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Objective To evaluate the interobserver reliability of a new scale created for quantitatively assessing brain swelling in traumatic brain injury (TBI) patients using the computed tomography (CT) findings in three levels. Methods Computed tomography scans of severe head injury patients were randomly selected from a tertiary hospital image database and evaluated by independent groups of neurosurgeons, neurosurgery residents, radiologists, and intensivists from the same hospital. Each specialist assessed the tomographic findings, applying zero to six points in a new scale. The Kappa coefficient was calculated to assess interobserver agreement. Results The highest reliability coefficient was obtained by the neurosurgeons group (0.791; 95% confidence interval [CI]: 0.975–0.607; p Conclusion The proposed scale showed good reliability among neurosurgeons, and moderate overall reliability. This tomographic classification might be useful to better assist severe TBI victims, allowing to identify the worsening or amelioration of brain swelling, which should be further investigated. The scale seems to be feasible, even in low income countries, where the cost of intracranial pressure (ICP) monitoring is higher than that of CTs.

Early cranioplasty has been encouraged after decompressive craniectomy (DC), aiming to reduce consequences of atmospheric pressure over the opened skull. However, this practice may not be often available in low-middle-income countries (LMICs). We evaluated clinical improvement, hemodynamic changes in each hemisphere, and the hemodynamic balance between hemispheres after late cranioplasty in a LMIC, as the institution’s routine resources allowed. Prospective cohort study included patients with bone defects after DC evaluated with perfusion tomography (PCT) and transcranial Doppler (TCD) and performed neurological examinations with prognostic scales (mRS, MMSE, and Barthel Index) before and 6 months after surgery. A final sample of 26 patients was analyzed. Satisfactory improvement of neurological outcome was observed, as well as significant improvement in the mRS (p = 0.005), MMSE (p

Background: Invasive monitoring of intracranial pressure (ICP) is currently the gold standard method for the safe diagnosis and treatment of intracranial hypertension (ICHy), but it is subject to hemorrhage, infection and malfunction. Ultrasound of the optic nerve sheath diameter (ONSD) has been applied as a non-invasive alternative that is cost effective and available at the bedside. However, ONSD time-lapse behavior in a set of ICHy and its relief by means of whether saline infusion or surgery is still unknown. The objective of this study was to correlate intracranial pressure and ultrasonography of the optic nerve sheath in an experimental animal model of ICHy, and the interval needed to ONSD to return to its baseline levels.Methods: An experimental study was conducted on 30 male and female pigs weighing about 20 kg. The diameter of the optic nerve sheath was evaluated by ultrasound at different measures of ICP given by intraventricular catheter and intracranial balloon inflation, saline infusion and balloon deflation. Laboratory and hemodynamic data were collected from the animals. ICP and ONSD values were correlated at each time point of the study.Results: All the variables obtained by ONSD ultrasonography as left optic nerve, right optic nerve and average of optic nerve sheath (AON) diameter were statistically significant to estimate ICP value. ONSD values changed immediately at balloon inflation, with a delay of 30 minutes average to return to baseline levels after balloon deflation (p = 0.016). No statistical significance was observed in ICP and ONSD values with hypertonic saline infusion. Correlation between ICP and ONSD was linear and can be estimated using the formula: -80.5 + 238.2 x AON, in this swine model. Conclusion: In the present study, ultrasound of optic nerve sheath diameter disclosed linear correlation with ICP, although a short delay in returning to its baseline levels may be observed in the case of sudden intracranial hypertension relief.

OBJECTIVESmall acute epidural hematomas (EDHs) treated conservatively carry a nonmeasurable risk of late enlargement due to middle meningeal artery (MMA) lesions. Patients with EDHs need to stay hospitalized for several days, with neurological supervision and repeated CT scans. In this study, the authors analyzed the safety and efficacy of the embolization of the involved MMA and associated lesions.METHODSThe study group consisted of 80 consecutive patients harboring small- to medium-sized EDHs treated by MMA embolization between January 2010 and December 2014. A literature review cohort was used as a control group.RESULTSThe causes of head injury were falls, traffic-related accidents (including car, motorcycle, and pedestrian vs vehicle accidents), and assaults. The EDH topography was mainly temporal (lateral or pole). Active contrast leaking from the MMA was seen in 57.5%; arteriovenous fistulas between the MMA and diploic veins were seen in 10%; and MMA pseudoaneurysms were found in 13.6% of the cases. Embolizations were performed under local anesthesia in 80% of the cases, with N-butyl-2-cyanoacrylate, polyvinyl alcohol particles, or gelatin sponge (or a combination of these), obtaining MMA occlusion and complete resolution of the vascular lesions. All patients underwent follow-up CT scans between 1 and 7 days after the embolization. In the 80 cases in this series, no increase in size of the EDH was observed and the clinical evolution was uneventful, without Glasgow Coma Scale score modification after embolization and with no need for surgical evacuation. In contrast, the control cohort from the literature consisted of 471 patients, 82 (17.4%) of whom shifted from conservative treatment to surgical evacuation.CONCLUSIONSThis study suggests that MMA embolization is a highly effective and safe method to achieve size stabilization in nonsurgically treated acute EDHs.

