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Moderate traumatic brain injury (TBI) is a diagnosis that describes diverse patients with heterogeneity of primary injuries. Defined by a Glasgow Coma Scale between 9 and 12, this category includes patients who may neurologically worsen and require increasing intensive care resources and/or emergency neurosurgery. Despite the unique characteristics of these patients, there have not been specific guidelines published before this effort to support decision-making in these patients. A Delphi consensus group from the Latin American Brain Injury Consortium was established to generate recommendations related to the definition and categorization of moderate TBI. Before an in-person meeting, a systematic review of the literature was performed identifying evidence relevant to planned topics. Blinded voting assessed support for each recommendation. A priori the threshold for consensus was set at 80% agreement. Nine PICOT questions were generated by the panel, including definition, categorization, grouping, and diagnosis of moderate TBI. Here, we report the results of our work including relevant consensus statements and discussion for each question. Moderate TBI is an entity for which there is little published evidence available supporting definition, diagnosis, and management. Recommendations based on experts' opinion were informed by available evidence and aim to refine the definition and categorization of moderate TBI. Further studies evaluating the impact of these recommendations will be required.

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Introduction Traumatic brain injury (TBI) is among the main causes of death and neurological sequelae worldwide. Injuries are classified as diffuse (diffuse axonal injury and brain swelling) or focal (cerebral contusion [CCo], epidural hematoma, and acute subdural hematoma). Among all TBIs, CCos are the most frequent focal lesion, and treatment modalities are many. Hematoma evacuation using large craniotomies has been well described in the literature. The main goal of the present study is to discuss the advantages of minimally invasive approaches for the treatment of CCos, regarding operative time, blood loss, and postoperative tomographic results. Methods An integrative literature review was conducted on the SciELO, LILACS, and PubMed databases. Seven case reports were included in the present study. Retrospective data collection was performed, analyzing gender, age, Glasgow coma scale score on hospital admission, surgical approach, and postoperative (tomographic) results. Results The minimally invasive keyhole approach was used in seven patients with CCos. The supraorbital approach (n » 5) was performed for frontal lobe contusions, and the minipterional approach (n » 2) was performed for temporal lobe contusions. All cases had adequate hematoma evacuation, confirmed by postoperative computed tomography scans. Conclusion The minimally invasive approaches were effective for hematoma evacuation, with adequate clinical and radiological postoperative results.

Introdução O traumatismo cranioencefálico se encontra entre as principais causas de óbito e sequelas neurológicas na estatística mundial. As lesões são classificadas como difusas (lesão axonal difusa e edema cerebral traumático) ou focais (contusões cerebrais [CoC], hematoma epidural, e hematoma subdural agudo). Dentre todos os tipos de lesões cerebrais traumáticas, as contusões são a lesão focal mais comum, e são reservadas a elas múltiplas modalidades de tratamento. O principal objetivo desse estudo é discutir as vantagens dos acessos minimamente invasivos no tratamento de contusões cerebrais, especialmente no que concerne à duração do procedimento, perda sanguínea e resultados tomográficos pós-operatórios. Métodos Uma revisão integrativa de literatura foi conduzida nas plataformas Scientific Electronic Library Online (SciELO), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) e PubMed. Sete relatos de caso foram incluídos neste estudo. A coleta retrospectiva de dados foi realizada com a análise das seguintes variáveis: gênero, idade, escala de coma de Glasgow à admissão, acesso cirúrgico utilizado e resultados tomográficos pós-operatórios. Resultados O acesso cirúrgico minimamente invasivo foi utilizado em sete pacientes com CoC. O acesso supraorbital (n » 5) foi usado para tratar contusões frontais, enquanto o acesso minipterional (n » 2) foi usado para o tratamento de contusões temporais. Em todos os casos, foi obtida drenagem satisfatória do hematoma, confirmada por meio de tomografias pós-operatórias. Conclusão Os acessos minimamente invasivos foram efetivos para evacuação dos hematomas intraparenquimatosos, com resultados clínicos e tomográficos favoráveis.

