Dionei Freitas de Morais

Clinical application of magnetic resonance in acute traumatic brain injury

PURPOSE To evaluate the clinical applications of magnetic resonance imaging (MRI) in patients with acute traumatic brain injury (TBI): to identify the type, quantity, severity; and improvement clinical-radiological correlation. METHOD Assessment of 55 patients who were imaged using CT and MRI, 34 (61.8%) males and 21 (38.2%) females, with acute (0 to 5 days) and closed TBI. RESULTS Statistical significant differences (McNemar test): ocurred fractures were detected by CT in 29.1% and by MRI in 3.6% of the patients; subdural hematoma by CT in 10.9% and MRI in 36.4 %; diffuse axonal injury (DAI) by CT in 1.8% and MRI in 50.9%; cortical contusions by CT in 9.1% and MRI in 41.8%; subarachnoid hemorrhage by CT in 18.2% and MRI in 41.8%. CONCLUSION MRI was superior to the CT in the identification of DAI, subarachnoid hemorrhage, cortical contusions, and acute subdural hematoma; however it was inferior in diagnosing fractures. The detection of DAI was associated with the severity of acute TBI.

Perfil epidemiológico de pacientes com traumatismo raquimedular atendidos em hospital terciário

OBJETIVO: Evaluar las caracteristicas epidemiologicas de los pacientes con lesion medular atendidos en hospital de tercer nivel. METODOS: Estudio descriptivo, transversal, prospectivo con 321 pacientes que sufrieron lesiones de la medula espinal, realizado desde enero del 2008 hasta junio del 2012. Se estudiaron las variables: sexo; edad; estado civil; profesion; escolarizacion; religion; origen; etiologia, la morfologia y la region del lesion; estado neurologico por la escala ASIA y lesiones asociadas. RESULTADOS: La muestra se compone de 72% de hombres y 28% de mujeres, con prevalencia del grupo de edad de 21-30 anos. el estado civil mas frequente fue casados (46.8%) y solteros (41.7%). El nivel de escolaridad fue educacion primaria incompleta (57%) y completa (17,8%). Las causas mas frecuentes fueron los accidentes de autos (38.9%) y las caidas (27,4%). La lesion mas comun fue la fractura por estallido (23,7%), la region mas afectada fue la subaxial cervical (41.7%) y la transicion lumbar toracica (30.5%). La lesion asociada mas frecuente fue la cerebral traumatica (LCT) (28.2%). El estado neurologico mas encontrado en la admision/alta fue ASIA-E. Hubo 25 muertes (7.8%), 76% de lesiones en la region cervical fueron estratificados como ASIA-A, y el 68% tuvo complicaciones respiratorias. CONCLUSION: La lesion de la medula espinal afecta mas jovenes varones casados y con bajo nivel de educacion. La causa mas comun fue el accidente de auto, el tipo de lesion fue fractura por estallido y la region cervical fue la mas afectada. El estado neurologico mas comun fue ASIA-E y las LCT asociadas fueron las mas frecuentes y mas graves en ASIA. La mayor gravedad por la clasificacion de ASIA en casos de afectacion cervical aumento el riesgo de complicaciones respiratorias y la morbi-mortalidad.OBJETIVO: Avaliar o perfil epidemiologico de pacientes com traumatismo raquimedular atendidos em hospital terciario. METODOS: Estudo descritivo, transversal, prospectivo, com 321 pacientes vitimas de traumatismo