Traumatic brain injury (TBI) is a major public health problem in Western countries. A TBI brings many negative consequences, including behavioral and cognitive changes, which affect social adjustment and the performance of functional activities. Cognitive evaluation after TBI is a complex issue in what pertains to definition of the most appropriate questionnaires for clinical use in a comprehensive analysis of the condition of the patient. In this paper, we described a critical review of the main cognitive assessment tests currently used in clinical and research settings in patients with TBI.

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.

Background Craniectomies and cranioplasty are common neurosurgical procedures performed after brain trauma, ischemia, tumor resection, or infection. Post-cranioplasty autologous bone flap resorption may occur in patients after delayed cranial reconstruction. The occurrence is usually low when bone flaps are stored in subcutaneous abdominal tissue. We report a unique case of post-cranioplasty cranial bone flap. Case description We report a total autologous bone flap resorption in a 28-year-old man with a history of alcohol abuse. He was found unconscious in his bedroom with a head trauma of unknown mechanism. After an emergency room assessment, he was diagnosed with an acute subdural hematoma and underwent to emergency surgical drainage and a craniectomy. Three months later, a cranioplasty was performed and he exhibited exceptional outcomes. During a follow-up assessment, 7 months post-cranioplasty, total bone flap resorption was observed on computerized tomography image. Conclusion This case described an abnormal accelerated resorption of an autologous bone flap cranioplasty inserted after 3 months. Thus, to avoid bone flap resorption, an as early as possibly strategy may prevent this. Still, the exact mechanisms underlying bone resorption are poorly understood.

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.

A hipertensao intracraniana continua a ser a causa mais frequente de morte em pacientes com traumatismo cranioencefalico. Assim, a monitoracao invasiva da pressao intracraniana consiste em ferramenta de grande importância em neurointensivismo. Recentemente, resultados de um ensaio clinico questionaram a aplicacao desse metodo. Neste artigo, realizamos uma revisao sumaria da literatura referente as evidencias atuais e relevância clinica da monitoracao invasiva de pressao intracraniana.

Objectives A few recent studies have focused on epidural hematomas (EDHs) that are routine in emergency rooms. The study was to evaluate the latest situation of affected patients by encephalic trauma associated with EDH in our service. Methods Prospective study between September 1, 2003 and May 30, 2009. Data were computed regarding age, sex, trauma mechanism, qualification by Glasgow coma scale admission, presence of anisocoria, and evaluation by the recovery of Glasgow scale high, with all patients by computed tomography (CT) scan. Results Among the 173 analyzed patients, mortality reached 20 patients (11.5%). Mortality was higher in the subgroup of 76 patients (44%) admitted with Glasgow coma scale (GCS ≤ 8) with 17 deceased, corresponding to 85% of total deaths. Prevalence of male subjects (140 cases, 81%) with bruises located in the temporal, frontal and parietal regions; 147 (85%) patients underwent neurosurgical treatment by craniotomy. The worst prognosis was in patients with hematomas of higher-volume (50 mL), midline structures deviations greater than 1.5 mm and basal cisterns CSF closed. Conclusion The authors emphasize the correct indication of neurosurgery and the postoperative intensive care unit (ICU) as key factors for success in the treatment of patients with EDHs.

