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Cerebral vasospasm is determined as a temporary narrowing of cerebral arteries a few days after an aneurysmal subarachnoid hemorrhage. The onset of this vascular event usually evolves with new neurological deficits or progression of ischemic areas. The success of interventions to treat or revert this condition is not satisfying. In addition to cerebral vasospasm, early brain injury plays an important role as a contributor to subarachnoid hemorrhage's mortality. In this sense, stellate ganglion block appears as an alternative to reduce sympathetic system's activation, one of the main pathophysiological mechanisms involved in brain injury. Over the past few years, there is growing evidence that stellate ganglion block can contribute to decline patient morbidity from subarachnoid hemorrhage. Is it time to include this procedure as a standard treatment after aneurysm rupture?

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PURPOSE: Stellate ganglion (SG) block by thermal radiofrequency ablation (RFA) is frequently conducted as a therapeutic intervention for sympathetic-maintained and neuropathic pain syndromes. RFA's partial lack of effectiveness could be partly due to the ablation zone (AZ) not completely covering the SG section and therefore preventing the 'cutting' of the afferent pathways. Our objective was to build a theoretical model to conduct computer simulations to assess the effect of the electrode position relative to the SG. METHODS: A three-dimensional model was built including the SG and adjacent tissues (vertebrae C7-T1-T2, trachea, carotid artery and vertebral artery). RFA (90-s, 80 °C) was simulated considering a 22 G-5 mm electrode. The AZ was computed using the 50 °C isotherm. RESULTS: An electrode displacement of 2 mm in any direction from the optimal position (centered on the SG) meant that the AZ did not fully cover the SG section. Likewise, SG size considerably affected the RFA effectiveness since the AZ fully covered the section of small but not large SGs. CONCLUSIONS: The findings suggest that the currently used SG RFA settings (i.e., 22 G-5 mm electrode, 90-s, 80 °C) may not be appropriate due to their inability to achieve an AZ that fully covers the SG cross section under certain circumstances, such as a large SG and non-optimal positioning of the RF electrode with respect to the SG center.

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OBJECTIVE: To observe the effects of preoperative right stellate ganglion block on perioperative atrial fibrillation in patients undergoing lung lobectomy. METHODS: Two hundred patients who underwent a scheduled lobectomy were randomly divided into the S and C groups. The S group was injected with 4mL of 0.2% ropivacaine under ultrasound guidance, and the C group did not receive stellate ganglion block. The patients underwent continuous ECG monitoring, and the incidences of atrial fibrillation and other types of arrhythmias were recorded from the start of surgery to 24hours after surgery. RESULTS: The respective incidences of atrial fibrillation in the S group and the C group were 3% and 10% (p=0.045); other atrial arrhythmias were 20% and 38% (p=0.005); and ventricular arrhythmia were 28% and 39% (p=0.09). CONCLUSIONS: The results of the study indicated that preoperative right stellate ganglion block can effectively reduce the incidence of intraoperative and postoperative atrial fibrillation.

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Abstract Objective: To observe the effects of preoperative right stellate ganglion block on perioperative atrial fibrillation in patients undergoing lung lobectomy. Methods: Two hundred patients who underwent a scheduled lobectomy were randomly divided into the S and C groups. The S group was injected with 4 mL of 0.2% ropivacaine under ultrasound guidance, and the C group did not receive stellate ganglion block. The patients underwent continuous ECG monitoring, and the incidences of atrial fibrillation and other types of arrhythmias were recorded from the start of surgery to 24 hours after surgery. Results: The respective incidences of atrial fibrillation in the S group and the C group were 3% and 10% (p = 0.045); other atrial arrhythmias were 20% and 38% (p = 0.005); and ventricular arrhythmia were 28% and 39% (p = 0.09). Conclusions: The results of the study indicated that preoperative right stellate ganglion block can effectively reduce the incidence of intraoperative and postoperative atrial fibrillation.