raquimedular, realizado de janeiro de 2008 a junho de 2012. Foram estudadas as variaveis: sexo; idade; estado civil; profissao; escolaridade; religiao; procedencia; etiologia, morfologia e regiao da lesao; condicao neurologica pela escala da ASIA e lesoes associadas. RESULTADOS: Amostra constituida por 72% pacientes do sexo masculino e 28% do feminino, prevalencia da faixa etaria de 21 a 30 anos. Os estados civis mais frequentes foram uniao estavel (46,8%) e solteiros (41,7%). O nivel de escolaridade foi ensino fundamental incompleto (57%) e completo (17,8%). As causas mais frequentes foram acidentes automobilisticos (38,9%) e queda (27,4%). A lesao mais presente foi fratura explosao (23,7%), as regioes mais afetadas foram cervical subaxial (41,7%) e transicao toracolombar (30,5%). A lesao associada mais frequente foi traumatismo cranioencefalico (TCE) (28,2%). O estado neurologico mais observado na internacao/alta foi ASIA-E. Ocorreram 25 obitos (7,8%), sendo que 76% com lesao na regiao cervical foram estratificados com ASIA-A, e 68% tiveram complicacoes respiratorias. CONCLUSAO: O trauma raquimedular acometeu mais adultos jovens do sexo masculino com uniao estavel e baixo nivel de escolaridade. A causa mais frequente foi acidente automobilistico, o tipo de lesao foi fratura explosao e a regiao cervical a mais acometida. A condicao neurologica mais presente foi ASIA-E, o TCE foi a lesao associada mais frequente e a maior gravidade pela classificacao da ASIA nos casos de envolvimento cervical aumentou o risco de complicacoes respiratorias e morbidade e mortalidade.OBJECTIVE: Evaluate the epidemiological profile of patients with spinal cord injury (SCI) treated in a tertiary hospital. METHODS: Descriptive, transversal and prospective study with 321 patients, conducted from January/2009 to June/2012. Variables studied: sex; age; marital status; profession; schooling; religion; origin; etiology, morphology and region of the lesion; neurological status by ASIA and the associated lesions. RESULTS: The sample consisted of 72% males and 28% females, the prevalent age group was 21-30 years. The most common marital status was married (46.8%) and singles (41.7%). The educational level was incomplete (57%) and complete (17.8%) elementary school. The most common causes were traffic accidents (38.9%) and falls (27.4%). The most common injury was burst fracture (23.7%), the most affected areas were subaxial cervical (41.7%) and thoracolumbar transition (30.5%). The most frequent associated injury was traumatic brain injury (TBI) (28.2%). The most frequent neurological condition at admission/discharge was ASIA-E. There were 25 deaths (7.8%) and 76% with lesion in the cervical region were classified with ASIA-A and 68% had respiratory complications. CONCLUSION: SCI affected more married young adult males with low level of education. The most common cause was motor vehicle accident, the type of injury was burst fracture and the cervical region was the most affected. The most common neurological status was ASIA-E and TBI was the most frequente associated injury and the greater severity by ASIA in cases with the cervical involvement increased the risk of respiratory complications and morbidity and mortality.

