O comportamento clínico e neurofisiológico da neuropatia durante os episódios reacionais da hanseníase

A hanseníase, uma doença conhecida por suas lesões de pele anestésicas, é a principal causa de neuropatia periférica nos países endêmicos. Os episódios reacionais são classicamente conhecidos por promover piora da função nervosa através das chamadas neurites que variam de quadros exuberantes a assintomáticos. Estas características da neuropatia tornam o diagnóstico precoce excepcionalmente desafiador assim como a necessidade de se intervir para se prevenir lesões permanentes nos nervos. Este estudo clínico, prospectivo, foi realizado selecionando-se pacientes com hanseníase, independente da forma clínica, no Ambulatório Souza Araujo, Fiocruz, Rio de Janeiro, que apresentavam episódios reacionais. O objetivo foi estudar o perfil neurológico clínico, eletroneurofisiológico e por imagem do nervo antes e após o tratamento das reações. Foram avaliados vinte e cinco pacientes levando-se em conta: exame neurológico, avaliação fisioterápica, estudo de condução nervosa, avaliação de espessura e ecogenicidade nervosa pelo método ultrassonográfico, fluxometria por laser Doppler e teste quantitativo da sensibilidade durante e um ano após o tratamento da reação. Estes pacientes foram divididos em três grupos: oito pacientes com neurite aguda, nove pacientes com neurite silenciosa e oito pacientes com reação cutânea sem neurite. Nos pacientes com episódios reacionais, observou-se predomínio do sexo masculino (60%), do grupo multibacilar (80%) e da forma clínica borderline-lepromatosa (36%). A neurite isolada foi o tipo de reação mais frequente, seguida de neurite associada à reação do tipo1, seguida da neurite associada à reação do tipo 2. O nervo motor mais acometido por neurite foi o fibular seguido pelo ulnar, enquanto o nervo sensitivo mais acometido foi o sural. O padrão eletroneuromiográfico característico dos episódios reacionais foi a mononeurite múltipla. A ultrassonografia, a fluxometria por laser Doppler e o teste quantitativo de sensibilidade, associados à clínica e ao estudo da condução nervosa, foram tidos como exames úteis para avaliação inicial e para acompanhar o tratamento dos episódios reacionais. Após o tratamento, foi constatada melhora nos parâmetros referentes à função motora, mas o mesmo não ocorreu para sensibilidade. Com esse estudo, observa-se a necessidade de acompanhamento multidiciplinar com exames especializados para os pacientes com hanseníase a fim de diagnóstico de reação e tratamento precoce evitando sequelas neurológicas.

Prognostication after cardiac arrest and hypothermia: a prospective study.

Current American Academy of Neurology (AAN) guidelines for outcome prediction in comatose survivors of cardiac arrest (CA) have been validated before the therapeutic hypothermia era (TH). We undertook this study to verify the prognostic value of clinical and electrophysiological variables in the TH setting. A total of 111 consecutive comatose survivors of CA treated with TH were prospectively studied over a 3-year period. Neurological examination, electroencephalography (EEG), and somatosensory evoked potentials (SSEP) were performed immediately after TH, at normothermia and off sedation. Neurological recovery was assessed at 3 to 6 months, using Cerebral Performance Categories (CPC). Three clinical variables, assessed within 72 hours after CA, showed higher false-positive mortality predictions as compared with the AAN guidelines: incomplete brainstem reflexes recovery (4% vs 0%), myoclonus (7% vs 0%), and absent motor response to pain (24% vs 0%). Furthermore, unreactive EEG background was incompatible with good long-term neurological recovery (CPC 1-2) and strongly associated with in-hospital mortality (adjusted odds ratio for death, 15.4; 95% confidence interval, 3.3-71.9). The presence of at least 2 independent predictors out of 4 (incomplete brainstem reflexes, myoclonus, unreactive EEG, and absent cortical SSEP) accurately predicted poor long-term neurological recovery (positive predictive value = 1.00); EEG reactivity significantly improved the prognostication. Our data show that TH may modify outcome prediction after CA, implying that some clinical features should be interpreted with more caution in this setting as compared with the AAN guidelines. EEG background reactivity is useful in determining the prognosis after CA treated with TH.

