Análise crítica da sedação e analgesia no traumatismo craniano grave

Introduction Head injury is a direct determinant of morbidity, disability, and mortality in the young population. Sedatives and analgesics are commonly used in patients with brain injury to retrieve an ICP, CMRO2, and CBF, preserving the cerebral regulation system and self-avoiding hypotension. Objective The objective of this paper is to review on this topic, linking the main drugs, side effects, costs, anxiolytic properties, anticonvulsants, and correlating them with complacency and brain metabolism. Methods We perform a literature review using PubMed database, MEDLINE, EMBASE, Science Direct, The Cochrane Database, Google Scholar, and Clinical trials. We selected papers from the period between 1958 and 2014, which totaled 254 papers. Of these, we selected 129 papers based on keywords, inclusion, and exclusion criteria. Evidence Review The volume of the brain decreases due to dislocation of the CBV out of the skull. The main sedatives and analgesics are propofol, midazolam, etomidate, ketamine, barbiturates, dexedetomedina, morphine, fentanyl, alfentanil, sulfenatil, and remifentanil. We hereby discuss the algorithm for a fast intubation sequence and the algorithm for intracranial hypertension treatment regarding the systematic sedation therapy. A range of sedatives and analgesic agents are available for sedation. Each class has its own positive and negative effects on neurotrauma patients. Conclusions The correct analysis of sedation and analgesia in neurotrauma, rapid sequence intubation, and management of medications in intracranial hypertension can lead to an ideal management of brain injury._________________________________________________________________________________________ RESUMO: Introdução Traumatismo Craniano (TCE) é determinante direto na morbidade, incapacidade e mortalidade na população jovem. Sedativos e analgésicos são comumente usados em pacientes com lesão cerebral com o objetivo de recuperar PIC, CMRO2 e FBC, preservando o sistema de autorregulação cerebral, evitando hipotensão. Objetivo O objetivo deste trabalho é fazer uma revisão sobre este tema, correlacionando as principais drogas, efeitos colaterais, custos, propriedades ansiolíticas, anticonvulsivantes, correlacionando com complacência e metabolismo cerebral. Métodos Revisão da literatura utilizando base de dados PubMed, MEDLINE, EMBASE, Science Direct, The Cochrane Detabase, Google Scholar, ensaios clínicos. Os trabalhos selecionados de 1958 a 2014. Somou-se 254 trabalhos. Foram selecionados 129, através de palavras-chave, inclusão e critérios de exclusão. Evidência Revisão O volume do cérebro é reduzido devido o deslocamento do volume cerebral. Os principais sedativos e analgésicos são: propofol, midazolam, etomidato, cetamina, barbitúricos, a dexmedetomidina, morfina, fentanil, alfentanil, sulfato, remifentanil. Discute-se algoritmo para a sequência rápida de intubação e algoritmo para tratamento de hipertensão intracraniana. Uma série de sedativos e analgésicos agentes estão disponíveis para sedação. Cada classe tem seu próprio efeitos positivos e negativos em pacientes no neurotrauma. Conclusões e Relevância O presente trabalho contribui com a análise correta da sedação e analgesia em neurotrauma, sequência rápida de intubação e administração de medicamentos para analgesia e sedação em hipertensão intracraniana, e um ideal manejo na lesão cerebral

Vascularization of the uncus : anatomical study and clinical implications

Background: The objective of this paper was to describe the arterial supply of the uncus and quantify the branches directed to the anteromedial aspect of the human temporal cortex. Methods: We studied 150 human cerebral hemispheres identifying main afferent arteries supplying the anteromedial temporal cortex with particular attention to the uncus, determining the territory supplied by each artery through either cortical or perforating branches. Results: The uncus was supplied by 419 branches of the anterior choroidal artery (AChA), 210 branches of the internal carotid artery (ICA), 353 branches of the middle cerebral artery (MCA), and 122 branches of the posterior cerebral artery (PCA). The total of supplying vessels was 1104 among the 150 hemispheres studied, which corresponds to 7.36 arteries per uncus. The average of branches per hemisphere was as follows: 2.79 from AChA, 1.40 from ICA, 2.35 from MCA, and 0.81 from PCA. The relative contribution of each artery for the total of specimens studied was as follows: 38% from AChA, 19% from ICA, 32% from the MCA, and 11% from the PCA. We identified cortical anastomoses mostly between the MCA and PCA (27 cases). Conclusion: We described and quantified the uncus’ vascularization, including anatomical variations. This updated, detailed description of the mesial temporal vascularization is paramount to improve the treatment of neurosurgical conditions

O impacto da terapia cognitivo-comportamental no transtorno do espectro autista / The impacto of cognitive-behavioral therapy on autistic spectrum disorder