Predictors of clinical complications in patients with spinomedullary injury

Objetivo: Analizar los pacientes en un hospital de tercer nivel con lesion de la medula espinal que tuvieron complicaciones clinicas, asi como las variables que pueden influir en el pronostico. Metodos: Estudio prospectivo de 321 pacientes con lesiones de la medula espinal, que recopilo datos sobre las siguientes variables: edad, sexo, causa del accidente, distribucion anatomica, estado neurologico, lesiones asociadas, complicaciones clinicas y mortalidad. Solo se analizaron los pacientes que desarrollaron complicaciones. Resultados: Se analizaron 72 pacientes (85% varones) con una edad media de 44,72±19,19 anos. Aquellos individuos con lesion de la medula espinal progresaron con complicaciones clinicas intrahospitalarias, en su mayoria varones y mayores de 50 anos, siendo la caida accidental la principal causa. Ademas, estos pacientes tenian una estancia hospitalaria mas prolongada y riesgo de progresar a la muerte. La neumonia fue la principal complicacion clinica. En cuanto a las variables que pueden influir en el pronostico de estos pacientes, se observa que la lesion de la medula espinal en el segmento cervical con cuadro sindromico de tetraplejia y el estado neurologico ASIA-A aporta un mayor riesgo de desarrollar complicaciones clinicas, siendo la neumonia la mas frecuente, asi como mayor riesgo de aumento de la mortalidad. Conclusion: Las complicaciones clinicas secundarias a la lesion de la medula espinal se ven afectadas por factores demograficos, asi como por las caracteristicas relacionadas con la lesion, que influyen en el aumento de la mortalidad.OBJETIVO: Analisar pacientes com trauma raquimedular (TRM) que evoluiram com complicacoes clinicas intra-hospitalar, e as variaveis que podem interferir no prognostico, em um hospital terciario. METODOS: Estudo prospectivo com 321 pacientes vitimas de TRM, as variaveis coletadas foram: idade, sexo, etiologia do acidente, distribuicao anatomica, status neurologico, lesoes associadas, complicacoes clinicas e mortalidade. Analisados apenas os pacientes que evoluiram com complicacoes. RESULTADOS: Foram analisados 72 pacientes (85% do sexo masculino), com media de idade de 44,72 ± 19,19 anos. Individuos com TRM que evoluiram com complicacoes clinicas intra-hospitalar, sendo a maioria do sexo masculino, com idade maior que 50 anos, e a principal causa foi queda acidental. Alem disso, estes pacientes apresentam um tempo maior de permanencia hospitalar e risco de evoluir com obito. A pneumonia foi a principal complicacao clinica. Com relacao as variaveis que podem interferir no prognostico destes pacientes, observa-se que o TRM no segmento cervical, com quadro sindromico de tetraplegia, e status neurologico ASIA-A, possuem maior risco de desenvolver complicacoes clinicas, sendo pneumonia a mais frequente, assim como aumentar a mortalidade. CONCLUSAO: As complicacoes clinicas secundarias ao TRM sao influenciadas por fatores demograficos, assim como por caracteristica relacionadas a lesao, influenciando no aumento da mortalidade.

Gross-total resection of temporal low grade gliomas is a critically important factor in achieving seizure-freedom

OBJECTIVE To present a surgical series of patients with low grade temporal gliomas causing intractable epilepsy, focusing on long-term seizure outcome. METHOD A retrospective study was conducted with patients with temporal low-grade gliomas (LGG). RESULTS Sixty five patients with were operated in our institution. Males were more affected than females and the mean age at surgery was 32.3 ± 8.4 (9-68 years). The mean age at seizure onset was 25.7 ± 9.2 (11-66 years). Seizure outcome was classified according with Engel classification. After one year of follow up, forty two patients (64.6%) were Engel I; seventeen (26.2%) Engel II; four (6.2%) Engel III and two (3.1%) Engel IV. Statistically significant difference in seizure outcome was obtained when comparing the extension of resection. Engel I was observed in 39 patients (69.6%) with total resection and in only 3 (33.3%) patients with partial resection. CONCLUSION Gross-total resection of temporal LGGs is a critically important factor in achieving seizure-freedom.

Epidemiological profile of patients suffering from cord spinal injury treated in tertiary hospital

