, 95% Confidence Interval, CI = 1.243-2.091, p &lt; 0.001) compared to patients who received eTIL. No difference was observed when comparing mild-moderate TIL with eTIL (HR = 1.017, 95% CI = 0.823-1.257, p = 0.873). No significant association between the use of TIL and neurological outcome was observed. Conclusions: During the first week of ICU admission, therapies to control high ICP are frequently used, especially mild-moderate TIL. In selected patients, the use of aggressive strategies can have a beneficial effect on six&nbsp;months mortality but not on neurological outcome