Brain abscess secondary to frontal osteomyelitis

Frontal osteomyelitis is a rare complication of sinusitis. Common intracranial complications of the frontal osteomyelitis are meningitis, epidural empyema, subdural empyema and brain abscess. We described a case of frontal osteomyelitis with brain abscess caused by Staphylococcus aureus with improve after needle aspiration and antibiotics to brain abscess for eight weeks and for chronic osteomyelitis for four months.

Profile of pregnant women and children treated at a reference center for congenital toxoplasmosis in the northern state of Minas Gerais, Brazil

INTRODUCTION: To describe the clinical and epidemiological profile of pregnant women and children treated at a reference outpatient clinic for congenital toxoplasmosis. METHODS: Pregnant women potentially exposed to Toxoplasma gondii were observed. Diagnoses were made using serologic tests compatible with acute toxoplasmosis. Children presenting with: Toxoplasma-specific antibodies (IgM or IgA or ascending IgG titers higher than maternal titers in the first 3 months of life) coupled with toxoplasmosis symptoms; intracranial calcifications (by transfontanelar ultrasound or cephalic segment tomography); or retinochoroiditis (by fundoscopy examination) in the first 8 months of life were also included in the study. RESULTS: Fifty-eight mother-child pairs were observed (mean age of the mothers was 22.1 years). Most patients lived in urban areas (86.2%) and had attended less than 8 years of school (51.7%). Diagnosis was made after birth in 19 (32.8%) children. Thirty-four (58.6%) women received some type of treatment during pregnancy. Most (72.4%) of the children did not present with clinical alterations at birth. The main findings were ophthalmological: 20 (34.5%) children with retinochoroiditis, 17 (29.3%) with strabismus, and 7 (12.1%) with nystagmus. Of the children with retinochoroiditis, 9 presented with subnormal vision. Ten (32.3%) out of 31 children presented with intracranial calcifications by cephalic segment congenital toxoplasmosis, and 9 (42.9%) children presented with delayed psychomotor development. CONCLUSIONS: Our results highlight a critical situation. Protocols for follow-up of pregnant women and their children must be created to improve medical care and minimize sequelae.

Peri-intraventricular hemorrhage in newborns weighing less than 1500 grams: comparative analysis between 2 institutions

PURPOSE: This study aims to characterize the peri-intraventricular hemorrhages in the neonatal period in very low birth weight newborns in 2 institutions that provide neonatal tertiary assistance. METHOD: This was a comparative and observational study in 2 neonatal intensive care units, the Maternity Hospital of Campinas and the "Centro de Atenção Integrada à Saúde da Mulher" of the State University of Campinas, from December 01, 1998 to November 30, 1999. We examined 187 newborns for peri-intraventricular hemorrhages, using transfontanel ultrasound (76 and 11 respectively at the first and second unit), and classified them into 4 grades. We observed their gender, intrauterine growth, weight, and gestational age at birth. RESULTS: We diagnosed 34 cases of peri-intraventricular hemorrhages (13 and 21, respectively), and both groups differed as to the birth weight and the adequacy of weight to the gestational age at birth. There was no difference in the prevalence or extent of peri-intraventricular hemorrhages among cases. There was a statistically significant occurrence of lower birth weight at gestational ages of less than 30 weeks. CONCLUSIONS: The prevalence of peri-intraventricular hemorrhages in our study was compared to that reported in the world literature. Although the cases of the second institution had a smaller mean birth weight, the prevalence of peri-intraventricular hemorrhages was similar to that at the first institution, probably because in the first one, 69% of the gestational ages of the neonates with hemorrhage were less than 30 weeks as compared to 48% in the second one. We stress the importance of the ultrasonographic method for diagnosing peri-intraventricular hemorrhages in very low birth weight newborns.

Comparison of ACUITY and CRUSADE Scores in Predicting Major Bleeding during Acute Coronary Syndrome