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BACKGROUND: The most frequent cause of death in neurosurgical patients is due to the increase in intracranial pressure (ICP); consequently, adequate monitoring of this parameter is extremely important. OBJECTIVES: In this study, we aimed to analyze the accuracy of noninvasive measurement methods for intracranial hypertension (IH) in patients with traumatic brain injury (TBI). METHODS: The data were obtained from the PubMed database, using the following terms: intracranial pressure, noninvasive, monitoring, assessment, and measurement. The selected articles date from 1980 to 2021, all of which were observational studies or clinical trials, in English and specifying ICP measurement in TBI. At the end of the selection, 21 articles were included in this review. RESULTS: The optic nerve sheath diameter (ONSD), pupillometry, transcranial doppler (TCD), multimodal combination, brain compliance using ICP waveform (ICPW), HeadSense, and Visual flash evoked pressure (FVEP) were analyzed. Pupillometry was not found to correlate with ICP, while HeadSense monitor and the FVEP method appear to have good correlation, but sensitivity and specificity data are not available. The ONSD and TCD methods showed good-to-moderate accuracy on invasive ICP values and potential to detect IH in most studies. Furthermore, multimodal combination may reduce the error possibility related to each technique. Finally, ICPW showed good accuracy to ICP values, but this analysis included TBI and non-TBI patients in the same sample. CONCLUSIONS: Noninvasive ICP monitoring methods may be used in the near future to guide TBI patients' management.

ANTECEDENTES: A causa mais frequente de morte em pacientes neurocirúrgicos é devido ao aumento da pressão intracraniana (PIC); consequentemente, o monitoramento adequado desse parâmetro é de extrema importância. OBJETIVOS: Avaliar na literatura científica os principais métodos não invasivos de medida da PIC em pacientes com traumatismo cranioencefálico (TCE). MéTODOS: Os dados foram obtidos na base de dados PubMed, utilizando os seguintes termos: pressão intracraniana, não invasivo, monitoramento, avaliação e medida, resultando em 147 artigos. Os artigos selecionados datam de 1980 a 2021, sendo todos estudos observacionais ou ensaios clínicos, em inglês e especificando a medida da pressão intracraniana em traumatismo cranioencefálico. Ao final da seleção, 21 artigos foram incluídos nesta revisão. RESULTADOS: Foram analisados os seguintes métodos: diâmetro da bainha do nervo óptico (ONSD), pupilometria, doppler transcraniano (TCD), combinação multimodal, complacência cerebral por meio da análise de ondas intracerebrais (ICPW), HeadSense e visual evocado por flashes de luz (FVEP). A pupilometria não se correlacionou com os valores de PIC, enquanto que o monitor HeadSense e o método FVEP parecem ter uma boa correlação, mas os dados de sensibilidade e especificidade desses métodos não estão disponíveis. Os métodos ONSD e TCD mostraram acurácia de boa a moderada quanto aos valores de IPCi, além de bom potencial para detectar hipertensão intracraniana. Ademais, a combinação multimodal pode reduzir a possibilidade de erro relacionado a cada técnica. Por fim, o ICPW apresentou boa acurácia quanto aos valores de ICPi, mas, no estudo analisado, foram incluídos pacientes com e sem TCE em uma mesma amostra. CONCLUSõES: Métodos não invasivos de medição da PIC podem atuar no futuro no manejo de pacientes com TCE como uma potencial ferramenta de triagem para TCE grave e para a detecção de hipertensão intracraniana.