OBJETIVO: Evaluar las caracteristicas epidemiologicas de los pacientes con lesion medular atendidos en hospital de tercer nivel. METODOS: Estudio descriptivo, transversal, prospectivo con 321 pacientes que sufrieron lesiones de la medula espinal, realizado desde enero del 2008 hasta junio del 2012. Se estudiaron las variables: sexo; edad; estado civil; profesion; escolarizacion; religion; origen; etiologia, la morfologia y la region del lesion; estado neurologico por la escala ASIA y lesiones asociadas. RESULTADOS: La muestra se compone de 72% de hombres y 28% de mujeres, con prevalencia del grupo de edad de 21-30 anos. el estado civil mas frequente fue casados (46.8%) y solteros (41.7%). El nivel de escolaridad fue educacion primaria incompleta (57%) y completa (17,8%). Las causas mas frecuentes fueron los accidentes de autos (38.9%) y las caidas (27,4%). La lesion mas comun fue la fractura por estallido (23,7%), la region mas afectada fue la subaxial cervical (41.7%) y la transicion lumbar toracica (30.5%). La lesion asociada mas frecuente fue la cerebral traumatica (LCT) (28.2%). El estado neurologico mas encontrado en la admision/alta fue ASIA-E. Hubo 25 muertes (7.8%), 76% de lesiones en la region cervical fueron estratificados como ASIA-A, y el 68% tuvo complicaciones respiratorias. CONCLUSION: La lesion de la medula espinal afecta mas jovenes varones casados y con bajo nivel de educacion. La causa mas comun fue el accidente de auto, el tipo de lesion fue fractura por estallido y la region cervical fue la mas afectada. El estado neurologico mas comun fue ASIA-E y las LCT asociadas fueron las mas frecuentes y mas graves en ASIA. La mayor gravedad por la clasificacion de ASIA en casos de afectacion cervical aumento el riesgo de complicaciones respiratorias y la morbi-mortalidad.OBJETIVO: Avaliar o perfil epidemiologico de pacientes com traumatismo raquimedular atendidos em hospital terciario. METODOS: Estudo descritivo, transversal, prospectivo, com 321 pacientes vitimas de traumatismo raquimedular, realizado de janeiro de 2008 a junho de 2012. Foram estudadas as variaveis: sexo; idade; estado civil; profissao; escolaridade; religiao; procedencia; etiologia, morfologia e regiao da lesao; condicao neurologica pela escala da ASIA e lesoes associadas. RESULTADOS: Amostra constituida por 72% pacientes do sexo masculino e 28% do feminino, prevalencia da faixa etaria de 21 a 30 anos. Os estados civis mais frequentes foram uniao estavel (46,8%) e solteiros (41,7%). O nivel de escolaridade foi ensino fundamental incompleto (57%) e completo (17,8%). As causas mais frequentes foram acidentes automobilisticos (38,9%) e queda (27,4%). A lesao mais presente foi fratura explosao (23,7%), as regioes mais afetadas foram cervical subaxial (41,7%) e transicao toracolombar (30,5%). A lesao associada mais frequente foi traumatismo cranioencefalico (TCE) (28,2%). O estado neurologico mais observado na internacao/alta foi ASIA-E. Ocorreram 25 obitos (7,8%), sendo que 76% com lesao na regiao cervical foram estratificados com ASIA-A, e 68% tiveram complicacoes respiratorias. CONCLUSAO: O trauma raquimedular acometeu mais adultos jovens do sexo masculino com uniao estavel e baixo nivel de escolaridade. A causa mais frequente foi acidente automobilistico, o tipo de lesao foi fratura explosao e a regiao cervical a mais acometida. A condicao neurologica mais presente foi ASIA-E, o TCE foi a lesao associada mais frequente e a maior gravidade pela classificacao da ASIA nos casos de envolvimento cervical aumentou o risco de complicacoes respiratorias e morbidade e mortalidade.OBJECTIVE: Evaluate the epidemiological profile of patients with spinal cord injury (SCI) treated in a tertiary hospital. METHODS: Descriptive, transversal and prospective study with 321 patients, conducted from January/2009 to June/2012. Variables studied: sex; age; marital status; profession; schooling; religion; origin; etiology, morphology and region of the lesion; neurological status by ASIA and the associated lesions. RESULTS: The sample consisted of 72% males and 28% females, the prevalent age group was 21-30 years. The most common marital status was married (46.8%) and singles (41.7%). The educational level was incomplete (57%) and complete (17.8%) elementary school. The most common causes were traffic accidents (38.9%) and falls (27.4%). The most common injury was burst fracture (23.7%), the most affected areas were subaxial cervical (41.7%) and thoracolumbar transition (30.5%). The most frequent associated injury was traumatic brain injury (TBI) (28.2%). The most frequent neurological condition at admission/discharge was ASIA-E. There were 25 deaths (7.8%) and 76% with lesion in the cervical region were classified with ASIA-A and 68% had respiratory complications. CONCLUSION: SCI affected more married young adult males with low level of education. The most common cause was motor vehicle accident, the type of injury was burst fracture and the cervical region was the most affected. The most common neurological status was ASIA-E and TBI was the most frequente associated injury and the greater severity by ASIA in cases with the cervical involvement increased the risk of respiratory complications and morbidity and mortality.