Resumo Objetivo: Observar os efeitos do bloqueio do gânglio estrelado na fibrilação atrial no período perioperatório em pacientes submetidos a lobectomia pulmonar. Método: Duzentos pacientes programados para lobectomia foram divididos aleatoriamente nos grupos S e C. O grupo S recebeu infusão de 4 mL de ropivacaína a 0,2% orientada por ultrassom e o grupo C não foi submetido a bloqueio do gânglio estrelado. Os pacientes foram submetidos à monitoração contínua de ECG, e as incidências de fibrilação atrial e outros tipos de arritmias foram registradas do início da cirurgia até 24 horas depois da cirurgia. Resultados: As incidências de fibrilação atrial no grupo S e no grupo C foram 3% e 10%, respectivamente (p = 0,045); as de outras arritmias atriais foram 20% e 38% (p = 0,005); e de arritmias ventriculares, 28% e 39% (p = 0,09). Conclusões: Os resultados do estudo indicaram que o bloqueio do gânglio estrelado no pré-operatório pode ser efetivo na redução da incidência de fibrilação atrial nos períodos intra- e pós-operatório.

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Introducción: el síndrome doloroso regional complejo tipo 1 de los miembros superiores está dado por la variedad de condiciones dolorosas de localización regional, posteriores a una lesión que presentó predominio distal, de síntomas anormales, que exceden en magnitud y duración el curso clínico esperado por el incidente inicial. Objetivos: evaluar la efectividad del bloqueo simpático del ganglio estrellado en el tratamiento del síndrome doloroso regional complejo tipo 1 de las extremidades superiores. Método: se realizó un estudio descriptivo para evaluar la evolución del tratamiento mediante bloqueos del ganglio estrellado en 229 pacientes afectos de síndrome doloroso regional complejo tipo I de miembros superiores en la Clínica del Dolor del Hospital Saturnino Lora de Santiago de Cuba, entre enero de 2004 y diciembre de 2014, a los cuales se les realizó tratamiento dos veces en la semana. En cada sesión se les administraron 5 ml de bupivacaína 0,25 por ciento. Se evaluó la intensidad del dolor mediante la escala de valoración verbal y en cada consulta la escala de grado de alivio del dolor, así como la de efectos secundarios. Resultados: predominó el grupo de edades de 40 a 49 años, el 72,48 por ciento de los pacientes pertenecieron al sexo femenino. El 58,3 por ciento del total, llegaron a la octava consulta con alivio total del dolor. Se encontraron mínimos efectos secundarios, que no requirieron tratamiento ni impidieron continuar el tratamiento. Hubo una respuesta terapéutica final satisfactoria. Conclusiones: el bloqueo del ganglio estrellado demostró utilidad y probada eficacia en el tratamiento del síndrome doloroso regional complejo tipo 1 de los miembros superiores. La bupivacaína al 0,25 por ciento (5 ml) fue suficiente para producir bloqueo simpático de intensidad y duración adecuada(AU)

Introduction: Regional pain syndrome type 1 of the upper extremities is given by the variety of painful conditions of regional location, after a lesion that presented distal predominance, of abnormal symptoms, exceeding in magnitude and length the clinical course expected for the initial incident. Objectives: To evaluate the effectiveness of stellate ganglion sympathetic blockade in the treatment of complex regional pain syndrome type 1 of upper extremities.Method : A descriptive study was conducted to assess the progress of treatment by stellate ganglion block in 229 patients with complex regional pain syndrome type I in upper extremities at the Saturnino Lora Hospital Pain Clinic of Santiago de Cuba between January 2004 and December 2014, who received treatment twice a week. In each session, they were administered 5 mL of bupivacaine 0.25 percent. Pain intensity was assessed by the verbal rating scale and, in each appointment, the pain relief degree scale, as well as that of side effects were assessed. Results : Age group 40-49 years predominated, 72.48 percent of patients belonged to the female sex. 58.3 percent of the total arrived to the office with total pain relief. Minimal side effects were found that did not require any treatment or prevented to continue it. There was a satisfactory therapeutic final response. Conclusions : Stellate ganglion block proved useful in the treatment of complex regional pain syndrome type 1 of the upper limbs. Bupivacaine 0.25 percent (5 ml) was sufficient to produce sympathetic block of appropriate length and intensity(AU)