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Abstract Background The most frequent cause of death in neurosurgical patients is due to the increase in intracranial pressure (ICP); consequently, adequate monitoring of this parameter is extremely important. Objectives In this study, we aimed to analyze the accuracy of noninvasive measurement methods for intracranial hypertension (IH) in patients with traumatic brain injury (TBI). Methods The data were obtained from the PubMed database, using the following terms: intracranial pressure, noninvasive, monitoring, assessment, and measurement. The selected articles date from 1980 to 2021, all of which were observational studies or clinical trials, in English and specifying ICP measurement in TBI. At the end of the selection, 21 articles were included in this review. Results The optic nerve sheath diameter (ONSD), pupillometry, transcranial doppler (TCD), multimodal combination, brain compliance using ICP waveform (ICPW), HeadSense, and Visual flash evoked pressure (FVEP) were analyzed. Pupillometry was not found to correlate with ICP, while HeadSense monitor and the FVEP method appear to have good correlation, but sensitivity and specificity data are not available. The ONSD and TCD methods showed good-to-moderate accuracy on invasive ICP values and potential to detect IH in most studies. Furthermore, multimodal combination may reduce the error possibility related to each technique. Finally, ICPW showed good accuracy to ICP values, but this analysis included TBI and non-TBI patients in the same sample. Conclusions Noninvasive ICP monitoring methods may be used in the near future to guide TBI patients' management.

Resumo Antecedentes A causa mais frequente de morte em pacientes neurocirúrgicos é devido ao aumento da pressão intracraniana (PIC); consequentemente, o monitoramento adequado desse parâmetro é de extrema importância. Objetivos Avaliar na literatura científica os principais métodos não invasivos de medida da PIC em pacientes com traumatismo cranioencefálico (TCE). Métodos Os dados foram obtidos na base de dados PubMed, utilizando os seguintes termos: pressão intracraniana, não invasivo, monitoramento, avaliação e medida, resultando em 147 artigos. Os artigos selecionados datam de 1980 a 2021, sendo todos estudos observacionais ou ensaios clínicos, em inglês e especificando a medida da pressão intracraniana em traumatismo cranioencefálico. Ao final da seleção, 21 artigos foram incluídos nesta revisão. Resultados Foram analisados os seguintes métodos: diâmetro da bainha do nervo óptico (ONSD), pupilometria, doppler transcraniano (TCD), combinação multimodal, complacência cerebral por meio da análise de ondas intracerebrais (ICPW), HeadSense e visual evocado por flashes de luz (FVEP). A pupilometria não se correlacionou com os valores de PIC, enquanto que o monitor HeadSense e o método FVEP parecem ter uma boa correlação, mas os dados de sensibilidade e especificidade desses métodos não estão disponíveis. Os métodos ONSD e TCD mostraram acurácia de boa a moderada quanto aos valores de IPCi, além de bom potencial para detectar hipertensão intracraniana. Ademais, a combinação multimodal pode reduzir a possibilidade de erro relacionado a cada técnica. Por fim, o ICPW apresentou boa acurácia quanto aos valores de ICPi, mas, no estudo analisado, foram incluídos pacientes com e sem TCE em uma mesma amostra. Conclusões Métodos não invasivos de medição da PIC podem atuar no futuro no manejo de pacientes com TCE como uma potencial ferramenta de triagem para TCE grave e para a detecção de hipertensão intracraniana.

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Very few studies have investigated cognition and impulsivity following mild traumatic brain injury (mTBI) in the general population. Furthermore, the neurobiological mechanisms underlying post-TBI neurobehavioral syndromes are complex and remain to be fully clarified. Herein, we took advantage of machine learning based-modeling to investigate potential biomarkers of mTBI-associated impulsivity. Twenty-one mTBI patients were assessed within one-month post-TBI and their data were compared to 19 healthy controls on measures of impulsivity (Barratt Impulsiveness Scale - BIS), executive functioning, episodic memory, self-report cognitive failures and blood biomarkers of inflammation, vascular and neuronal damage. mTBI patients were significantly more impulsive than controls in BIS total and subscales. Serum levels of sCD40L, Cathepsin D, IL-4, Neuropilin-1, IFN-α2, and Copeptin were associated with impulsivity in mTBI patients. Besides showing that mTBI are associated with impulsivity in non-military people, we unveiled different pathophysiological pathways potentially implicated in mTBI-related impulsivity.

