Search

Objective To present a rare cause of thunderclap headache Case presentation Female patient, 39 years old, was admitted to the emergency department of a private hospital in the city of São Paulo, after a sudden and explosive headache followed by two episodes of syncope and motor deficit in the left upper limb. Neurological examination showed weakness of the left upper limb without sensitive impairment. She had previous history of bipolar affective disorder, chronic anemia, and overweight with previous bariatric surgery. The patient was submitted to computed tomography (CT), arterial angiotomography of the skull and cervical neck, which showed rare small gaseous foci in the perivertebral soft tissues and extradural site on the left side in the craniovertebral transition, near the foramen magnum. Small foci of pneumocephalus were found in the posterior fossa, near the left sphenopetrous fissure. Electroneuromyography (ENMG) of four limbs and brain and cervical magnetic resonance imaging (MRI) were performed 48 hours after initial CT scan. ENMG was normal and MRI showed no more expression of the changes described on CT. She was treated with analgesia and was discharged with full reversion of initial symptoms. Conclusion Spontaneous pneumorrhachia is rare disease and is characterized by the presence of air in the spinal canal, both in the intradural and extradural compartments. It is usually benign with spontaneous resolution. Our patient was included in a stroke investigation protocol, due to the thunderclap headache and focal motor deficit. CT revealed the diagnosis. The cervical CT that was performed in the context of cervical CT angiography of the stroke protocol allowed the correct diagnosis. Key-words: Thunderclap headache, Spontaneous Pneumorrhachia, Cervical Computed Tomography Angiography.

Introduction Patients with headache complaints are among those who most frequently seek care in emergency units. Unfortunately, the assistance provided to these patients frequently does not reflect the best scientific evidence, compromising clinical results and exposing patients to unacceptable risks and unnecessary procedures. Among these errors, we cite the high rate of prescription of opioids for primary headaches, the excessive number of unnecessary CT scans, high stay rates in emergency units, and high rate of hospital admissions. Objectives To evaluate changes in care outcomes after beginning a care protocol in a private hospital network. Methods We evaluated all the headache data in the emergence units of Americas Serviços Médicos, a private hospitals network with 18 units distributed in 3 regions of Brazil. Headache was identified in the electronic medical record system through the international code of diseases (CID). The following data were collected: rate of opioids prescription, rate of TC scan, time of stay in emergence room, hospitalization rate, and hospital length of stay. Data were collected in the four months before the protocol (pre-protocol) and in the last four months (post-protocol). Categorical data were evaluated with chi-square and continuous data with unpaired t test. Results The data of 9,060 patients in the pre-protocol and 8,828 patients in the post-protocol periods were assessed. The rate of opioids prescription reduced from 19.9% to 18.5% (P=0.0173). The rate of CT scan was 16.75 in pre and post protocol periods P=1). The stay time in emergence room was 227.46±61.07 minutes in the pre and 196±16.11 in the post protocol period (P=0.37). The rate of hospitalization increased from 1,53% in the pre to 2.24% in the post protocol period (P=0.005). The length of hospital stay reduced from 5.9±2.2 in the pre to 3.5±0.6 in... (To see the complet abstract, please, check out the PDF.)

Laparoscopy was performed in 140 patients who ranged in age from eight to eighty-five years. It was employed only when other methods had failed to give a firm diagnosis. The results were compared with the diagnosis made before the examination, and with the final results of biopsy, cholangiography, surgery and/or autopsy. The endoscopie diagnosis was correct in 137 cases (97.9 per cent), incorrect in three (2.1 per cent). Laparoscopy was highly efficient in the differential diagnosis of ascites, hepatomegaly and abdominal tumors. It was possible to differentiate hepatic jaundice from obstructive jaundice but the cause of the obstruction often could not be demonstrated by laparoscopy alone. In patients with known carcinoma, metastases to the liver or peritoneum could be visualized, but it was not possible to establish exactly the local spread of the tumor.

In this study, 1023 patients ranging in age from 13 to 78 years were examined. Two blind biopsies of gastric mucosa were obtained in each patient. Acid secretion was measured by means of the augmented histamine test. Gastric alkaline and peptic secretion as well as uropepsinogen levels were determined at the same time.

Allogeneic transplantation of the liver between Dalmatian and mongrel dogs revealed its effects on uric acid metabolism. In the presence of satisfactory hepatic function, when a liver was transplanted between mongrels, daily urinary excretion of uric acid remained low, and when a liver was transplanted between Dalmatians, the excretion remained high. More important, when mongrel dogs received Dalmatian livers, or vice versa, the recipient took on the uric acid excretion pattern of the donor, which indicates that the liver determines the difference in uric acid metabolism between mongrels and Dalmatians. The significance of this finding is discussed in relation to possible differences in transport of uric acid across cell membranes or uricase content of the hepatic cells. This study has demonstrated that liver allografts retain their metabolic specificity after transfer to a new host.