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There is currently no efficacious intervention for preventing post-traumatic epilepsy (PTE). Preclinical studies support the potential use of anticholinergics for this condition. The purpose of this study was to evaluate the effects of biperiden as an intervention for preventing PTE. A randomized, double-blinded clinical trial was conducted at HC/FMUSP between 2018–2022. Adults with acute traumatic brain injury (TBI) were randomly assigned to receive biperiden or placebo, for 10 days. The primary outcome was the incidence of PTE while the secondary outcomes included the frequency of seizures, the frequency of any adverse events and mortality after 24 months. The study was powered at a planned enrolment of 132 patients. The trial began in January 2018 and was halted by researchers on March 2020 (and terminated in December 2022) in the face of the global COVID-19 pandemic. Overall, 123 participants were randomized and 112 contributed with data for modified mITT analysis, being that 61 (49.5%) participants completed the 24-month follow-up consult. Data analysis indicated lack of evidence of biperiden for either, the incidence of post-traumatic epilepsy (2.6, 95%CI, 0.65–10.57; p = 0.170) or the mortality rate (1.57, 95%CI, 0.73–3.38; p = 0.248). The frequency of late post-traumatic seizures was higher for biperiden group (2.03, 95%CI = 0.912–3.1597; p

BackgroundSkull defects after decompressive craniectomy (DC) cause physiological changes in brain function and patients can have neurologic symptoms after the surgery. The objective of this study is to evaluate whether there are morphometric changes in the cortical surface and radiodensity of brain tissue in patients undergoing cranioplasty and whether those variables are correlated with neurological prognosis.MethodsThis is a prospective cohort with 30 patients who were submitted to cranioplasty and followed for 6 months. Patients underwent simple head CT before and after cranioplasty for morphometric and cerebral radiodensity assessment. A complete neurological exam with Mini-Mental State Examination (MMSE), modified Rankin Scale, and the Barthel Index was performed to assess neurological prognosis.ResultsThere was an improvement in all symptoms of the syndrome of the trephined, specifically for headache (p = 0.004) and intolerance changing head position (p = 0.016). Muscle strength contralateral to bone defect side also improved (p = 0.02). Midline shift of intracranial structures decreased after surgery (p = 0.004). The Anterior Distance Difference (ADif) and Posterior Distance Difference (PDif) were used to assess morphometric changes and varied significantly after surgery. PDif was weakly correlated with MMSE (p = 0.03; r = −0.4) and Barthel index (p = 0.035; r = −0.39). The ratio between the radiodensities of gray matter and white matter (GWR) was used to assess cerebral radiodensity and was also correlated with MMSE (p = 0.041; r = −0.37).ConclusionMorphological anatomy and radiodensity of the cerebral cortex can be used as a tool to assess neurological prognosis after DC.

Abstract Background Intracranial hypertension (ICH) is a common final pathway of most neurosurgical pathologies and leads to poor prognosis if not detected and treated properly. Inflammatory markers have been assessed in clinical scenarios of neurological injuries, in which systemic and brain tissue aggressions may introduce bias. There is a lack of studies under controlled settings to isolate the ICH effect on inflammation. This study aims to evaluate the effects of ICH on the serum concentration of cytokines as biomarkers of neuroinflammation in an experimental model which isolates ICH from potential confounding variables. Methods An established model of ICH using an intracerebral pediatric bladder catheter and a multisensor intraparenchymal catheter was used in adult pigs (Sus domesticus). The animals were randomly allocated to 2 groups based on the catheter balloon volume used to simulate the ICP increase (4 ml or 7 ml). Cytokines were measured in 4 timepoints during the experiment: (1) 15 min before balloon insufflation; (2) 5 min after insufflation; (3) 125 min after insufflation; (4) 60 min after deflation. The following cytokines were measured IL-1α; IL-1β; IL–1ra; IL-2; IL-4; IL-6; IL-8; IL-10; IL-12; IL-18; TNFα. Generalized estimating equations were modeled to compare the ICP and cytokines values between the groups along the experiment. The study sample size was powered to detect interactions between the groups and the study moments with an effect size (f) of at least 0.3. The ARRIVE checklist was followed. Results A total of 20 animals were studied (10 in each group, 4 ml or 7 ml balloon volume insufflation). The animal model was successful in increasing the ICP along the moments of the experiment (p

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.