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BACKGROUND: Traumatic brain injury (TBI) is a serious public health problem worldwide. Although TBI is common in developing countries, there are few epidemiological studies. OBJECTIVE: To investigate the sociodemographic and clinical features of patients with TBI at the Hospital João XXIII, a public reference center for trauma in Belo Horizonte, Brazil, and to systematically review the available literature on TBI in Brazil. METHODS: Clinical and sociodemographic data were collected from electronic medical records for the entire month of July 2016. The literature on epidemiology of TBI in Brazil was systematically reviewed using MeSH/DeCS descriptors in the PubMed and Lilacs databases. RESULTS: Most patients admitted with TBI were male and under 60 years of age. Mild TBI was the most prevalent form and the most common cause of TBI was falls. A Glasgow Coma Scale score below 12, neuroimaging changes on computer tomography, and presence of any medical conditions were significantly associated with longer hospital stay. Brazilian studies showed that TBI affected mainly men and young adults. In addition, mild TBI was the most common TBI severity reported and the most common causes were motor vehicle accidents and falls. CONCLUSIONS: Overall, the profile of TBI in this center reflects the data from other Brazilian studies.

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ABSTRACT Background: Traumatic brain injury (TBI) is a serious public health problem worldwide. Although TBI is common in developing countries, there are few epidemiological studies. Objective: To investigate the sociodemographic and clinical features of patients with TBI at the Hospital João XXIII, a public reference center for trauma in Belo Horizonte, Brazil, and to systematically review the available literature on TBI in Brazil. Methods: Clinical and sociodemographic data were collected from electronic medical records for the entire month of July 2016. The literature on epidemiology of TBI in Brazil was systematically reviewed using MeSH/DeCS descriptors in the PubMed and Lilacs databases. Results: Most patients admitted with TBI were male and under 60 years of age. Mild TBI was the most prevalent form and the most common cause of TBI was falls. A Glasgow Coma Scale score below 12, neuroimaging changes on computer tomography, and presence of any medical conditions were significantly associated with longer hospital stay. Brazilian studies showed that TBI affected mainly men and young adults. In addition, mild TBI was the most common TBI severity reported and the most common causes were motor vehicle accidents and falls. Conclusions: Overall, the profile of TBI in this center reflects the data from other Brazilian studies.

RESUMO Antecedentes: O traumatismo cranioencefálico (TCE) representa, mundialmente, um problema sério de saúde pública. Apesar de o TCE ser prevalente em países em desenvolvimento, estudos epidemiológicos permanecem escassos. Objetivo: Investigar as características sociodemográficas e clínicas de pacientes acometidos por TCE no Hospital João XXIII - centro de referência em trauma situado em Belo Horizonte, Brasil - e revisar sistematicamente toda a literatura disponível sobre o TCE no Brasil. Métodos: Os dados clínicos e sociodemográficos foram coletados apenas para o mês de julho, 2016, por meio de prontuários eletrônicos. A literatura sobre a epidemiologia do TCE no Brasil foi sistematicamente revisada usando descritores Medical Subject Headings (MeSH)/Descritores em Ciências da Saúde (DeCS) nos bancos de dados PubMed e Literatura Latino-Americana e do Caribe em Ciências da Saúde (Lilacs). Resultados: Os pacientes acometidos por TCE eram em sua maioria homens com menos de 60 anos. O TCE leve foi a gravidade mais prevalente entre os casos. O TCE foi causado principalmente por quedas. Escores menores que 12 na escala de Coma de Glasgow mais alterações de neuroimagem em tomografia computadorizada e a presença de qualquer comorbidade médica estão significativamente associados à maior estadia hospitalar. Estudos brasileiros demonstraram que o TCE acomete principalmente homens e adultos jovens. Além disso, o TCE leve foi a gravidade mais comum reportada, e os mecanismos de TCE mais comuns foram acidentes automobilísticos e quedas. Conclusões: O perfil de pacientes acometidos por TCE no centro de referência em questão reflete os dados de outros estudos brasileiros.