Resumo Objetivo: Neste trabalho temos o objetivo de avaliar a acurácia do sistema de aferição da pressão intracraniana (PIC) epidural com microchip. Métodos: Foram estudados 27 suínos sob anestesia geraI, devidamente assistidos com monitoração ventilatória e hemodinâmica. Durante o experimento foi reproduzido um processo expansivo intracerebral programado no lobo frontal direito. O experimento constou de três grupos (A, B e C) com hipertensão intracraniana gerada com balão reproduzindo um hematoma intracerebral. Em todos os grupos foram calibrados os parâmetros normais: os dois sistemas de PIC foram comparados e estudados quanto à correlação dos valores aferidos. Resultados: O comportamento médio da PIC ao longo dos momentos de avaliação foi estatisticamente diferente entre os grupos (p < 0,001). A reprodução de ressangramento resultou em elevação significativa da PIC (p < 0,001). Avaliando-se a acurácia comparativa geral, verificou-se um coeficiente de correlação intraclasse de 0,8. Conclusão: O modelo de hipertensão intracraniana por balão em suínos é factível e confiável na geração de hipertensão intracraniana. O sistema de aferição de pressão intracraniana epidural apresenta elevado coeficiente de correlação com o sistema de aferição parenquimatoso na avaliação global.

A 4-year-old girl was admitted to the emergency department after having been buried beneath a wall. A computed tomography scan revealed anterior grade V L5–S1 spondylolisthesis, and magnetic resonance imaging showed a traumatic rupture of the fibrous annulus of the L5–S1 intervertebral disc and lesion of the anterior longitudinal and yellow ligaments. The patient underwent anterior and posterior fixation. Four months later she was able to walk independently, despite a persistent left foot drop. Additionally, we conducted a literature review on lumbosacral spondyloptosis in the pediatric population published between 1990 and 2017. We found 16 cases, 86.6% of which were male, with a mean patient age of 16 ± 5.05 years. Most patients underwent spine instrumentation. Based on the data reviewed, the neurological status at admission might be a valid predictor of outcome. Pedicle screws are a safe and reliable procedure for stable fixation of the spine in these cases. The removal of screws is discouraged.

Resumo Considerado a principal causa de invalidez, morte e consumo de recursos, o traumatismo cranioencefálico (TCE) pode ser definido como uma alteração da função normal do cérebro causada por colisão ou movimentos bruscos na cabeça, ou ainda por um ferimento penetrante. Os TCEs são classificados como leves, moderados ou graves. No caso dos traumas leves, há uma grande variedade em sua classificação, que pode ser feita com base no uso da escala de Glasgow entre 13 e 15, em alterações da consciência, em amnésia, na nona revisão da Classificação Estatística Internacional de Doenças e Problemas Relacionados com a Saúde (CID-9), e até na escala abreviada de lesões (EAL). Devido a sua importância (corresponde a 75% de todos os TCEs e, segundo o Centers for Disease Control and Prevention [CDC], há aproximadamente 500 novos casos por 100 mil pessoas por ano), este trabalho faz uma revisão breve apontando a epidemiologia, as formas de diagnóstico e os possíveis prognósticos. Assim, podemos entender melhor os traumas leves, pois este é um dos poucos distúrbios da medicina em que a classificação benigna é enganosa, e pode estar associada a complicações ao longo da vida.

Background Halo fixation is one of the possible treatments for cervical spine fractures. However, improper use of these devices may lead to many complications, such as pin loosening, halo dislocation, pin site infection, and intradural penetration. Case Description We report the case of a 43-year-old man who first presented with a seizure and an altered level of consciousness 5 months after halo-vest placement for an odontoid fracture. Brain imaging showed a brain abscess, under the previous left parietal pin. The patient underwent abscess drainage and antibiotics were administered for 12 weeks. On hospital discharge, he presented with only mild impairments. Conclusions Misapplication of halo fixation devices may lead to serious complications, including intracranial pin penetration and brain abscesses. Proper use of the recommended technique may decrease the risk for complications related to the procedure.

Traumatic brain injury (TBI) is an important cause of death and disability worldwide. The prognosis evaluation is a challenge when many variables are involved. The authors aimed to develop prognostic model for assessment of survival chances after TBI based on admission characteristics, including extracranial injuries, which would allow application of the model before in-hospital therapeutic interventions. A cohort study evaluated 1275 patients with TBI and abnormal CT scans upon admission to the emergency unit of Hospital das Clinicas of University of Sao Paulo and analyzed the final outcome on mortality. A logistic regression analysis was undertaken to determine the adjusted weigh of each independent variable in the outcome. Four variables were found to be significant in the model: age (years), Glasgow Coma Scale (3–15), Marshall Scale (MS, stratified into 2,3 or 4,5,6; according to the best group positive predictive value) and anysochoria (yes/no). The following formula is in a logistic model ( USP index to head injury ) estimates the probability of death of patients according to characteristics that influence on mortality. We consider that our mathematical probability model ( USP Index ) may be applied to clinical prognosis in patients with abnormal CT scans after severe traumatic brain injury.