Background: In a time when the incidence of severe traumatic brain injury (TBI) is increasing in low- to middle-income countries (LMICs), it is important to understand the behavior of predictive variables in an LMIC's population. There are few previous attempts to generate prediction models for TBI outcomes from local data in LMICs. Our study aim is to design and compare a series of predictive models for mortality on a new cohort in TBI patients in Brazil using Machine Learning.Methods: A prospective registry was set in São Paulo, Brazil, enrolling all patients with a diagnosis of TBI that require admission to the intensive care unit. We evaluated the following predictors: gender, age, pupil reactivity at admission, Glasgow Coma Scale (GCS), presence of hypoxia and hypotension, computed tomography findings, trauma severity score, and laboratory results.Results: Overall mortality at 14 days was 22.8%. Models had a high prediction performance, with the best prediction for overall mortality achieved through Naive Bayes (area under the curve = 0.906). The most significant predictors were the GCS at admission and prehospital GCS, age, and pupil reaction. When predicting the length of stay at the intensive care unit, the Conditional Inference Tree model had the best performance (root mean square error = 1.011), with the most important variable across all models being the GCS at scene.Conclusions: Models for early mortality and hospital length of stay using Machine Learning can achieve high performance when based on registry data even in LMICs. These models have the potential to inform treatment decisions and counsel family members.Level of evidence: This observational study provides a level IV evidence on prognosis after TBI.

Abstract Background Photobiomodulation describes the use of red or near-infrared light to stimulate or regenerate tissue. It was discovered that near-infrared wavelengths (800–900 nm) and red (600 nm) light-emitting diodes (LED) are able to penetrate through the scalp and skull and have the potential to improve the subnormal cellular activity of compromised brain tissue. Different experimental and clinical studies were performed to test LED therapy for traumatic brain injury (TBI) with promising results. One of the proposals of this present study is to develop different approaches to maximize the positive effects of this therapy and improve the quality of life of TBI patients. Methods/design This is a double-blinded, randomized, controlled trial of patients with diffuse axonal injury (DAI) due to a severe TBI in an acute stage (less than 8 h). Thirty two patients will be randomized to active coil helmet and inactive coil (sham) groups in a 1:1 ratio. The protocol includes 18 sessions of transcranial LED stimulation (627 nm, 70 mW/cm2, 10 J/cm2) at four points of the frontal and parietal regions for 30 s each, totaling 120 s, three times per week for 6 weeks, lasting 30 min. Patients will be evaluated with the Glasgow Outcome Scale Extended (GOSE) before stimulation and 1, 3, and 6 months after the first stimulation. The study hypotheses are as follows: (1) transcranial LED therapy (TCLT) will improve the cognitive function of DAI patients and (2) TCLT will promote beneficial hemodynamic changes in cerebral circulation. Discussion This study evaluates early and delayed effects of TCLT on the cognitive rehabilitation for DAI following severe acute TBI. There is a paucity of studies regarding the use of this therapy for cognitive improvement in TBI. There are some experimental studies and case series presenting interesting results for TBI cognitive improvement but no clinical trials. Trial registration ClinicalTrials.gov, NCT03281759. Registered on 13 September 2017.

Abstract Background Photobiomodulation using low-level laser therapy (LLLT) has been tested as a new technique to optimize recovery of patients with traumatic brain injury (TBI). The aim of this study is to evaluate inhibitory attentional control after 18 sessions of active LLLT and compare with the placebo group (sham LLLT). Our exploratory analysis will evaluate the efficacy of the active LLLT on verbal and visuospatial episodic memory, executive functions (working memory, verbal and visuospatial fluency, attentional processes), and anxiety and depressive symptoms compared to the sham group. Methods/Design A randomized double-blinded trial will be made in 36 patients with moderate and severe TBI. The active LLLT will use an optical device composed of LEDs emitting 632 nm of radiation at the site with full potency of 830 mW. The cranial region with an area of 400 cm2 will be irradiated for 30 min, giving a total dose per session of 3.74 J/cm2. The sham LLLT group contains only an LED device with power

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.

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.