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Traumatic brain injury (TBI) is a serious public health problem, affecting 69 million people worldwide annually. Mild TBI (mTBI) comprises the majority of the cases and remains the most neglected TBI severity. Its intricate pathophysiology involves complex cellular and molecular processes that remain uncomprehended. Although the renin-angiotensin system (RAS) has its well-known roles in blood pressure regulation and fluid balance, accumulating evidence demonstrates its active expression and signaling in the central nervous system. Over the past years, pre-clinical studies have been supporting the role of RAS in mTBI. However, particularly for human TBI, evidence is still missing. Herein, we investigated peripheral levels of angiotensin II (Ang II) and angiotensin-converting enzyme (ACE), components of RAS classical axis, as well as angiotensin-(1-7) [Ang-(1-7)] and ACE2, components of RAS counter-regulatory axis, in 28 mTBI patients and 24 healthy controls. In the first 24 h, mTBI patients displayed lower ACE (p = 0.0004) and ACE2 (p = 0.0047) concentrations and an increase in Ang II (p = 0.0234) and Ang-(1-7) (p = 0.0225) levels compared to controls. Interestingly, at 30 days follow-up, mTBI patients increased the levels of ACE (p = 0.0415) and ACE2 (p = 0.0416) along with a decrease in Ang II (p = 0.0039) and Ang-(1-7) (p = 0.0015) concentrations compared with their measures at 24 h after TBI. Also, our receiver operating curve (ROC) analysis demonstrated that ACE concentration was a good predictor of mTBI diagnosis (AUC = 0.798, p < 0.0001). The current study provides the first clinical evidence of RAS molecule's involvement in mTBI and their possible role as discriminating biomarkers.

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Objective Hydrocephalus is characterized by multi- or uniloculated ventricular dilatation, and there are differences between the etiology and therapeutic response of each type. Endoscopic third ventriculostomy (ETV) is indicated for the treatment of obstructive hydrocephalus, with a reported efficacy between 50% and 76%. Reduced efficacy of the procedure has been demonstrated in communicating hydrocephalus due to multifactorial pathogenesis, and, in patients with myelomeningocele, its efficacy ranges from 15% to 20% at birth. The present study aims to compare the efficacy of ETV in the treatment of congenital obstructive hydrocephalus (COH) and acquired obstructive hydrocephalus (AOH) in the pediatric population. Methods A retrospective study of 169 endoscopic surgeries performed by the senior author in two institutions, one public (Hospital João XXIII, Belo Horizonte, Minas Gerais) and another private (Hospital Felício Rocho, Belo Horizonte, Minas Gerais), in the period from 2003 a 2020. From the selection of 169 patients, only 77 cases fit the age profile12 years of the present study. Of these, 46 were male, and the age range ranged from 10 days to 12 years. The study included multiple etiologies, which were divided into 2 groups, 34 related to COH, and 43 to AOH. Results Regarding the cases of COH, 22 were submitted to ETV as the main treatment, with 14 (63.63%) effective and 8 (36.36%) ineffective procedures. As for the cases of AOH, 13 patients underwent ETV, and 8 (61.53%) procedures were effective, and 5 (38.46%), ineffective. Conclusions Through the calculation of the p-value of 0.49, we concluded that it cannot stated that the efficacy of ETV is greater in COH than in AOH.

