Ivan Rocha Ferreira da Silva

Neurologic Complications Associated With the Zika Virus in Brazilian Adults

Importance There are no prospective cohort studies assessing the incidence and spectrum of neurologic manifestations secondary to Zika virus (ZIKV) infection in adults. Objective To evaluate the rates of acute ZIKV infection among patients hospitalized with Guillain-Barré syndrome (GBS), meningoencephalitis, or transverse myelitis. Design, Setting, and Participants A prospective, observational cohort study was conducted at a tertiary referral center for neurological diseases in Rio de Janeiro, Brazil, between December 5, 2015, and May 10, 2016, among consecutive hospitalized adults (>18 years of age) with new-onset acute parainfectious or neuroinflammatory disease. All participants were tested for a series of arbovirosis. Three-month functional outcome was assessed. Interventions Samples of serum and cerebrospinal fluid were tested for ZIKV using real-time reverse-transcriptase–polymerase chain reaction and an IgM antibody-capture enzyme-linked immunosorbent assay. Clinical, radiographic (magnetic resonance imaging), electrophysiological, and 3-month functional outcome data were collected. Main Outcomes and Measures The detection of neurologic complications secondary to ZIKV infection. Results Forty patients (15 women and 25 men; median age, 44 years [range, 22-72 years]) were enrolled, including 29 patients (73%) with GBS (90% Brighton level 1 certainty), 7 (18%) with encephalitis, 3 (8%) with transverse myelitis, and 1 (3%) with newly diagnosed chronic inflammatory demyelinating polyneuropathy. Of these, 35 patients (88%) had molecular and/or serologic evidence of recent ZIKV infection in the serum and/or cerebrospinal fluid. Of the patients positive for ZIKV infection, 27 had GBS (18 demyelinating, 8 axonal, and 1 Miller Fisher syndrome), 5 had encephalitis (3 with concomitant acute neuromuscular disease), 2 had transverse myelitis, and 1 had chronic inflammatory demyelinating polyneuropathy. Admission to the intensive care unit was required for 9 patients positive for ZIKV infection (26%), and 5 (14%) required mechanical ventilation. Compared with admission during the period from December 5, 2013, to May 10, 2014 (before the Brazilian outbreak of ZIKV), admissions for GBS increased from a mean of 1.0 per month to 5.6 per month, admissions for encephalitis increased from 0.4 per month to 1.4 per month, and admissions for transverse myelitis remained constant at 0.6 per month. At 3 months, 2 patients positive for ZIKV infection (6%) died (1 with GBS and 1 with encephalitis), 18 (51%) had chronic pain, and the median modified Rankin score among survivors was 2 (range, 0-5). Conclusions and Relevance In this single-center Brazilian cohort, ZIKV infection was associated with an increase in the incidence of a diverse spectrum of serious neurologic syndromes. The data also suggest that serologic and molecular testing using blood and cerebrospinal fluid samples can serve as a less expensive, alternative diagnostic strategy in developing countries, where plaque reduction neutralization testing is impractical.

Worldwide Barriers to Organ Donation

IMPORTANCE The disparity between patients awaiting organ transplantation and organ availability increases each year. As a consequence, organ trafficking has emerged and developed into a multibillion-dollar-a-year industry. OBJECTIVE To identify and address barriers to organ donation in the United States and globally. EVIDENCE REVIEW Evidence-based peer-reviewed articles, including prospective and retrospective cohort studies, as well as case series and reports were identified in a PubMed search of organ donation, barriers to organ donation, brain death, donation after cardiac death, and organ trafficking. Additional Internet searches were conducted of national and international transplant and organ donation websites and US Department of Health of Health and Human Services websites. Citation publication dates ranged from August 1, 1968, through June 28, 2014. FINDINGS The lack of standardization of brain death and organ donation criteria worldwide contributes to a loss of potential donors. Major barriers to donation include variable clinical and legal definitions of brain death; inconsistent legal upholding of brain death criteria; racial, ethnic, and religious perspectives on organ donation; and physician discomfort and community misunderstanding of the process of donation after cardiac death. Limited international legislation and oversight of organ donation and transplant has contributed to the dilemma of organ trafficking. CONCLUSIONS AND RELEVANCE An urgent need exists for a global standard on the definition of brain death and donation after death by cardiac criteria to better regulate organ donation and maximize transplantation rates. Unified standards may have a positive effect on limiting organ trafficking.