Este artigo buscou identificar de que forma a terapia cognitivo-comportamental (TCC) auxilia no tratamento e prognóstico do Transtorno do Espectro Autista (TEA). Verificou-se que o TEA atinge cerca de 1% da população mundial. A clínica caracteriza-se, predominantemente, por déficits em três áreas: no comportamento, nas relações sociais e na comunicação. O diagnóstico é pautado em achados clínicos: anamnese e observação de comportamentos. Não há exame complementar que ratifique o diagnóstico. Para o tratamento, além de intervenções medicamentosas, a TCC é considerada padrão ouro. É estabelecido um plano individualizado, onde os principais instrumentos são sistemas de reforço, condicionamento e levantamento criterioso dos aspectos que estejam relacionados aos comportamentos desejáveis ou não do paciente. Estima-se que, em 2017, uma a cada 160 crianças em todo o mundo, possuam o TEA. Segundo a Organização Pan-Americana de Saúde (OPAS), esse dado é um valor médio, sendo que a prevalência varia totalmente entre diferentes estudos. Embora alguns estudos mostrem números significativamente maiores. Trata-se de um transtorno comportamental complexo, do desenvolvimento neurológico, e deve estar presente desde o nascimento ou começo da infância, mas pode não ser detectado antes, devido às demandas sociais mínimas na mais tenra infância, e do intenso apoio dos pais ou cuidadores nos primeiros anos de vida.  

Role of temporary arterial occlusion in subarachnoid hemorrhage outcomes: a prospective cohort study

ABSTRACT Purpose: Temporary arterial occlusion (TAO) is a widespread practice in the surgical treatment of intracranial aneurysms. This study aimed to investigate TAO’s role during ruptured aneurysm clipping as an independent prognostic factor on short- and long-term outcomes. Methods: This prospective cohort included 180 patients with ruptured intracranial aneurysms and an indication of microsurgical treatment. Patients who died in the first 12 hours after admission were excluded. Results: TAO was associated with intraoperative rupture (IOR) (odds ratio – OR = 10.54; 95% confidence interval – 95%CI 4.72–23.55; p < 0.001) and surgical complications (OR = 2.14; 95%CI 1.11–4.07; p = 0.01). The group with TAO and IOR had no significant difference in clinical (p = 0.06) and surgical (p = 0.94) complications compared to the group that had TAO, but no IOR. Among the 111 patients followed six months after treatment, IOR, number of occlusions, and total time of occlusion were not associated with Glasgow Outcome Scale (GOS) in the follow-up (respectively, p = 0.18, p = 0.30, and p = 0.73). Among patients who underwent TAO, IOR was also not associated with GOS in the follow-up (p = 0.29). Conclusions: TAO was associated with IOR and surgical complications, being the latter independent of IOR occurrence. In long-term analysis, neither TAO nor IOR were associated with poor clinical outcomes

Molecular analysis of viral DNA in patients with ruptured and unruptured intracranial aneurysms