Examen neurológico

Se realizó un capítulo sobre la descripción del examen neurológico como herramienta principal en el abordaje del paciente con patología neurológica.

Physical-chemical analysis of the cerebrospinal fluid of healthy dogs submitted to different storage periods and temperatures

Disfunções envolvendo o sistema nervoso são de grande importância na Medicina Veterinária, pois tratam-se de enfermidades de elevada incidência e com poucos subsídios auxiliares no seu diagnóstico, prognóstico e na avaliação de terapias empregadas. Ainda hoje, o diagnóstico baseia-se, em grande parte, no histórico e no exame clínico neurológico. Dessa forma, a análise dos constituintes do fluido cefalorraquidiano torna-se uma das poucas alternativas de acesso clínico ao sistema nervoso central (SNC). Mesmo com a grande utilidade do exame físico-químico e citoscópico do liquor na neurologia veterinária, poucos são os estudos sobre a estabilidade dos seus constituintes sob estocagem. Dessa forma, o presente trabalho teve como finalidade verificar a influência da temperatura e do tempo de conservação nas características físico-químicas do liquor de cães hígidos. Para tanto, foram coletadas amostras de LCR, através da punção da cisterna cerebelo-medular de cães clinicamente sadios, as quais foram submetidas à análise da densidade específica, do pH, da glicorraquia, das proteínas totais e das atividades das enzimas creatina quinase (CK) e aspartato aminotransferase (AST), após conservá-las em diferentes temperaturas (25°C, 4°C e -4°C) e por diferentes períodos de tempo (logo após a colheita, 24 horas, 48 horas, uma semana e um mês). Dentre os resultados obtidos, foi possível verificar, principalmente, que houve estabilidade dos parâmetros estudados por até um mês de estocagem nas amostras mantidas sob a temperaturas de congelamento de -4°C.

Estudo multicêntrico sobre escalas para grau de comprometimento em disfagia orofaríngea neurogênica

OBJETIVO: Analisar a concordância entre distintas escalas para grau de comprometimento em disfagia orofaríngea neurogênica. MÉTODOS: Foi realizado estudo clínico transversal. Participaram 200 indivíduos com disfagia orofaríngea neurogênica, 108 do gênero masculino e 92 do gênero feminino, com idades de 3 meses a 91 anos. Foram aplicadas quatro escalas para classificar o grau de comprometimento da disfagia orofaríngea, sendo duas escalas clínicas e duas videofluoroscópicas. Análises estatísticas foram realizadas para verificar a concordância entre as escalas clínicas e objetivas. RESULTADOS: Os resultados mostraram concordância muito boa entre as escalas clínicas estudadas (Kappa=0,92) e concordância moderada entre as escalas objetivas (Kappa=0,52). CONCLUSÃO: Embora a concordância entre as escalas clínicas tenha sido muito boa e entre as escalas objetivas tenha sido moderada, ainda é necessária ampla discussão e possível revisão dos parâmetros que definem o grau de comprometimento da disfagia orofaríngea em pacientes neurológicos.

Avaliação dos reflexos espinhais em bezerros

Este trabalho objetivou avaliar, quantificar e padronizar a ocorrência dos reflexos espinhais em bezerros da raça holandesa de 15 a 90 dias de idade, os quais foram submetidos a avaliação nos membros torácicos (reflexo carpo radial, reflexo bicipital, reflexo tricipital e reflexo flexor) e nos membros pélvicos (reflexo patelar, reflexo tibial cranial, reflexo gastrocnêmio, reflexo ciático e reflexo flexor). Para quantificação da resposta involuntária frente ao reflexo realizado, padronizou-se a ausência do reflexo como sendo o algarismo 0; resposta discreta do reflexo como sendo l e a presença evidente da resposta como sendo 2. Os reflexos mais evidentes e constantes foram os reflexos flexor, carpo radial, patelar e tricipital. Os reflexos menos evidentes e menos freqüentes foram os reflexos tibial cranial, bicipital, gastrocnêmio e ciático.