Objetivo A hidrocefalia é caracterizada por dilatação ventricular multi ou uniloculada, e há diferenças entre a etiologia e a resposta terapêutica de cada tipo. A terceiro ventriculostomia endoscópica (TVE) está indicada no tratamento da hidrocefalia obstrutiva, com uma eficácia relatada entre 50% e 76%. O procedimento demonstrou eficácia reduzida em hidrocefalia comunicante devido à patogênese multifatorial, sendo que, em pacientes com mielomeningocele, sua eficácia é de 15% a 20% no nascimento. Este estudo visa comparar a eficácia da TVE no tratamento da hidrocefalia obstrutiva congênita (HOC) e hidrocefalia obstrutiva adquirida (HOA) na população pediátrica. Métodos Realizou-se um estudo retrospectivo de 169 cirurgias endoscópicas realizadas pelo autor sênior em duas instituições, uma pública (Hospital João XXIII, Belo Horizonte, Minas Gerais) e outra privada (Hospital Felício Rocho, Belo Horizonte, Minas Gerais), no período de 2003 a 2020. Da seleção de 169 pacientes, apenas 77 casos se enquadraram no perfil de idade 12 anos do presente estudo. Destes, 46 eram do sexo masculino, e a faixa etária variou de 10 dias a 12 anos. O estudo contemplou múltiplas etiologias, que foram divididas em 2 grupos, sendo 34 relacionadas à HOC, e 43, à HOA. Resultados Entre os casos de HOC, 22 foram submetidos a TVE como tratamento principal, sendo que 14 (63,63%) procedimentos foram eficazes, e 8 (36,36%), ineficazes. Já entre os casos de HOA,13 pacientes foram submetidos a TVE, sendo 8 (61,53%) procedimentos eficazes, e 5 (38,46%), ineficazes. Conclusões Por meio do cálculo do valor de p de 0,49, concluiu-se que não se pode afirmar que a eficácia da TVE é maior nas HOCs do que nas HOAs.

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Up to 20% of victims from skull fractures are represented by the pediatric population, and 50% of these lesions are depressed skull fractures. The treatment is multimodal in nature, ranging from conservative treatment to open surgical repair. The last one is associated, although in a small proportion, to complications, such as infections, hematomas and even death, besides the risks of the anesthetic procedure itself. The authors of the present article present a case report of the successful treatment of a depressed skull fracture in a newborn patient, using the vacuum-suction technique. The use of vacuum-suction may be beneficial for the pediatric patients, as it is a quick, non-invasive procedure, without the need for general anesthesia.

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BACKGROUND: Pediatric minor head trauma approaches aim to ensure the absence of traumatic brain lesions, minimize ionizing radiation, and enhance cost control. We evaluated the applicability and cost-effectiveness of the Pediatric Emergency Care Applied Research Network (PECARN) rules after head trauma and rationalize the use of head computed tomography (CT) scans. METHODS: We retrospectively divided patients <18 years old who presented at a single institution in Brazil with minor head trauma into four groups: Group I (skull X-ray only), Group II (head CT only), Group III (X-ray and CT), and Group IV (observation only). Direct costs were calculated based on examination and length of hospitalization. The PECARN rules were applied retrospectively in each patient to determine who required a CT scan, and the costs were re-calculated. RESULTS: Of the 1328 patients, CT scans were performed in 36.4% and X-rays in 52.6%. The mean cost was USD 5.88, 34.58, 41.85, and 4.04 for Groups I-IV, respectively. After applying the PECARN rules, 77.6% of patients no longer required a CT scan, and overall costs were reduced from USD 16.71 to 7.88 (p < .001). Conclusion: The PECARN rules demonstrated a meaningful cost-effectiveness and should be applied to the Brazilian pediatric population.