ResumoA embolia gordurosa é constituída pela presença de glóbulos de gordura dentro da microcirculação periférica e pulmonar, com ou sem quadro clínico. Há uma fase precoce, representada por uma obstrução mecânica, e uma fase tardia, representada por um fenômeno inflamatório, que se inicia aproximadamente 48 a 72 horas após a obstrução mecânica. O diagnóstico clínico da síndrome de embolia gordurosa pode ser auxiliado pelos critérios de Gurd-Wilson e deve ser suspeitado em doentes com traumatismo e fraturas de ossos longos e deterioração neurológica de forma inexplicada. É necessário no mínimo um critério maior (insuficiência respiratória, sinais neurológicos não relacionados ao traumatismo craniano e manifestações dermatológicas) e quatro menores ou dois maiores. Exames complementares são geralmente inespecíficos. A tomografia de crânio pode estar normal. A ressonância magnética de encéfalo pode mostrar áreas puntiformes que costumam desaparecer em 20 dias, sugerindo que a lesão pode ser predominantemente inflamatória, e não necrótico-isquêmica. Um tratamento específico para a síndrome de embolia gordurosa não existe. Ele consiste no suporte cardiopulmonar e neurológico, além de prevenção e diagnóstico precoce, auxiliando nos cuidados com o doente.

BACKGROUND Infection is a major complication in patients undergoing external ventricular drainage (EVD). Our study aimed to evaluate the incidence of infection in a series with the monoblock EVD system. MATERIAL AND METHODS 46 patients treated with EVD at our emergency department were analyzed prospectively to research the incidence of infections with a new EVD system. RESULTS The average rate of infection was 8.7%. When we stratified the patients according to the exclusive use of EVD without craniotomies, we identified a reduction in the overall incidence of ventriculitis from 8.7% to 2.3%. Age, etiology, and the presence of ventricular bleeding were not statistically significant risk factors. CONCLUSIONS Despite the small sample examined in this study, we believe that the monoblock system is a simple, inexpensive device that reduces accidental disconnection of the system.

Traumatic carotid-cavernous fistula (CCF) in children is a rare condition. Early diagnosis and treatment is still a challenge, and it is associated with good neurological recovery. We present a rare case of a 10-year-old boy with mild head trauma, who developed a CCF at the anterior segment of the ascending internal carotid artery. The patient was treated with endovascular coil embolization and evolved with a favorable outcome. Most of reports in the literature address the traumatic CCF in adult patients, in which early treatment may prevent poor recovery or fatal outcomes. The diagnosis and management of this condition are discussed based on a literature review. It is important to keep a high degree of suspicion for CCF, especially in traumatic head injury associated with skull base fracture, since the early diagnosis and treatment may prevent potentially permanent neurological deficits.

Background Traumatic posterior fossa subdural hematomas (SDHs) are rare lesions. Despite improvements in intensive care and surgical management of traumatic brain injuries over the last decades, the outcome for posterior fossa subdural hematomas remains poor. Methods We conduct a retrospective study over a 2-year period of patients sustaining traumatic brain injury and posterior fossa SDH. Additionally, a systematic review of case series published to date was performed. Results The incidence of posterior fossa SDH was 0,01 % (4/326). All patients in this current series had poor prognosis. Three out of four exhibited ischemic/edema lesions in postoperative CTscans leading to fourth ventricle effacement and persistent brainstem compression. Our literature review retrieved 57 patients from only seven case series. Unfavorable outcomes were seen in 63 % of patients. Conclusions Our data and data from the literature do not provide sufficient evidence to establish an optimal treatment strategy for posterior fossa SDH. However, based on lessons learned with these four cases, together with results from review of the literature, we propose an algorithm for the management of this rare condition.