Corpectomia da coluna toracolombar com colocação de cage por acesso único via posterior: técnica cirúrgica e resultados de seis pacientes

Objective: To evaluate retrospectively the results of a series of patients undergone thoracic or lumbar corpectomy via single posterior approach with placement of cage and segmental instrumented arthrodesis. The surgical technique performed was described. Methods: The retrospective study evaluated six patients with vertebral collapse, biomechanical instability or neurological damage caused by different etiologies. These patients showed neural decompression and received indication to perform corpectomy and circumferential reconstruction with cage being conducted exclusively by posterior approach. Results: Four patients were male and 2 female. The average age was 58 years (22-82 years) and mean follow up was 10.5 months (2-24 months). In three cases the resection was only one vertebral body and in three cases two vertebral bodies. All patients improved in neurological status and low back pain or radicular pain. The indications for surgery were three cases of spondylodiscitis, one of osteoporotic fracture, one case of metastatic tumor and one case of primary tumor. Three patients had complications requiring surgical revision; which resulted in improvement of symptoms. The complications that occurred were cerebrospinal fluid leakage, lumbar radiculopathy, wound infection, meningitis and failure of instrumentation. Conclusion: Patients submitted to corpectomy via single posterior approach showed favorable outcomes with improvement of neurological deficit or pain in all cases. This technique was efficient in the reconstruction of circumferential column avoiding the complications of the traditional anterior-posterior approach.

Contralateral extradural hematoma following decompressive craniectomy for acute subdural hematoma (the value of intracranial pressure monitoring): a case report

IntroductionDecompressive surgery for acute subdural hematoma leading to contralateral extradural hematoma is an uncommon event with only few cases previously reported in the English medical literature.Case presentationThe present study describes the case of a 39-year-old White Brazilian man who had a motorcycle accident; he underwent decompressive craniectomy for the treatment of acute subdural hematoma and evolved contralateral extradural hematoma following surgery.ConclusionThe present case highlights the importance of close monitoring of the intracranial pressure of severe traumatic brain injury, even after decompressive procedures, because of the possible development of contralateral extradural hematoma.

Longer epilepsy duration and multiple lobe involvement predict worse seizure outcomes for patients with refractory temporal lobe epilepsy associated with neurocysticercosis.

OBJECTIVE To investigate the surgical outcomes of temporal lobe epilepsy associated with hippocampal sclerosis (TLE-HS) and neurocysticercosis (NCC). METHODS A retrospective investigation of patients with TLE-HS was conducted in a tertiary center. RESULTS Seventy-nine (62.2%), 37 (29.1%), 6 (4.7%), and 5 (3.9%) patients were Engel class I, II, III, and IV, respectively. Fifty-two (71.2%) patients with epilepsy durations ≤ 10 years prior to surgery were seizure-free 1 year after the operation compared to 27 (50.0%) patients with epilepsy durations > 10 years (p = 0.0121). Forty-three (72.9%) patients with three or fewer lobes affected by NCC were seizure-free one year after the operation, and 36 (52.9%) patients with more than three involved lobes were seizure-free after surgery (p = 0.0163). CONCLUSIONS Longer epilepsy durations and multiple lobe involvement predicted worse seizure outcomes in TLE-HS plus NCC patients.