Introdução: A hemorragia subaracnóidea (HSA) causada por aneurisma intracraniano (AI) pode causar, aproximadamente, 50% de mortalidade entre pacientes na faixa etária laboral. A fraqueza estrutural do vaso arterial e sua ruptura ainda são fenômenos pouco compreendidos. Recentes avanços na detecção de DNA viral e a associação de vírus com doenças vasculares fomenta a hipótese de correlacionar a presença de DNA viral na parede do vaso arterial e o AI. O vírus Torque teno vírus (TTV), recentemente, foi descrito e possui alta prevalência na população mundial. Este vírus causa uma viremia no hospedeiro, associada a diversas infecções em estados de imunossupressão do paciente, como sepse e transplante. Por outro lado, o Pan-Herpes vírus humano (pan-HHV), também é muito prevalente. A presença de vírus pode levar a uma resposta inflamatória crônica silenciosa, consequentemente, fragilizando a parede dos vasos arteriais sistêmicos a longo prazo. Objetivo: Avaliar a presença de DNA viral dos vírus TTV e panHHV em tecidos arteriais de AI rotos e não rotos Método: 401 pacientes foram atendidos na Divisão de Clínica Neurocirúrgica do Hospital das Clínicas da FMUSP. Os pacientes foram divididos em dois grupos: os com aneurismas rotos (244) e os com aneurismas não rotos (177). Os vírus analisados foram pan-HHV e TTV nas amostras de tecido vascular cerebral. Os critérios de inclusão e exclusão foram aplicados para seleção da população do estudo. As amostras foram coletadas após a clipagem microcirúrgica e, em seguida, conservadas e submetidas à extração de DNA e à reação em cadeia da polimerase para TTV e pan-HHV, sendo analisados seus oito subtipos. Resultados: foram analisados 35 casos de pacientes elegíveis em que a coleta do material foi factível, destes 22 (62,8%) eram AIs rotos e 13 (37,2%) AIs não rotos. O gênero feminino representou a maior parte da amostra (n = 29; 82,9%), sendo 18 (81,8%) casos rotos e 11(18,2%) não rotos. Os vírus foram detectados em 16 amostras (46%). O TTV em 15 (43%) casos, sendo 10 (28,6%) rotos e cinco (14,4%) não rotos. Apenas um caso da análise revelou-se positivo para pan-HHV com detecção do Epstein-Barr (3%), sendo este paciente do sexo feminino, aneurisma roto e apresentando múltiplos aneurismas. Os aneurismas múltiplos corresponderam a 14 pacientes (40%) da amostra, sendo sete pacientes igualmente distribuídos entre os grupos roto e não roto. A associação entre presença do vírus e múltiplos aneurismas esteve presente em seis (17,2%, p=0,781) casos não sendo estatisticamente significativo. As associações entre a presença do vírus na parede de AI não roto e de AI roto, não se mostraram estatisticamente significativos (p=0,507). Conclusão: A presença de DNA viral de HHV e TTV na parede de AI, correspondeu a 46% da amostra, sendo estes 68% AI rotos. Este achado sugere que a infecção crônica viral pode desempenhar papel na fisiopatologia da formação de AI como fator de risco, no que se refere à influência da alteração da citoarquitetura do vaso, em razão do processo inflamatório envolvidoIntroduction: Subarachnoid hemorrhage (SAH) caused by intracranial aneurysm (IA) can cause approximately 50% mortality among patients in the working age group. The mechanism of aneurysm formation, the structural weakness of the vessel, and its rupture remain poorly understood. Recent advances in the detection of viral DNA and the association of viruses with vascular diseases justify studying the hypothesis on the relationship between viral infection and the development of cerebral aneurysmal disease. The Torque teno virus (TTV) has recently been discovered and has a high prevalence in the worldwide population. It promotes a lifelong viremia that is associated with many host infections in cases of immunosuppression. On the other hand, the human pan-Herpesvirus (pan-HHV) is also very prevalent. The presence of pathogens implies a silent chronic inflammatory response and changes in the systemic vessel wall. Objective: This study aims to evaluate the prevalence of viral DNA of TTV and pan-HHV in ruptured and non-ruptured IA arterial tissues. Method: 401 patients were admitted in the Neurosurgery Department of Hospital das Clinicas FMUSP at Instituto Central. The patients were divided into two groups: those with ruptured aneurysm (244) and those with non-ruptured aneurysm (177). The viruses analyzed were pan-HHV and TTV in samples of aneurism wall. Inclusion and exclusion criteria were applied. In the operating room, the samples were collected after microsurgical clipping. They were properly preserved and subjected to DNA extraction and polymerase chain reaction for TTV and pan-HHV (eight sub-types were analyzed). Results: Thirty-five cases were eligible, of which 22 (62.8%) were ruptured aneurysms, and 13 (37.2%) were non-ruptured aneurysms. The female gender represented most of the sample (n = 29; 82.9%), with 18 (81.8%) ruptured cases and 11 (18.2%) nonruptured aneurysms. The virus was detected in 16 samples (46%). TTV was detected in 15 (43%) cases, 10 (28,6%) of which were ruptured and five (14,4%) were non-ruptured. Only one case of pan-HHV analysis was positive with the EpsteinBarr virus (3%). This female patient had a ruptured aneurysm and multiple aneurysms. Multiple aneurysms accounted for 14 (40%) cases, with seven patients equally distributed between the ruptured and non-ruptured groups. The association between the presence of the virus and multiple aneurysms was present in six (17.2%, p = 0.781) cases and was not statistically significant. The associations between the presence of the virus on the unruptured IA wall and the ruptured IA was not statistically significant (p = 0.507). Conclusion: The TTV and HHV DNA in the wall of IA, represent 46% of the sample, and 68% of ruptured IA. This finding suggests that infection may play a role in the pathophysiology of IA as a risk factor, regarding the influence of the virus on the inflammatory proces

Spontaneous healing of bucket handle tear of the medial meniscus associated with ACL tear Resolução espontânea da lesão alça de balde do menisco medial associado com rotura de LCA