BackgroundMild traumatic brain injury (MTBI) represents 70–80% of all treated brain injuries. A considerable proportion of MTBI patients experience post-concussion symptoms for a prolonged period after MTBI, and these symptoms are diagnosed as persistent post-concussion syndrome (PPCS). PPCS is defined as a range of physical, cognitive, and emotional symptoms. However, memory and executive dysfunction seems to be one of the most debilitating symptoms. Recently, non-invasive brain stimulation has been studied as a potential treatment method for traumatic brain injury (TBI) patients. Therefore, our primary goal is to verify the effects of transcranial direct current stimulation (tDCS) in patients with PPCS who demonstrate cognitive deficits in long-term episodic memory, working memory, and executive function following MTBI.Methods/designThis is a randomized crossover trial of patients with a history of MTBI with cognitive deficits in memory and executive function. Thirty adult patients will be randomized in a crossover manner to receive three weekly sessions of anodal tDCS (2 mA) at left dorsolateral prefrontal cortex, left temporal cortex, and sham stimulation that will be performed at 7-day intervals (washout period). The clinical diagnosis of PPCS will be determined using the Rivermead Post-Concussion Symptoms Questionnaire. Patients who meet the inclusion criteria will be assessed with a neuropsychological evaluation. A new battery of computerized neuropsychological tests will be performed before and immediately after each stimulation. Statistical analysis will be performed to determine trends of cognitive improvement.DiscussionThere is paucity of studies regarding the use of tDCS in TBI patients, and although recent results showed controversial data regarding the effects of tDCS in such patients, we will address specifically patients with PPCS and MTBI and no brain abnormalities on CT scan other than subarachnoid hemorrhage. Moreover, due to the missing information on literature regarding the best brain region to be studied, we will evaluate two different regions to find immediate effects of tDCS on memory and executive dysfunction.Clinical Trial Registrationwww.ClinicalTrials.gov, identifier NCT02292589 (https://register.clinicaltrials.gov).

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.

A 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.

Abstract 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.

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.

O 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.

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.

O 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.

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: 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.

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.

Mais 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.

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.

Tumores neuroectodérmicos primitivos (PNET) são tumores originados de células pluripotentes da crista neural e podem ocorrer tanto no sistema nervoso central (SNC) como fora dele. Na maioria das vezes têm comportamento biológico maligno. A variante toracopulmonar dessas lesões é denominada tumor de Askin. Metástases no SNC são pouco descritas na literatura, sendo difícil estimar sua incidência e aferir a importância terapêutica e prognóstica. Os autores relatam um caso de um paciente com metástase cerebral de um tumor de Askin, realçando aspectos de tratamento e prognóstico. Mais relatos são necessários para se verificar o impacto da metástase no SNC na sobrevida desses pacientes.

A Sociedade Brasileira de Neurocirurgia, pelo Departamento de Trauma, com a Divisão de Clínica Neurocirúrgica da Faculdade de Medicina da Universidade de São Paulo e da Equipe Médica de Emergência do Pronto-Socorro de Neurocirurgia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, elaborou as Diretrizes do Atendimento ao Paciente com Traumatismo Cranioencefálico, buscando a homogeneidade de condutas e a redução dos índices de mortalidade e morbidade em todo país. Essas diretrizes possuem uma versão dedicada ao Atendimento Pré-hospitalar (Unidades de Resgate) e ao Atendimento Hospitalar imediato na Sala de Emergência. Com essa uniformização proposta, os estudos epidemiológicos poderão ser realizados de forma mais ampla e com dados mais seguros, permitindo identificar os pontos fracos e atuar com objetivos específicos, visando diminuir a morbidade e a mortalidade do paciente com traumatismo cranioencefálico.