Background:The ACUITY and CRUSADE scores are validated models for prediction of major bleeding events in acute coronary syndrome (ACS). However, the comparative performances of these scores are not known.Objective:To compare the accuracy of ACUITY and CRUSADE in predicting major bleeding events during ACS.Methods:This study included 519 patients consecutively admitted for unstable angina, non-ST-elevation or ST-elevation myocardial infarction. The scores were calculated based on admission data. We considered major bleeding events during hospitalization and not related to cardiac surgery, according to the Bleeding Academic Research Consortium (BARC) criteria (type 3 or 5: hemodynamic instability, need for transfusion, drop in hemoglobin ≥ 3 g, and intracranial, intraocular or fatal bleeding).Results:Major bleeding was observed in 31 patients (23 caused by femoral puncture, 5 digestive, 3 in other sites), an incidence of 6%. While both scores were associated with bleeding, ACUITY demonstrated better C-statistics (0.73, 95% CI = 0.63 - 0.82) as compared with CRUSADE (0.62, 95% CI = 0.53 - 0.71; p = 0.04). The best performance of ACUITY was also reflected by a net reclassification improvement of + 0.19 (p = 0.02) over CRUSADE’s definition of low or high risk. Exploratory analysis suggested that the presence of the variables ‘age’ and ‘type of ACS’ in ACUITY was the main reason for its superiority.Conclusion:The ACUITY Score is a better predictor of major bleeding when compared with the CRUSADE Score in patients hospitalized for ACS.

Involvement of central nervous system in the schistosomiasis

The involvement of the central nervous system (CNS) by schistosomes may or may not determine clinical manifestations. When symptomatic, neuroschistosomiasis (NS) is one of the most severe presentations of schistosomal infection. Considering the symptomatic form, cerebral involvement is almost always due to Schistosoma japonicum and the spinal cord disease, caused by S. mansoni or S. haematobium. Available evidence suggests that NS depends basically on the presence of parasite eggs in the nervous tissue and on the host immune response. The patients with cerebral NS usually have the clinical manifestations of increased intracranial pressure associated with focal neurological signs; and those with schistosomal myeloradiculopathy (SMR) present rapidly progressing symptoms of myelitis involving the lower cord, usually in association with the involvement of the cauda esquina roots. The diagnosis of cerebral NS is established by biopsy of the nervous tissue and SMR is usually diagnosed according to a clinical criterion. Antischistosomal drugs, corticosteroids and surgery are the resourses available for treating NS. The outcome is variable and is better in cerebral disease.

Condroma de sela turca associado a hipopituitarismo: relato de um caso

Os condromas intracranianos são raros, sendo mais comumente encontrados na base do crânio e na região esfenoetmoidal. Nesta localização podem ser confundidos com meningiomas, neurinomas e craniofaringiomas. Os autores apresentam a evolução clínica e as características pela imagem de um paciente portador de condroma da sela turca submetido a excisão tumoral.

An ABC for decision making

The present study was aimed at proposing a systematic evaluation of cranial computed tomography, identifying the main aspects to be analyzed in order to facilitate the decision making process regarding diagnosis and management in emergency settings. The present descriptive study comprised a literature review at the following databases: Access Medicine and Access Emergency Medicine (McGraw- Hill Education); British Medical Journal Evidence Center; UptoDate; Bireme; PubMed; Lilacs; SciELO; ProQuest; Micromedex (Thomson Reuters); Embase. Once the literature review was completed, the authors identified the main diseases with tomographic repercussions and proposed the present system to evaluate cranial computed tomography images. An easy-to-memorize ABC system will facilitate the decision making in emergency settings, as it covers the main diseases encountered by intensivists and emergency physicians, and provides a sequential guidance about anatomical structures to be investigated as well as their respective alterations.

Boundless thought. The case of conceptual mental episodes

I present and defend here a thesis named vehicleless externalism for conceptual mental episodes. According to it, the constitutive relations there are between the production of conceptual mental episodes by an individual and the inclusion of this individual in social discursive practices make it non-necessary to equate, even partially, conceptual mental episodes with the occurrence of physical events inside of that individual. Conceptual mental episodes do not have subpersonal vehicles; they have owners: persons in interpretational practices. That thesis is grounded on inferentialism and on the endorsement of the idea that "meaning is normative". After having recapitulated this heritage and after having presented that thesis, the paper especially attempts to articulate how, in that framework, we may then positively conceive the relations there are between conceptual mental episodes, intracranial events and inferential behaviour.