We report a case of injury of the medial bucket handle meniscal tears (BH), which resolved spontaneously, in association with anterior cruciate ligament (ACL) injury. The patient twisted his left knee during a fight in martial arts, progressing to pain and joint locking and a sense of distortion. In NMR it could be seen bucket-handle tear of the medial meniscus with displacement of the fragment to the intercondylar region, rupture of the lateral meniscus and ACL tear. After conservative treatment and physiotherapy, in an interval of one year, later examinations showed that there was spontaneous healing of ABNeste trabalho &#233; relatado um caso de les&#227;o do menisco medial do tipo em al&#231;a de balde (AB), que se resolveu espontaneamente, em associa&#231;&#227;o com les&#227;o de ligamento cruzado anterior (LCA). O paciente torceu o joelho esquerdo durante uma luta em artes maciais, evoluindo com dor e bloqueio articular e sensa&#231;&#227;o de falseamento. Na RMN havia rotura em al&#231;a de balde do menisco medial com deslocamento do fragmento para a regi&#227;o intercondilar, rotura do menisco lateral e rotura do LCA. Ap&#243;s tratamento cl&#237;nico e fisioter&#225;pico, em um intervalo de um ano, o exame de controle demonstrou que havia ocorrido resolu&#231;&#227;o espont&#226;nea da AB

Traumatic brain lesions in newborns

ABSTRACT The neonatal period is a highly vulnerable time for an infant. The high neonatal morbidity and mortality rates attest to the fragility of life during this period. The incidence of birth trauma is 0.8%, varying from 0.2-2 per 1,000 births. The aim of this study is to describe brain traumas, and their mechanism, anatomy considerations, and physiopathology of the newborn traumatic brain injury. Methods A literature review using the PubMed data base, MEDLINE, EMBASE, Science Direct, The Cochrane Database, Google Scholar, and clinical trials. Selected papers from 1922 to 2016 were studied. We selected 109 papers, through key-words, with inclusion and exclusion criteria. Discussion This paper discusses the risk factors for birth trauma, the anatomy of the occipito-anterior and vertex presentation, and traumatic brain lesions. Conclusion Birth-related traumatic brain injury may cause serious complications in newborn infants. Its successful management includes special training, teamwork, and an individual approach

Pterygopalatine Fossa: Microsurgical Anatomy and its Relevance for Skull Base Surgery

Introduction The purpose of this study was to define the anatomical relationships of the pterygopalatine fossa (PPF) and its operative implications in skull base surgical approaches. Methods Ten cadaveric heads were dissected at the Dianne and M Gazi Yasargil Educational Center MicrosurgicaLaboratory, in Little Rock, AK, USA. The PPF was exposed through an extended dissection with mandible and pterygoid plate removal. Results The PPF has the shape of an inverted cone. Its boundaries are the pterygomaxillary fissure; the maxilla, anteriorly; the medial plate of the pterygoid process, and greater wing of the sphenoid process, posteriorly; the palatine bone, medially; and the body of the sphenoid process, superiorly. Its contents are the maxillary division of the trigeminal nerve and its branches; the pterygopalatine ganglion; the pterygopalatine portion of the maxillary artery (MA) and its branches; and the venous network. Differential diagnosis of PPF masses includes perineural tumoral extension along the maxillary nerve, schwannomas, neurofibromas, angiofibromas, hemangiomas, and ectopic salivary gland tissue. Transmaxillary and transpalatal approaches require extensive resection of bony structures and are narrow in the deeper part of the approach, impairing the surgical vision and maneuverability. Endoscopic surgery solves this problem, bringing the light source to the center of the surgical field, allowing proper visualization of the surgical field, extreme close-ups, and different view angles. Conclusion We provide detailed information on the fossa's boundaries, intercommunications with adjacent structures, anatomy of the maxillary artery, and its variations. It is discussed in the context of clinical affections and surgical approaches of this specific region, including pterygomaxillary disjunction and skull base tumors

Technical Description of Minimally Invasive Extradural Anterior Clinoidectomy and Optic Nerve Decompression. Study of Feasibility and Proof of Concept

© 2019 Elsevier Inc.Background: Several diseases that involve the optic canal or its contained structures may cause visual impairment. Several techniques have been developed to decompress the optic nerve. Objective: To describe minimally invasive extradural anterior clinoidectomy (MiniEx) for optic nerve decompression, detail its surgical anatomy, present clinical cases, and established a proof of concept. Methods: Anatomic dissections were performed in cadaver heads to show the surgical anatomy and to show stepwise the MiniEx approach. In addition, these surgical concepts were applied to decompress the optic nerve in 6 clinical cases. Results: The MiniEx approach allowed the extradural anterior clinoidectomy and a nearly 270° optic nerve decompression using the no-drill technique. In the MiniEx approach, the skin incision, dissection of the temporal muscle, and craniotomy were smaller and provided the same extent of exposure of the optic nerve, anterior clinoid process, and superior