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Sympathetic ganglion block (SGB) or intravenous regional block (IVRB) has been recommended for pain management in patients with complex regional pain syndrome type I (CRPS-I). Forty-five patients were initially selected but only 43 were accepted for the study. The present study evaluated the efficacy of IVRB produced by combining 70 mg lidocaine with 30 µg clonidine (14 patients, 1 male/13 females, age range: 27-50 years) versus SGB produced by the injection of 70 mg lidocaine alone (14 patients, 1 male/13 females, age range: 27-54 years) or combined with 30 µg clonidine (15 patients, 1 male/14 females, age range: 25-50 years) into the stellate ganglion for pain management in patients with upper extremity CRPS-I. Each procedure was repeated five times at 7-day intervals, and pain intensity and duration were measured using a visual analog scale immediately before each procedure. A progressive and significant reduction in pain scores and a significant increase in the duration of analgesia were observed in all groups following the first three blocks, but no further improvement was obtained following the last two blocks. Drowsiness, the most frequent side effect, and dry mouth occurred only in patients submitted to SGB with lidocaine combined with clonidine. The three methods were similar regarding changes in pain intensity and duration of analgesia. However, IVRB seems to be preferable to SGB due to its easier execution and lower risk of undesirable effects.

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RESUMEN Objetivo. Evaluación y seguimiento de dos pacientes a los que se les realizó la técnica de Bloqueo del Ganglio Estrellado (BGE) como tratamiento del ángor refractario. Casos clínicos. Se controla durante un período de 12 meses la evolución de dos pacientes con angina crónica refractaria a los que se les realizó la técnica de BGE por abordaje anterior izquierdo bajo fluoroscopía. Durante el control evolutivo se registraron la aparición de episodios anginosos y su relación con la actividad diaria, así como el incremento en el uso de medicación antiisquémica. En ambos casos se logró remisión de la sintomatología sin constatarse complicaciones, permaneciendo libres de síntomas entre dos y tres meses, reiterándose el procedimiento ante la aparición de dolor precordial al esfuerzo. Conclusión. La simpatectomía temporal aparece como una opción efectiva, bien tolerada y de bajo riesgo en pacientes ambulatorios con angina refractaria a tratamiento médico y revascularización, aplicada en el marco de un tratamiento de Cuidado Integral Cardiovascular.

summary Objective. Evaluation and follow-up of two patients whom Stellate Ganglion Blockade (SGB) Technique was performed to treat chronic refractory angina. Clinical cases. We analyzed during a year period two patients with refractory angina despite optimal medication who underwent repeated Stellate Ganglion Block under fluoroscopic guidance by left anterior approach. We recorded the presence or absence of chest pain and the number of anti-angina medications pre and post-treatment. Both patients achieve pain relief without complications. The period of complete pain relief was two and three months for each patient. SGB was repeated when angina returned. Conclusions. Temporal sympathectomy may provide a safe and effective option in patients with angina pectoris that is refractory to optimal medication and revascularization as part of holistic care. Continuous fluoroscopy monitoring may also prevent serious complications.

resumo Objetivo. Avaliação e seguimento de dois pacientes nos quais realizou-se a técnica do Bloqueio do Gânglio Estrelado (BGE) como tratamento da dor anginosa refratária. Casos Clínicos. Controla-se durante um período de 12 meses a evolução de dois pacientes com angina crônica refratária nos quais realizou-se a técnica de BGE por abordagem anterior esquerda sob fluoroscopia. Durante o controle evolutivo registrou-se o aparecimento de episódios anginosos e sua relação com a atividade diária assim como o incremento no uso de medicação anti-isquêmica. Em ambos casos logrou-se remissão da sintomato-logia sem que se constatasse complicações, permanecendo livres de sintomas por 2 a 3 meses, reiterando-se o procedimento ante a aparição de dor pré-cordial ao esforço. Conclusão. A simpatectomia temporal surge como uma opção efetiva, bem tolerada e de baixo risco em pacientes ambulatoriais com angina refratária a tratamento médico e revascularizacão, aplicada no conjunto de um tratamento cardiovascular integral.