Evaluation of prognostic factors of decompressive craniectomy in the treatment of severe traumatic brain injury

OBJECTIVE: to determine predictive factors for prognosis of decompressive craniectomy in patients with severe traumatic brain injury (TBI), describing epidemiological findings and the major complications of this procedure.METHODS: we conducted a retrospective study based on analysis of clinical and neurological outcome, using the extended Glasgow outcome in 56 consecutive patients diagnosed with severe TBI scale treated in the emergency department from February 2004 to July 2012. The variables assessed were age, mechanism of injury, presence of pupillary changes, Glasgow coma scale (GCS) score on admission, CT scan findings (volume, type and association of intracranial lesions, deviation from the midline structures and classification in the scale of Marshall and Rotterdam).RESULTS: we observed that 96.4% of patients underwent unilateral decompressive craniectomy (DC) with expansion duraplasty, and the remainder to bilateral DC, 53.6% of cases being on the right 42.9% on the left, and 3.6% bilaterally, with predominance of the fourth decade of life and males (83.9%). Complications were described as transcalvarial herniation (17.9%), increased volume of brain contusions (16.1%) higroma (16.1%), hydrocephalus (10.7%), swelling of the contralateral lesions (5.3%) and CSF leak (3.6%).CONCLUSION: among the factors studied, only the presence of mydriasis with absence of pupillary reflex, scoring 4 and 5 in the Glasgow Coma Scale, association of intracranial lesions and diversion of midline structures (DML) exceeding 15mm correlated statistically as predictors of poor prognosis.

Comparative analysis of the frequency and the severity of diagnosed lesions between pedestrians struck by motor vehicles and other blunt trauma mechanisms victims

ABSTRACTObjective:to compare the frequency and the severity of diagnosed injuries between pedestrians struck by motor vehicles and victims of other blunt trauma mechanisms.Methods:retrospective analysis of data from the Trauma Registry, including adult blunt trauma patients admitted from 2008 to 2010. We reviewed the mechanism of trauma, vital signs on admission and the injuries identified. Severity stratification was carried using RTS, AIS-90, ISS e TRISS. Patients were assigned into group A (pedestrians struck by motor vehicle) or B (victims of other mechanisms of blunt trauma). Variables were compared between groups. We considered p<0.05 as significant.Results:a total of 5785 cases were included, and 1217 (21,0%) of which were in group A. Pedestrians struck by vehicles presented (p<0.05) higher mean age, mean heart rate upon admission, mean ISS and mean AIS in head, thorax, abdomen and extremities, as well as lower mean Glasgow coma scale, arterial blood pressure upon admission, RTS and TRISS. They also had a higher frequency of epidural hematomas, subdural hematomas, subarachnoid hemorrhage, brain swelling, cerebral contusions, costal fractures, pneumothorax, flail chest, pulmonary contusions, as well as pelvic, superior limbs and inferior limbs fractures.Conclusion:pedestrian struck by vehicles sustained intracranial, thoracic, abdominal and extremity injuries more frequently than victims of other blunt trauma mechanism as a group. They also presented worse physiologic and anatomic severity of the trauma.

Chronic subdural hematoma: epidemiological and prognostic analysis of 176 cases

Objective : To characterize patients with chronic subdural hematoma undergoing surgery and to identify prognostic indicators. Methods : We conducted a retrospective analysis of patients diagnosed with chronic subdural hematoma (CSDH) undergoing surgical treatment. We analyzed: age, period from trauma to diagnostic imaging, pre and postoperative Glasgow coma scale, type of surgery, associated comorbidities, use of postoperative drainage and outpatient treatment. Results : The sample consisted of 176 patients, 126 male and 50 female patients (ratio 2.5 : 1), ages ranged from six months to 97 years, with an average of 59.3 years. CSDH was caused by trauma in 52% of patients, with the time from trauma to imaging averaging 25.05 days; 37.7% were hypertensive patients and 20% had a neurological disease. Eighty-five (48.3%) patients were elderly and altered consciousness was present in 63% of cases. Of the 91 (51.7%) non-elderly patients, 44% presented with headache, altered consciousness occurred in 40% and motor abnormalities in 27.5%. The CSDH was located on the right in 41%, left in 43% and bilaterally in 16% of patients. Conclusion : the change of consciousness was the most common clinical alteration in the elderly and headache in non-elderly. The most associated comorbidity was the arterial hypertension and the most frequent cause, head trauma. The trepanation with two oriffices associated with a closed drainage system was the most used operating, with high efficacy and low complication rate.

Facial paralysis and vestibular syndrome in feedlot cattle in Argentina

This paper reports 6 outbreaks of neurological disease associated with paralysis of the facial and vestibulocochlear nerves caused by intracranial space occupying lesions in feedlot cattle. The clinical signs observed were characterized by head tilt, uni or bilateral drooping and paralysis of the ears, eyelid ptosis, keratoconjunctivitis, and different degrees of ataxia. Morbidity and mortality rates ranged from 1.1 to 50% and 0 to 1%, respectively. Gross lesions observed included yellow, thickened leptomeninges, and marked enlargement of the roots of cranial nerves VII (facial) and VIII (vestibulocochlear). Histopathologically, there was severe, chronic, granulomatous meningitis and, in one case, chronic, granulomatous neuritis of the VII and VIII cranial nerves. Attempts to identify bacterial, viral, or parasitic agents were unsuccessful. Based on the morphologic lesions, the clinical condition was diagnosed as facial paralysis and vestibular syndrome associated with space occupying lesions in the meninges and the cranial nerves VII and VIII. Feedlot is a practice of growing diffusion in our country and this is a first report of outbreaks of facial paralysis and vestibular disease associated with space occupying lesions in Argentina.