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Necrotizing otitis externa (NOE), also known as malignant otitis externa (MOE), is a severe and rare infectious disease of the external auditory canal (EAC). Without treatment, it may progress to skull base involvement. The bacteria Pseudomonas aeruginosa is the most common causative agent (90% of the cases), and affects immunocompromised subjects, particularly diabetic patients. Severe chronic otalgia, otorrhea, and cranial nerve palsy are the most common clinical presentations. Patients with NOE are frequently referred to neurosurgery because of the neurological impairment and skull base compromise. The definitive diagnosis is frequently elusive, requiring a high index of suspicion. Several laboratorial tests, imaging modalities, and the histologic exclusion of malignancy may be required. An early diagnosis and aggressive treatment reduce morbidity and mortality. We present four NOE cases to illustrate the spectrum of clinical presentation and complementary exams. According to the literature, more effort for early diagnosis and treatment is required, and neurosurgeons play an important role in this task.

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Patients with mild traumatic brain injury (mTBI) may present cognitive deficits within the first 24 h after trauma, herein called "acute phase," which in turn may lead to long-term functional impairment and decrease in quality of life. Few studies investigated cognition in mTBI patients during the acute phase. The objectives of this study were to investigate the cognitive profile of patients with mTBI during the acute phase, compared to controls and normative data, and whether loss of consciousness (LOC), previous TBI and level of education influence cognition at this stage. Fifty-three patients with mTBI (aged 19-64 years) and 28 healthy controls participated in the study. All patients were evaluated at bedside within 24 h post-injury. Demographic and clinical data were registered. Cognitive function was assessed with the Mini-mental state examination (MMSE), the Frontal Assessment Battery (FAB), Digit Span (working memory), and the Visual Memory Test/Brief Cognitive Battery (for episodic memory). The clinical sample was composed mainly by men (58.5%). The mean age was 39 years-old and 64.3% of the patients had more than 8 years of education. The most common causes of mTBI were fall from own height (28.3%), aggression (24.5%), and fall from variable heights (24.5%). Compared to controls, mTBI patients exhibited significantly worse performance on MMSE, FAB, naming, incidental memory, immediate memory, learning, and delayed recall. Compared to normative data, 26.4% of patients had reduced global cognition as measured by the MMSE. Episodic memory impairment (13.2%) was more frequent than executive dysfunction (9.4%). No significant differences were found in cognitive performance when comparing patients with or without LOC or those with or without history of previous TBI. Patients with lower educational level had higher rates of cognitive impairment (VMT naming-28.6 vs. 4.2%; VMT immediate memory-32 vs. 4.2%; VMT learning-39.3 vs. 4.2%, all p < 0.05). In sum, we found significant cognitive impairment in the acute phase of mTBI, which was not associated with LOC or history of TBI, but appeared more frequently in patients with lower educational level.

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O trauma raquimedular (TRM) é uma importante causa de incapacidade, sendo constatado uma incidência média de 21 pacientes por milhão de habitantes por ano por uma revisão sistemática realizada nas cinco regiões do pais em. Em Belo Horizonte essa incidência chegou a 26 pacientes por milhão por ano. Trata-se de AFC, 28 anos, que foi encaminhado com urgência para o Hospital João XXIII com história de agressão por arma branca (um facão) na região supra clavicular esquerda no dia 22/10. Ao exame neurológico o paciente encontrava-se consciente, orientado e com hemiplegia á esquerda. Anestesia tátil e vibratória á esquerda (lesão do trato corticoespinhal e fascículo grácil e cuneiforme) e preservada á direita, além de anestesia térmica/dolorosa contralateral a hemissecção (lesão do trato espinotalâmico), que configuram a síndrome de Brown Sequard completa. Foi realizada tomografia computadorizada da coluna que evidenciou fratura de lâmina de T1. A ferida lacerante foi suturada e paciente manteve quadro estável por 5 dias. Após 7 dias da admissão hospitalar constatou-se anisocoria com pupila miótica à esquerda e ptose de pálpebra também a esquerda, que configura a síndrome de Horner concomitantemente. Foi realizada punção lombar constatando liquor hemorrágico e com alta celularidade, iniciado antibioticoterapia com Meropenem e Vancomicina. Relata-se a correlação anátomoclínica de paciente vitima de TRM aberto, com síndromes associadas, de hemissecção medular e Horner. Ressalta-se a importância dos conhecimentos em neuroanatomia. (AU)