Sudden bilateral deafness from hyperleukocytosis in chronic myeloid leukemia

Sudden-onset bilateral deafness as a clinical manifestation of hyperleukocytosis in chronic myeloid leukemia (CML) is a rare occurrence. We found only 27 clinical descriptions in 16 published papers. In this work, the authors present a review on deafness in CML and describe a new case with prominent hyperleukocytosis, where the neurological findings suggest slowing of the circulation through small blood vessels in the brainstem as the cause of deafness. The evolution was good after treatment. To our knowledge, this is the second case documented with electrical auditory brainstem-evoked potentials and the first with magnetic resonance imaging. Copyright (C) 2000 S. Karger AG, Basel.

Neonatal rat exposure to pyrethroid and organophosphate insecticides: A physiological and biochemical trial of progeny

A manufactured product (Ectoplus®) composed by a cypermethrin (44.7%) and dichlorvos (4.2%) mixture was administered (10mg/kg/day, orally, by gavage) to pregnant rats, during the periods of gestation+lactation, gestation, and lactation. Control mothers received vehicle aqueous solution during the gestation+lactation period. With the progeny, in the 1-15 post-natal days (PNDI-15) there were observed alterations in the periods of occurrence of teeth, hair, unfolding of ears, and in the developmental period for following reflexes: postural, palmar grasp, negative geotaxis, and acoustic startle reflex. After weaning (PND21), there were observed the presence of cypermethrin and dichlorvos in the blood brain and liver; decrease in weight of liver, of cholinesterase activity in the plasma, liver, and brain, and hepatic metabolizing activity of drugs; alterations of levels of gamma glutamyl transferase enzymes, of creatinine, and of potassium in the serum of the animals. In conclusion, neonatal exposure to a formulated mixture of cypermethrin and dichlorvos is inductive to alterations in characteristics that indicate somatic and neuromuscular development of the progeny, and in certain biochemical parameters. The results suggest that enzymatic assessment associated with somatic and neuromotor assessment can be important markers of developmental characteristics in neonatal toxicity by pesticide formulations based on mixtures of insecticides.

Trochlear nerve palsy associated with claude bernard-horner syndrome after brainstem stroke

The association of unilateral trochlear nerve palsy with Claude Bernard-Horner syndrome represents a rare clinical condition. We present the case of a patient with this unusual presentation. The investigation performed implicated cerebrovascular disease as the underlying cause of the condition in this patient. © 2011 S. Karger AG, Basel.

Pilomyxoid astrocytoma of the brainstem

A pilomyxoid astrocytoma is a recently described tumor that occurs predominantly in the hypothalamic-chiasmatic region and is rarely found elsewhere. It has similar features as pilocytic astrocytomas, but has distinct histological characteristics and a poorer prognosis. A pilomyxoid astrocytoma is an aggressive tumor, and increased awareness is necessary with a suspect case. We present the first case of a pilomyxoid astrocytoma of the brainstem described after the newest World Health Organization classification of central nervous system tumors. © F.O. Pereira et al., 2013. Licensee PAGEPress, Italy.