PREDITORES DE COMPLICAÇÕES CLINICAS EM PACIENTES COM TRAUMA RAQUIMEDULAR

Objetivo: Analizar los pacientes en un hospital de tercer nivel con lesion de la medula espinal que tuvieron complicaciones clinicas, asi como las variables que pueden influir en el pronostico. Metodos: Estudio prospectivo de 321 pacientes con lesiones de la medula espinal, que recopilo datos sobre las siguientes variables: edad, sexo, causa del accidente, distribucion anatomica, estado neurologico, lesiones asociadas, complicaciones clinicas y mortalidad. Solo se analizaron los pacientes que desarrollaron complicaciones. Resultados: Se analizaron 72 pacientes (85% varones) con una edad media de 44,72±19,19 anos. Aquellos individuos con lesion de la medula espinal progresaron con complicaciones clinicas intrahospitalarias, en su mayoria varones y mayores de 50 anos, siendo la caida accidental la principal causa. Ademas, estos pacientes tenian una estancia hospitalaria mas prolongada y riesgo de progresar a la muerte. La neumonia fue la principal complicacion clinica. En cuanto a las variables que pueden influir en el pronostico de estos pacientes, se observa que la lesion de la medula espinal en el segmento cervical con cuadro sindromico de tetraplejia y el estado neurologico ASIA-A aporta un mayor riesgo de desarrollar complicaciones clinicas, siendo la neumonia la mas frecuente, asi como mayor riesgo de aumento de la mortalidad. Conclusion: Las complicaciones clinicas secundarias a la lesion de la medula espinal se ven afectadas por factores demograficos, asi como por las caracteristicas relacionadas con la lesion, que influyen en el aumento de la mortalidad.OBJETIVO: Analisar pacientes com trauma raquimedular (TRM) que evoluiram com complicacoes clinicas intra-hospitalar, e as variaveis que podem interferir no prognostico, em um hospital terciario. METODOS: Estudo prospectivo com 321 pacientes vitimas de TRM, as variaveis coletadas foram: idade, sexo, etiologia do acidente, distribuicao anatomica, status neurologico, lesoes associadas, complicacoes clinicas e mortalidade. Analisados apenas os pacientes que evoluiram com complicacoes. RESULTADOS: Foram analisados 72 pacientes (85% do sexo masculino), com media de idade de 44,72 ± 19,19 anos. Individuos com TRM que evoluiram com complicacoes clinicas intra-hospitalar, sendo a maioria do sexo masculino, com idade maior que 50 anos, e a principal causa foi queda acidental. Alem disso, estes pacientes apresentam um tempo maior de permanencia hospitalar e risco de evoluir com obito. A pneumonia foi a principal complicacao clinica. Com relacao as variaveis que podem interferir no prognostico destes pacientes, observa-se que o TRM no segmento cervical, com quadro sindromico de tetraplegia, e status neurologico ASIA-A, possuem maior risco de desenvolver complicacoes clinicas, sendo pneumonia a mais frequente, assim como aumentar a mortalidade. CONCLUSAO: As complicacoes clinicas secundarias ao TRM sao influenciadas por fatores demograficos, assim como por caracteristica relacionadas a lesao, influenciando no aumento da mortalidade.

Clinical application of magnetic resonance (MR) imaging in injured patients with acute traumatic brain injury

DIONEI FREITAS DE MORAIS** closes unexpected cardiac sources of embolus in stroke patients aged more than 45 years”. Cerebral embolism f rom cardiac source is an important cause of stro k e , specially in patients younger than 45 years old. Objective: To describe the TEE findings in young and no-young stroke patients without any prior evidence of cardiac source for cerebral embolism. Method: Transversal study. 523 patients (267 men and 256 women) with ischemic stroke, without any evidence of cardiac abnormality, underwent to transesophageal echocardiography (TEE). Results: Ten percent were aged 45 years or less. Left ventricle hypert ro p h y, left atrial enlargement, spontaneous contrast in aorta, interatrial septum aneurysm, mitral and aortic valve calcification, aortic valve re g u rg i t ation, and athero s c l e rotic plaques in aorta were significantly more frequent in patients aged more than 45 years. 2.8% of no-young patients had thrombus in left heart. Conclusion: TEE is widely used to diagnose cardiac source of cerebral embolism in young patients, but it seems to be as useful for older ones, in whom cerebral embolism risk is underestimated; atherogenic and cardioembolic causes may actually coexist, and both should be treated.