INTRODUCTION: Head trauma is an important consequence of child abuse. Specific pathophysiological mechanisms in child abuse are responsible for the ''whiplash shaken-baby syndrome'', which would favour the occurrence of intracranial hemorrhages. CASE REPORT: We report the case of a child who developed epidural hematoma following minor-intensity head trauma. Initial diagnosis of child abuse was made, but subsequent investigation led to the diagnosis of hemophilia A. CONCLUSION: Even though epidural hematoma is not closely associated with child abuse, this aethiology must always be considered when the reported trauma mechanism is out of proportion to the magnitude of the encountered lesions.INTRODUÇÃO: Traumatismo crânio-encefálico é importante conseqüência de abuso infantil. Mecanismos fisiopatológicos específicos do abuso infantil são responsáveis pela ''whiplash shaken-baby syndrome'', o que favoreceria o aparecimento de hemorragias intracranianas. RELATO DE CASO: Relatamos o caso de uma criança que desenvolveu hematoma extradural após trauma de pequena intensidade. Foi feito diagnóstico inicial de abuso infantil, mas investigações subseqüentes levaram ao diagnóstico de hemofilia A. CONCLUSÃO: Embora o hematoma extradural não esteja intimamente relacionado com abuso infantil, esta etiologia deve ser sempre considerada quando o mecanismo de trauma relatado estiver fora de proporção com as lesões encontradas.

Objective. Subdural hygroma is reported to occur in 5%–20% of all patients with closed head trauma, the treatment is controversial and in symptomatic cases surgical drainage is need. We report on a new case with remote acute epidural hematoma (AEH) after subdural hygroma drainage. Case Presentation. A 38-year-old man suffered blunt head trauma and had diffuse axonal injury grade III in CT scan. A CT scan that was late performed showed an increasing subdural fluid collection with mild mass effect and some effacement of the left lateral ventricle. We perform a trepanation with drainage of a hypertensive subdural collection with citrine aspect. Postoperative tomography demonstrated a large left AEH. Craniotomy and evacuation of the hematoma were performed. Conclusion. The mechanism of remote postoperative AEH formation is unclear. Complete reliance on neurologic monitoring, trust in an early CT scan, and a relative complacency after an apparently successful initial surgery for hygroma drainage may delay the diagnosis of this postoperative AEH.

Traumatic aneurysms comprise less than 1% of all intracranial aneurysms. Most of these aneurysms are actually false aneurysms, or pseudoaneurysms, which are caused by the rupture of entire vessel wall layers, with the wall of the aneurysm being formed by the surrounding cerebral structures. Traumatic pseudoaneurysms of the middle meningeal artery are also rare. Only four cases have been reported in the literature with intracerebral hematoma. In this paper, the authors report a case of a patient with a ruptured traumatic pseudoaneurysm of the MMA who presented with an intracerebral hematoma in the left temporal region immediately after trauma; the patient underwent endovascular treatment.

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.

Os autores referem 13 casos de afundamentos crânio-encefálicos pós-traumáticos com ferimento aberto do couro cabeludo nos quais foi usado o metilmetacrilato em uma única intervenção cirúrgica. A sede do afundamento era frontal em 9 casos, parietal em dois, parieto-temporal em um e parieto-occipital em um. Os afundamentos interessavam apenas a tábua óssea em 5 casos, estavam associados a lesão de dura-mater em três e também do tecido cerebral em 5. Foi realizada cranioplastia simples em 5 casos e, em 8, ela foi precedida de plástica de dura-mater. O seguimento pós-operatório variou de dois meses a dois anos; até o momento não foi assinalada ocorrência de infecção ou de fenômeno de rejeição da prótese que obrigasse a sua retirada.Thirteen cases of open depressed fractures of the skull in which methyl-methacrylate was primarily used are reported. The site of the depressed fractures was frontal in 9 cases, parietal in two, parieto-temporal in one and parieto-occipital in one. In 5 cases, only the bone was injured; in three cases dura mater was damaged; in 5 cases brain and dura mater were damaged. In 5 cases, only a cranioplasty was performed and in 8 cases a dura mater graft was associated. The follow-up was from two months to two years without any complication as infection or rejection of the methylmethacrylate.

Com base em trabalhos anteriores, 13 casos de distrofia muscular progressiva foram tratados com lactato de sódio 1/6 molar associado a ATP e complexo B. O exame da força muscular, realizado antes e após o tratamento — salvo em dois casos nos quais ocorreram melhoras muito discretas — não mostrou qualquer efeito favorável da medicação. Os autores sugerem a verificação de possíveis alterações enzimáticas provocadas pelo lactato de sódio, o que serviria para melhor avaliação do efeito terapêutico.