Anxiogenic-like effect induced by TRPV1 receptor activation within the dorsal periaqueductal gray matter in mice

Pharmacological manipulation of TRPV1 (Transient Receptor Potential Vanilloid type-1) receptors has been emerging as a novel target in the investigation of anxiety states. Here, we attempt to show the role played by the TRPV1 receptors within the dorsal periaqueductal gray matter (dPAG), a midbrain structure strongly involved in the modulation of anxiety. Anxiety was assessed by recording spatiotemporal [percent open arm entries (%OE) and percent open arm time (%OT)] and ethological [e.g., head dipping (HD), stretched-attend postures (SAP)] measures in mice exposed to the elevated plus-maze (EPM). Mice received an intra-dPAG injection of the TRPV1 agonist capsaicin (0, 0.01, 0.1 or 1.0. nmol/0.2. μL; Experiment 1) or antagonist capsazepine (0, 10, 30 or 60. nmol/0.2. μL; Experiment 2), or combined injections of capsazepine (30. nmol) and capsaicin (1.0. nmol) (Experiment 3), and were exposed to the EPM to record spatiotemporal and ethological measures. While capsaicin produced an anxiogenic-like effect (it reduced %OE and %OT and frequency of SAP and HD in the open arms), capsazepine did not change any behavior in the EPM. However, when injected before capsaicin (1.0. nmol), intra-dPAG capsazepine (30. nmol-a dose devoid of intrinsic effects) antagonized completely the anxiogenic-like effect of the TRPV1 agonist. These results suggest that the anxiogenic-like effect produced by capsaicin is primarily due to TRPV1 activation within the dPAG in mice, but that dPAG TRPV1 receptors do not exert a tonic control over defensive behavior in mice exposed to the EPM. © 2013 Elsevier B.V.

Carotid artery atherosclerotic profile as a predictor of the aorta atherosclerotic profile in patients with cerebrovascular events

Background: It is well known that the presence of atheroma of the thoracic aorta is a risk factor for cerebrovascular events. We sought to evaluate whether the presence and the morphology of atherosclerotic plaque in the carotid artery detected by duplex ultrasonography is associated with disease in the proximal aorta visualized by transesophageal echocardiogram in patients with a cerebrovascular event. Methods: We carried out a cross-sectional prospective study including 147 consecutive patients with prior stroke or transient ischemic attack (TIA). Neurological evaluations were performed by an expert neurologist using clinical and tomographic diagnostic criteria including the definition of etiology and whether the patient suffered from stroke or TIA. Transthoracic and transesophageal echocardiograms and carotid artery duplex ultrasonography were performed by the same examiner. Patients with and without plaque in the carotid artery were compared using Student's t test or the χ2 test. Regression analysis was used to determine whether the presence of plaque in the carotid artery was predictive of the presence of plaque in the proximal aorta and to analyze the relationship between the echogenicity of carotid and aortic plaques. The significance level was set at p < 0.05. Results: All 147 patients (95 men) were included in the analysis. Patients' ages ranged from 23 to 85 years (65 ± 12.4 years). Most of the patients (58.5%) were Caucasian, while 41.5% were African-Brazilian. Arterial hypertension, diabetes and tobacco use were more frequent among patients with atherosclerotic plaque in the aorta. A normal carotid intima-media thickness halved the risk of atherosclerotic plaque in the aorta [odds ratio (OR) 0.46, 95% confidence interval (CI) 0.23-0.91; p = 0.026]. The presence of carotid plaque increased the risk of aortic plaque by 70-fold (OR 73.2, 95% CI 25.6-2,018.6; p < 0.001) in univariate analysis. The absence of atherosclerotic plaque in the carotid artery reduced the risk of plaque in the aorta to almost 0 (OR 0.014, 95% CI 0.004-0.041; p < 0.001). Considering the 86 patients with both aortic and carotid plaques, the presence of hypoechoic plaque in the carotid artery was a predictor of hypoechoic plaque in the aorta (OR 10.1, 95% CI 3.3-31.2; p < 0.001). Conclusions: The carotid artery atherosclerotic profile defined by ultrasonography is a strong predictor of the atherosclerotic profile of the proximal aorta. This should be taken into consideration before referring patients with acute cerebrovascular events for transesophageal echocardiogram. © 2013 S. Karger AG, Basel.