Patricio Mellado T

Craniectomía descompresiva en una paciente con encefalitis herpética asociada a hipertensión intracraneana refractaria

Herpetic encephalitis is the most common cause of viral encephali-tis in our country. Pathological studies show progressive necrosis and edema in specific territo-ries of the brain. The mortality of herpetic encephalitis was reduced from 70% to 20% with theuse of intravenous aciclovir in the first three days of illness. However, almost 50% of patientsdevelop a neurological deficit. One of the most important causes of death in herpetic encephali-tis is the refractory intracranial hypertension. There are anecdotal reports of patients with re-fractory intracranial hypertension due to herpetic encephalitis that were treated with decom-pressive craniectomy with good results. We report a 21 years old female patient with herpeticencephalitis and refractory intracranial hypertension that was successfully treated with a de-compressive craniectomy (Rev Med Chile 2003; 131: 1434-8).(

Características de la enfermedad cerebrovascular en un Servicio de Cuidados Intermedios Neurológicos, en Chile. Análisis de 459 pacientes consecutivos

.La creacion de unidades de tratamiento delataque cerebrovascular (UTAC) y el advenimientode la trombolisis intravenosa han producido undramatico cambio en la terapeutica de la ECV.Distintos metaanalisis han mostrado que los pa-cientes hospitalizados en UTAC tienen menor mor-bimortalidad que los controles hospitalizados enservicios generales

Infarto encefálico por embolia aérea: Caso clínico

Ischemic stroke due to embolic air is uncommon. There are fewreports of patients with air embolic stroke as a complication of endoscopic procedures. Thetemporal relationship between the stroke and this procedure is the most important clue for thediagnosis. CT scan and MRI of the brain are confirmatory tests. The morbidity and mortality ishigh. Patients should be hospitalized in a critical care service and treated as soon as possiblewith oxygen in a pressure camera. We report a 52 years old woman with an ovarian cancerthat, during an upper gastrointestinal endoscopy, had a severe alteration of consciousness thatdid not respond to the use of Flumazenil. A CT scan showed multiple areas of air embolism inthe watershed area between anterior and middle right cerebral arteries. A conservativetreatment was decided and the patients died 48 hours later (Rev Med Chile 2005; 133: 453-6).(

Hemicraniectomía descompresiva en dos pacientes con infarto maligno de la arteria cerebral media

Malignant middle cerebral territory infarction represents 5 to 10%of all brain infarctions. Its mortality is 80%, due to brain herniation and it is not reduced bymedical treatment. Decompressive hemicraniectomy reduces mortality to 12%, and thesubsequent quality of life of patients is acceptable. We report two male patients aged 61 and 54years, with a malignant middle cerebral territory infarction who were treated withdecompressive hemicraniectomy. After two years of follow up, both patients are self-sufficientand live at home with their families (Rev Med Chile 2005; 133: 447-52).(

Trombolisis intraarterial en trombosis de la arteria basilar: Recuperación de dos pacientes con síndrome de enclaustramiento

Locked-in syndrome is a dramatic clinical condition, the patient isawake, can listen and breath, but is unable to move any muscle, conserving only the vertical eyemovements. The most common cause of locked-in syndrome is the thrombosis of the basilar arteryand commonly leads to death, frequently due to pneumonia. Intravenous and intra arterialthrombolysis have been used successfully in a selective group of patients with ischemic stroke. Thereis only one report of two patients with locked-in syndrome who were treated successfully with intraarterial thrombolysis. Other authors, based in their experiences, do not recommend this treatment.We report two female patients aged 63 and 26 years, with Locked-in syndrome due to a basilarthrombosis who were treated successfully with intra arterial thrombolysis using ecombinant tissueplasminogen activator (r-TPA). The lapses between the onset of the symptoms and thrombolysis were5 and 8 hours respectively. A complete recanalization was obtained in both patients during thethrombolysis. One year after, the first patient has only a moderate ataxia, walking with assistanceand the other has a normal neurological examination (Rev Med Chile 2004; 132: 357-60 ).(Locked-in syndrome is a dramatic clinical condition, the patient is awake, can listen and breath, but is unable to move any muscle, conserving only the vertical eye movements. The most common cause of locked-in syndrome is the thrombosis of the basilar artery and commonly leads to death, frequently due to pneumonia. Intravenous and intra arterial thrombolysis have been used successfully in a selective group of patients with ischemic stroke. There is only one report of two patients with locked-in syndrome who were treated successfully with intra arterial thrombolysis. Other authors, based in their experiences, do not recommend this treatment. We report two female patients aged 63 and 26 years, with Locked-in syndrome due to a basilar thrombosis who were treated successfully with intra arterial thrombolysis using recombinant tissue plasminogen activator (r-TPA). The lapses between the onset of the symptoms and thrombolysis were 5 and 8 hours respectively. A complete recanalization was obtained in both patients during the thrombolysis. One year after, the first patient has only a moderate ataxia, walking with assistance and the other has a normal neurological examination.