Guillain–Barré syndrome and Zika virus outbreaks

Purpose of review Arboviruses have been associated with central and peripheral nervous system injuries, in special the flaviviruses. Guillain–Barré syndrome (GBS), transverse myelitis, meningoencephalitis, ophthalmological manifestations, and other neurological complications have been recently associated to Zika virus (ZIKV) infection. In this review, we aim to analyze the epidemiological aspects, possible pathophysiology, and what we have learned about the clinical and laboratory findings, as well as treatment of patients with ZIKV-associated neurological complications. Recent findings In the last decades, case series have suggested a possible link between flaviviruses and development of GBS. Recently, large outbreaks of ZIKV infection in Asia and the Americas have led to an increased incidence of GBS in these territories. Rapidly, several case reports and case series have reported an increase of all clinical forms and electrophysiological patterns of GBS, also including cases with associated central nervous system involvement. Finally, cases suggestive of acute transient polyneuritis, as well as acute and progressive postinfectious neuropathies associated to ZIKV infection have been reported, questioning the usually implicated mechanisms of neuronal injury. Summary The recent ZIKV outbreaks have triggered the occurrence of a myriad of neurological manifestations likely associated to this arbovirosis, in special GBS and its variants.

News from the battlefront: Zika virus–associated Guillain-Barré syndrome in Brazil

In the wake of the Zika virus (ZIKV) epidemic, international resources have been dedicated to combating the increasing rates of ZIKV-associated microcephaly. However, other severe neurologic complications, such as Guillain-Barré syndrome (GBS), have received less attention and funding. In July 2015, 76 patients with recent symptoms suggestive of ZIKV infection with neurologic syndromes were identified in the state of Bahia, northeast Brazil, of which 42 (55%) were confirmed GBS.1 In November 2015, the Aggeu Magalhães Research Center of the Oswaldo Cruz Foundation reported that ZIKV infection was found in 10 out of 224 suspected dengue cases.1 Seven of the 10 positive samples belonged to patients with a neurologic syndrome.

Targeted Temperature Management in Survivors of Cardiac Arrest

Mild therapeutic hypothermia (MTH) results in a significant decrease in mortality and improvement of neurologic outcomes in cardiac arrest (CA) survivors. Cardiologists and intensivists must be acquainted with the indications and technique because MTH is the only proven neuroprotective therapy for CA survivors. CA involves reinstituting meaningful cardiac activity and minimizing secondary neurologic injuries. This article focuses on MTH as the main strategy for post-CA care.

Hematologic counts as predictors of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage.

Purpose: Aneurysmal subarachnoid hemorrhage (SAH) is associated with high morbidity and mortality, but currently no single clinical method or ancillary test can reliably predict which subset of patients will develop delayed cerebral ischemia (DCI). The aim of this study was to find hematologic derangements and clinical factors present during the first 7 days after bleeding that could help identify patients at risk for development of DCI. Materials and methods: Databank analysis of patients with SAH admitted between 2010 and 2012 in a single center. Data from demographics, imaging, laboratory, and clinical factors were collected. Statistical testing was conducted to test for association to the outcome, and multivariate logistic regression was used to design a predictive model. Results: Of 55 patients, 14 developed DCI (25%). Anemia and leukocytosis on the third day after bleeding were significantly correlated with the outcome (for anemia: P < .032; confidence interval, 1.12‐15.16; odds ratio, 4.12; for leukocytosis: P < .046; confidence interval, 1.03‐26.13; odds ratio, 5.18). Anemia and leukocytosis were still statistically significant after adjustment for age, sex, modified Fisher scale, and Hunt‐Hess scale. Conclusion: The presence of leukocytosis and anemia during the third day after SAH was statistically correlated with the occurrence of DCI.