ResumoO traumatismo cranioencefálico (TCE) corresponde a uma das principais causas de morte em adultos jovens. Alguns pacientes com TCE podem ser vítimas de várias alterações hormonais decorrentes do trauma. Algumas são facilmente reconhecíveis, como diabetes insipidus, enquanto outras podem passar despercebidas inicialmente, como a deficiência do hormônio do crescimento (GH). As alterações neuroendócrinas após a ocorrência de trauma podem cursar com deficiências da hipófise anterior, da posterior ou de ambas, acometer apenas um eixo hormonal ou vários e, ainda, ser transitórias ou permanentes. A grande maioria dos pacientes que apresentam disfunção neuroendócrina foi vítima de traumas considerados moderados ou graves pela escala de Glasgow. No entanto, a maioria dos estudos não evidenciou relação entre a gravidade da lesão e a ocorrência de alteração hipofisária pós-TCE. As deficiências hipofisárias devem ser tratadas precocemente, uma vez que déficits hormonais hipofisários dificultam a recuperação dos pacientes traumatizados, constituindo-se em fator de pior prognóstico. Apesar da frequência com que ocorrem os TCE, existem poucos estudos a respeito das complicações neuroendócrinas decorrentes.

Computed tomography is essential in head injuried patients for the detection of structural damage to the brain. However, the ability of CT scanning to predict the presence or absence of intracranial hypertension has been debated in the literature. Since the optic nerve is part of the central nervous system and in case of raised pressure in the cerebrospinal fluid its sheath inflates. Based in this hypothesis the authors reviewed the role of the optic nerve sheat diameter in diagnosis intracranial hypertension after traumatic brain injury. This non-invasive method is useful to predict the risk of intracranial hypertension and select patients to ICP monitoring, especially in those with normal CT scans.

Diffuse axonal injury (DAI), a type of traumatic injury, is known for its severe consequences. However, there are few studies describing the outcomes of DAI and the risk factors associated with it. This study aimed to describe the outcome for patients with a primary diagnosis of DAI six months after trauma and to identify sociodemographic and clinical factors associated with mortality and dependence at this time point. Seventy-eight patients with DAI were recruited from July 2013 to February 2014 in a prospective cohort study. Patient outcome was analyzed using the Extended Glasgow Outcome Scale (GOS-E) within six months of the traumatic injury. The mean Injury Severity Score was 35.0 (SD = 11.9), and the mean New Injury Severity Score (NISS) was 46.2 (SD = 15.9). Mild DAI was observed in 44.9% of the patients and severe DAI in 35.9%. Six months after trauma, 30.8% of the patients had died, and 45.1% had shown full recovery according to the GOS-E. In the logistic regression model, the severity variables—DAI with hypoxia, as measured by peripheral oxygen saturation, and hypotension with NISS value—had a statistically significant association with patient mortality; on the other hand, severity of DAI and length of hospital stay were the only significant predictors for dependence. Therefore, severity of DAI emerged as a risk factor for both mortality and dependence.

ResumoO termo síndrome da disautonomia pós-traumática é usado para identificar uma síndrome de hiperatividade simpática e muscular paroxística após TCE. Essa síndrome representa uma afecção grave, frequentemente subestimada na assistência ao paciente com neurotrauma e que resulta em piora da recuperação funcional e elevação dos custos hospitalares por aumento do tempo de internação. Neste artigo, realizamos uma revisão crítica da literatura sobre os princípios fisiopatológicos e abordagem terapêutica na síndrome da disautonomia no paciente com traumatismo cranioencefálico.

Traumatic brain injury (TBI) constitutes a major health and socioeconomic problem throughout the world. Despite the significant advances in neuroradiology and cerebral monitoring it is still difficult to measure the degree of primary brain injury and continuing secondary damage with Glasgow Coma Scale score or the initial computed tomography. Predicting prognosis of TBI patients in early stages has a vital importance and is difficult in some instances. The present review shows that there has been an increasing interest in biochemical markers for traumatic brain injury during the last years. The potential correlation of markers with injury and outcome measures in severe head injury is promising.