Ventilación mecánica en pacientes con patologías agudas del Sistema Nervioso Central: sobrevida y pronóstico funcional

Background: The need of mechanical ventilation among patients with acute neurological diseases is considered a poor prognostic sign. Aim: To determine the mortality and functional recovery of neurological patients requiring mechanical ventilation. Patients and methods: Prospective study of 77 patients (42 men, age 54±19 years, with 11±4 points of Glasgow coma scale (GCS), 61% with cerebrovascular disease), that were admitted to the intensive care unit with neurological disease and that required mechanical ventilation. Functional recovery was assessed at 18 months with Glasgow outcome scale (GOS) and Barthel index. Results: Thirty percent of patients died during follow up. Among surviving patients, 47% had a good recovery or moderate disability, and 74% had a Barthel index equal to or over 70. Arterial hypertension, age over 70 and mechanical ventilation longer than 6 days were associated with bad functional prognosis. Conclusions: Neurological patients requiring mechanical ventilation had a lower mortality than previously reported, and half of the survivors have an independent life. This study supports intensive care management in this group of patients (Rev Med Chile 2004; 132: 11-8). (Key Words: Intensive care; Neurologic manifestations; Ventilators, mechanical)

Hipotermia intravascular inducida en el manejo de la hipertensión intracraneana en insuficiencia hepática aguda: Caso clínico

Acute liver failure has a mortality rate in excess of 80%. Most deaths are attributed to brain edema with intracranial hypertension and herniation of structures, where ammonium plays a major role in its generation. We report an 18 year-old female with a fulminant hepatic failure caused by virus A infection. The patient developed a profound sopor and required mechanical ventilation. A CT scan showed the presence of brain edema and intracranial hypertension. A Raudemic® catheter was inserted to measure intracranial pressure and brain temperature. Intracranial hypertension became refractory and intravascular hypothermia was started, reducing brain temperature to 33°C. Seventy two hours later, a liver transplantation was performed. After testing graft perfusion, rewarming was started, completing 122 hours of hypothermia at 33°C. The patient was discharged in good conditions after 69 days of hospitalization.

Xantomatosis cerebrotendínea: Una causa de aumento de volumen bilateral del tendón de Aquiles. Caso clínico

Cerebrotendinous xanthomatosis is an inherited autosomalrecessive disease caused by a mutation in the gene for the sterol 27-hydroxylase enzyme,which determines the accumulation of plasmatic cholestanol in various tissues. The naturalhistory of this disease is characterized by chronic diarrhea beginning in childhood, cataractin youth, tendinous xanthomas in adulthood and later progressive neurological dysfunctionmanifested as dementia, psychiatric disorders, cerebellar, pyramidal or extrapyramidal signsor seizures. We report a 39 year-old male with a history of diarrhea during childhood andbilateral cataracts requiring surgery at 20 years of age, who evolves later with psychiatricdisorders and bilateral increased volume in Achilles tendons. High levels of plasmaticcholestanol and magnetic resonance imaging confirmed the diagnosis of this disease (RevMed Chile 2009; 137: 815-20).(

Trombosis venosa cortical aislada: Comunicación de dos pacientes

Isolated cortical vein thrombosis is an uncommon presentation of central venous thrombosis. We report two females, aged 29 and 40 years, with isolated cortical vein thrombosis. Both presented with a focal neurological deficit and focal seizures that became generalized. The diagnosis was made with magnetic resonance imaging. Both had a history of oral contraceptive use. Both had a rapid response to unfractionated heparin. One patient had an antiphospholipid syndrome as a possible etiology. The most common manifestations of this disease are a transient or recurrent neurological deficit, visual disturbances and focal or generalized seizures, usually without intracanial hypertension. Neuroimages show ischemic abnormalities that do not follow an arterial vascular territory, often with an early hemorrhagic component. There is a good clinical response to heparin

Hematoma talámico bilateral simultáneo: Reporte de dos casos y revisión de la literatura

Resumen es: Las hemorragias encefalicas que comprometan diferentes territorios en forma simultanea son infrecuentes y de mal pronostico. Sus factores de riesgo son m...