Experience of a neurology service during the 2016 Olympic and Paralympic Games

Background We analyzed the utilization of acute neurologic care during the 2016 Olympic and Paralympic Games in Rio de Janeiro. Methods We conducted a retrospective analysis of data collected during the games. Results Sixty-three neurologic evaluations were performed in patients from the Olympic Family (OF), 22 of these involving athletes from 19 countries. Traumatic brain injuries (TBIs) were the most frequent reason for assessment among athletes, some associated with polytrauma. Four patients were admitted to the neurocritical care unit (NICU): 2 acute ischemic strokes, 1 TIA, and 1 polytrauma with moderate TBI. Among nonathletes, evaluation of TBI associated with motor vehicle accidents was surprisingly high, with 10 assessments, none requiring admission. Also, nonathletes with seizures, multiple sclerosis flare, functional deficits, and psychiatric complaints received neurologic evaluation. During the Paralympic Games, 17 neurologic evaluations were performed in patients from the Paralympic Family (PF), 13 involving athletes from 10 countries. Five athletes presented with mild TBI. One PG training coach was admitted to the NICU after receiving alteplase for an acute ischemic stroke. Conclusions As expected, many athletes with sports-related injuries were evaluated, but cases of diverse acute neurologic pathologies were observed among nonathlete members of the OF and PF. Olympic Games are large, logistically complex events involving thousands of people. Our observations suggest that a comprehensive and detailed plan for neurologic emergencies should be considered for future games.

Early Predictors of Fever in Patients with Aneurysmal Subarachnoid Hemorrhage

BACKGROUND Fever is commonly observed in patients who have had aneurysmal subarachnoid hemorrhage (SAH), and it has been associated with the occurrence of delayed cerebral ischemia and worse outcomes in previous studies. Frequently, fever is not the result of bacterial infections, and distinction between infection-related fever and fever secondary to brain injury (also referred as central fever) can be challenging. OBJECTIVES The current study aimed to identify risk factors on admission for the development of central fever in patients with SAH. METHODS Databank analysis was performed using information from demographic data (age, gender), imaging (transcranial Doppler ultrasound, computed tomography, and cerebral angiogram), laboratory (white blood cell count, hemoglobin, renal function, and electrolytes), and clinical assessment (Hunt-Hess and modified Fisher scales on admission, occurrence of fever). A multivariate logistic regression model was created. RESULTS Of 55 patients, 32 developed fever during the first 7 days of hospital stay (58%). None of the patients had identifiable bacterial infections during their first week in the neurocritical care unit. Hunt-Hess scale >2 and leukocytosis on admission were associated to the development of central fever, even after correction in a logistic regression model. CONCLUSION Leukocytosis and a poor neurologic examination on admission might help predict which subset of patients with SAH are at higher risk of developing central fever early in their hospital stay.

Effect of Age on Transcranial Doppler Velocities in Patients with Aneurysmal Subarachnoid Hemorrhage

Background: It is not well understood whether age impacts transcranial Doppler (TCD) mean flow velocities (MFVs) in patients with aneurysmal subarachnoid hemorrhage (SAH) with or without delayed cerebral ischemia (DCI). The aim of our study was to analyze the behavior of TCD MFV during the first 7 days after SAH in patients of different ages and correlate them with the occurrence of DCI. Methods: This study is a databank analysis of patients with SAH admitted between 2010 and 2012 in a single center. We analyzed mean MFV of bilateral middle cerebral arteries (MCAs) in all patients enrolled in the study on days 1, 3 and 7. The correlation between age and TCD MFV was analyzed using a univariate linear regression model. Results: Fifty-five patients were studied. Starting on the third day after the bleeding, increasing age was associated with slower MFVs. This trend was not affected by the interrogation of the right or left MCA. After correction to include only patients who developed DCI, the same findings persisted on days 3 and 7. Conclusion: Older age was correlated with a significant decrease on TCD velocities in patients with SAH, even after correction for patients who developed DCI.

Patient Safety in Acute Ischemic Stroke

Stroke is a common and serious disorder, and severe complications can occur at any time throughout the hospital stay. Previous studies have shown that medical complications are common in stroke patients, with estimates of frequencies ranging from 40 to 96 % of patients. Safety is a major issue in this population, as complications can increase the length of hospitalization as well as the costs of care, and are directly associated with worse outcomes. In addition, many of the complications described are potentially preventable or treatable if promptly recognized. The aim of this chapter is to introduce the importance of structured stroke care, minimizing complications and risks, as well as promoting safe, effective, and durable care interventions.