Resumo Introdução: A disautonomia ou hiperatividade simpática paroxística (HSP) pode ocorrer em até um terço dos pacientes vítimas de trauma de crânio grave, entretanto ainda é uma entidade sem tratamento estabelecido. O uso de morfina intravenosa é descrito para o tratamento da HSP, sendo observada melhora principalmente na diminuição das frequências respiratória e cardíaca. Partindo desses preceitos, este estudo analisa os efeitos da morfina peridural nos pacientes com HSP. Pacientes e métodos: Foram avaliados três pacientes (dois masculino e um feminino), com idade média de 20,6 anos, vítimas de trauma de crânio grave, que apresentaram durante a evolução quadro clínico sugestivo de disautonomia. Os dados coletados incluíram detalhes do trauma, parâmetros fisiológicos, medicações utilizadas e evolução dos sintomas. Nesses pacientes, foi realizada infusão de morfina 4-6 mg/d no espaço peridural, em nível torácico, com média de 25,6 dias. Resultados: Dois pacientes tinham sinais radiológicos de lesão axonal difusa e um paciente tinha um volumoso hematoma extradural que foi operado. Os principais sintomas encontrados nos três pacientes foram sudorese, taquicardia, hipertermia e posturas distônicas. Em dois pacientes a hipertonia era global e em um paciente a postura distônica predominava no hemicorpo esquerdo. Após a passagem do cateter epidural com infusão de morfina, foi observada, já na primeira semana, melhora dos sintomas da hiperatividade simpática e da hipertonia nos grupos musculares envolvidos. Conclusão: O uso de morfina peridural pode ser uma alternativa de tratamento nos pacientes com HSP refratários ao tratamento clínico.

Background: A 36-year-old immunocompetent woman with a posterior fossa arteriovenous malformation (PF-AVM) and hydrocephalus presented with low fever and mental confusion 4 days after ventriculoperitoneal shunting (VPS).Methods: Cerebrospinal fluid (CSF) and ventricular catheter tip cultures isolated Corynebacterium sp. Similar to previous cases in the literature, species determination was not possible. However, the antibiotic sensitivity profile of this isolate suggested Corynebacterium jeikeium. Conversion to external ventricular drainage (EVD) was done and intravenous vancomycin was administered for 21 days.Results and conclusions: The patient showed progressive improvement. Since the first CSF shunt infection caused by Corynebacterium sp., 16 other cases in the literatures have been reported. Additionally, this study reports the difficulties in recognizing CSF shunt infection caused by this agent and the possible clinical or laboratory patterns as observed in the literature.

ResumoMais da metade dos pacientes com hematoma cerebral espontâneo evolui desfavoravelmente. O controle inadequado da pressão arterial sistêmica é uma das principais causas para esse quadro dramático. Várias pesquisas clínicas visando ao controle da expansão do hematoma têm se mostrado satisfatórias, entretanto pouco houve de avanço no tratamento cirúrgico dessas condições. Há inúmeras variáveis que devem ser avaliadas em um paciente com hematoma intraparenquimatoso espontâneo, e esta revisão visa sistematizar o tratamento cirúrgico baseado em evidências.

Resumo Contexto: O manuseio dos pacientes com infarto cerebral isquêmico inclui várias abordagens de tratamento. O tratamento cirúrgico é raramente necessário, entretanto os médicos gerais, neurologistas e neurocirurgiões devem estar atentos para essa possibilidade. Objetivo: Esta revisão visa sistematizar o tratamento cirúrgico com base em evidências nos acidentes vasculares isquêmicos. Conclusões: Apesar da crescente pesquisa envolvendo os acidentes vasculares, a taxa de mortalidade após a tentativa de tratamento cirúrgico pouco se tem alterado nas últimas décadas. Questões como quando ou a quem indicar uma craniectomia descompressiva no infarto isquêmico hemisférico são motivos de controvérsias no âmbito neurocirúrgico, e os dados da literatura são pouco esclarecedores.

O traumatismo cranioencefálico (TCE) é a principal causa de morte e sequela em crianças e adultos jovens nos países industrializados ocidentais. A lesão encefálica definitiva que se estabelece após o TCE é o resultado de mecanismos fisiopatológicos que se iniciam com o acidente e estendem-se por dias ou semanas. As lesões encefálicas no TCE podem ser classificadas em difusas e focais. Esses dois mecanismos costumam associar-se em um mesmo paciente, embora, geralmente exista o predomínio de um tipo. O conhecimento dos mecanismos fisiopatológicos da lesão cerebral no traumatismo cranioencefálico é fundamental para o estabelecimento de medidas terapêuticas clínicas e cirúrgicas. Neste artigo, realizamos uma revisão crítica da literatura sobre os princípios fisiopatológicos da lesão cerebral no paciente com 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.