Implications of ischemic penumbra for the diagnosis of brain death

The data reviewed here suggest the possibility that a global reduction of blood supply to the whole brain or solely to the infratentorial structures down to the range of ischemic penumbra for several hours or a few days may lead to misdiagnosis of irreversible brain or brain stem damage in a subset of deeply comatose patients with cephalic areflexia. The following proposals are advanced: 1) the lack of any set of clinically detectable brain functions does not provide a safe diagnosis of brain or brain stem death; 2) apnea testing may induce irreversible brain damage and should be abandoned; 3) moderate hypothermia, antipyresis, prevention of arterial hypotension, and occasionally intra-arterial thrombolysis may contribute to good recovery of a possibly large subset of cases of brain injury currently regarded as irreversible; 4) confirmatory tests for brain death should not replace or delay the administration of potentially effective therapeutic measures; 5) in order to validate confirmatory tests, further research is needed to relate their results to specific levels of blood supply to the brain. The current criteria for the diagnosis of brain death should be revised.

Renal and extrarenal manifestations of autosomal dominant polycystic kidney disease

The objective of the present study was to determine the frequency of the most common clinical features in patients with autosomal dominant polycystic kidney disease in a sample of the Brazilian population. The medical records of 92 patients with autosomal dominant polycystic kidney disease attended during the period from 1985 to 2003 were reviewed. The following data were recorded: age at diagnosis, gender, associated clinical manifestations, occurrence of stroke, age at loss of renal function (beginning of dialysis), and presence of a family history. The involvement of abdominal viscera was investigated by ultrasonography. Intracranial alterations were prospectively investigated by magnetic resonance angiography in 42 asymptomatic patients, and complemented with digital subtraction arteriography when indicated. Mean age at diagnosis was 35.1 ± 14.9 years, and mean serum creatinine at referral was 2.4 ± 2.8 mg/dL. The most frequent clinical manifestations during the disease were arterial hypertension (63.3%), lumbar pain (55.4%), an abdominal mass (47.8%), and urinary infection (35.8%). Loss of renal function occurred in 27 patients (mean age: 45.4 ± 9.5 years). The liver was the second organ most frequently affected (39.1%). Stroke occurred in 7.6% of the patients. Asymptomatic intracranial aneurysm was detected in 3 patients and arachnoid cysts in 3 other patients. In conclusion, the most common clinical features were lumbar pain, arterial hypertension, abdominal mass, and urinary infection, and the most serious complications were chronic renal failure and stroke. Both intracranial aneurysms and arachnoid cysts occurred in asymptomatic patients at a frequency of 7.14%.

The oral motor capacity and feeding performance of preterm newborns at the time of transition to oral feeding

The objective of the present study was to determine the oral motor capacity and the feeding performance of preterm newborn infants when they were permitted to start oral feeding. This was an observational and prospective study conducted on 43 preterm newborns admitted to the Neonatal Intensive Care Unit of UFSM, RS, Brazil. Exclusion criteria were the presence of head and neck malformations, genetic disease, neonatal asphyxia, intracranial hemorrhage, and kernicterus. When the infants were permitted to start oral feeding, non-nutritive sucking was evaluated by a speech therapist regarding force (strong vs weak), rhythm (rapid vs slow), presence of adaptive oral reflexes (searching, sucking and swallowing) and coordination between sucking, swallowing and respiration. Feeding performance was evaluated on the basis of competence (defined by rate of milk intake, mL/min) and overall transfer (percent ingested volume/total volume ordered). The speech therapist's evaluation showed that 33% of the newborns presented weak sucking, 23% slow rhythm, 30% absence of at least one adaptive oral reflex, and 14% with no coordination between sucking, swallowing and respiration. Mean feeding competence was greater in infants with strong sucking fast rhythm. The presence of sucking-swallowing-respiration coordination decreased the days for an overall transfer of 100%. Evaluation by a speech therapist proved to be a useful tool for the safe indication of the beginning of oral feeding for premature infants.