Objective We studied the angiographic findings in patients with small epidural hematomas and cranial fractures crossing over the trajectory of the middle meningeal artery and its branches. Additionally, the occurrence of traumatic vascular lesions and their clinical relevance and treatment are discussed. Methods A consecutive analysis was performed for 24 patients who harbored small epidural hematomas in middle meningeal artery topography associated with cranial fractures. Computed tomographic scans and plain x-ray studies were used to diagnose linear cranial fractures. Patients with large epidural hematomas or associated traumatic lesions were excluded from the study. Selective ipsilateral external carotid angiograms were obtained, and an endovascular procedure was performed if any vascular injury was evidenced. Results In all patients with cranial fractures crossing over the middle meningeal artery and its branches, some kind of vascular lesion was seen. Two types of findings were noted: active extravasation of the contrast medium (71%) and pseudoaneurysms (29%). Early filling of diploic vessels was found in 8.3% of fractures concomitantly with active extravasation. Embolization was performed in all patients. No additional enlargement of the epidural hematoma was observed, and the postoperative period was uneventful. Conclusion This study shows that pseudoaneurysms and active extravasation of contrast are common findings in this subset of patients. Although the natural history of these lesions is still poorly understood, additional investigation with ipsilateral external carotid angiography may be recommended, considering the potentially catastrophic consequences of late rupture.

ResumoEste projeto é trabalho do Departamento de Trauma da Sociedade Brasileira de Neurocirurgia, realizado com a colaboração de diversas instituições, com o objetivo de conceber uma infra-estrutura que permita estudos prospectivos (multicêntricos ou não) de questões relacionadas à neurotraumatologia, coletando dados via Internet entre instituições. Descrevemos a situação atual do “Projeto Diretrizes de Atendimento ao Traumatismo Craniencefálico”. Apresentamos os resultados iniciais de um estudo cooperativo entre diversas instituições médicas através da criação de um banco de dados e estabelecemos um novo protocolo de estudo. Propomos que o sistema atual evolua à semelhança do BrainIT Group. No momento é uma proposta conceitual, de uma estrutura de coordenação entre serviços e de acesso a bancos de dados e que estabeleça critérios para publicação.

ResumoDescrevemos os resultados laboratoriais de um sistema de transdução modificado que elimina a maioria das desvantagens de sistemas hidrostáticos convencionais mencionados na literatura.Foram calculados medidas de acurácia absoluta, desvio-24 horas e testes dinâmicos de pressão. O ajuste da regressão linear utilizando-se os valores médios das 10 medidas efetuadas para cada transdutor propiciou coeficientes de correlação significativos. Os testes de desvio-24 horas foram muito semelhantes entre os transdutores comparados, não havendo diferença estatística. O teste dinâmico também foi extremamente significativo: coeficiente de correlacão (r) = 0,9999; (sd) = 0,78; p < 0,0001.Concluiu-se que a modificação do sistema reproduziu valores tão corretos quanto o sistema tradicional; o sistema hidrostático modificado pode se constituir em uma boa alternativa técnica neurocirúrgica se a sua funcionalidade for comprovada na prática.

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.

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. Atualmente, as controvérsias sobre os benefícios da craniectomia descompressiva no tratamento de doentes com tumefação encefálica pós-traumática ainda existem. Não há estudos disponíveis na literatura médica sobre os efeitos da craniectomia descompressiva na hemodinâmica encefálica avaliados pelo Doppler transcraniano. Estudamos dois doentes com tumefação encefálica pós-traumática associada à hipertensão intracraniana e evidências de herniação transtentorial. Um deles foi submetido à craniectomia bifrontal e outro, à craniectomia frontoparietotemporal unilateral. O primeiro doente apresentou seqüela neurológica moderada e reintegração social, enquanto o segundo manteve-se em estado vegetativo. Exames de Doppler transcraniano realizados imediatamente antes e após a cirurgia revelaram aumento significativo da velocidade do fluxo sangüíneo nas artérias intracranianas de ambos os doentes. Concluiu-se que a craniectomia descompressiva com plástica de ampliação da dura-máter pode resultar em elevação da velocidade do fluxo sangüíneo encefálico nestes doentes. O aumento da velocidade do fluxo sangüíneo pode ocorrer nos hemisférios cerebrais do lado operado e, também, do lado oposto.