Spinal cord trauma is an important cause of disability, with an average incidence of 21 patients per million inhabitants per year by a systematic review in the five regions of Brazil. In Belo Horizonte, this incidence reached 26 patients per million per year. This is the AFC, 28 years old, who was referred urgently to the Hospital João XXIII with a history of white-collar aggression (a machete) in the left supraclavicular region on 22/10. At the neurological examination the patient was conscious, oriented and with left hemiplegia. Tactile and vibratory anesthesia to the left (lesion of the corticospinal tract and gracile and cuneiform fasciculus) and preserved to the right, in addition to thermal / painful anesthesia contralateral to the hemisection (lesion of the spinothalamic tract), which constitute the complete Brown Sequard syndrome. Computed tomography of the spine was performed, showing a T1 fracture. The lacerating wound was sutured and patient maintained stable frame for 5 days. After 7 days of hospital admission, anisocoria was observed with miotic pupil on the left and ptosis of the eyelid also on the left, which configures Horner syndrome concomitantly. A lumbar puncture was performed, confirming hemorrhagic and high cellularity, and antibiotic therapy with Meropenem and Vancomycin. The anatomic-clinical correlation of a patient with open MTR with associated syndromes of medullary and Horner hemisection is reported. The importance of knowledge in neuroanatomy is emphasized. (AU)

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Spondylodiscitis consists of an inflammatory process of infectious origin that affects primarily the intervertebral disc and spreads to the adjacent vertebral bodies, often evolving into osteomyelitis, with consequent associated neurological damage. The diagnosis is often delayed, with an average of 2 to 6 months between the appearance of the first symptoms and the confirmation of the disease. Therefore, the laboratorial and imaging exams play an important role in the diagnosis of spondylodiscitis, as well as in the orientation for the treatment to be followed (conservative or surgical). We report a case of extensive involvement of the spine and discuss about the epidemiology of the disease, its diagnosis, and therapeutic principles.

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Introdução: O traumatismo cranioencefálico (TCE) é considerado a maior causa de morte e incapacidade em todo mundo, principalmente entre adultos jovens. No Brasil, estima-se que mais de um milhão de pessoas vivam com sequelas neurológicas decorrentes do TCE. Apesar da sua alta prevalência e taxas de incidência em constante elevação, estudos epidemiológicos permanecem escassos. Objetivo: Discutir as evidências disponíveis em relação ao perfil epidemiológico da população brasileira acometida por TCE. Métodos: Realizou- se uma revisão de literatura nas bases de dados SciELO, LILACS e PubMed. Os termos utilizados na busca foram traumatismo cranioencefálico, e/ou epidemiologia, e/ou Brasil. Para a busca no PubMed foram utilizados os termos em inglês traumatic brain injury, e/ou epidemiology, e/ou Brazil. Foram incluídos artigos originais, descritivos e de revisão que não restringiram a causa, a gravidade do TCE e a faixa etária estudada. Resultados: Foram encontrados oito estudos de 1993 a 2015, todos retrospectivos, sendo cinco deles realizados em hospitais de emergência e três baseados em bancos de dados. Indivíduos com menos de 40 anos, do sexo masculino foram os mais acometidos e as causas principais foram quedas e os acidentes de trânsito, destacando-se os motociclísticos. Conclusão: Estudos epidemiológicos robustos sobre o TCE no Brasil ainda são escassos. Todos os estudos foram retrospectivos e apenas dois apresentaram dados nacionais. Nesse contexto, estudos epidemiológicos de caráter prospectivo que investiguem de forma sistemática os fatores associados ao TCE, são urgentemente recomendados. (AU)

Introduction: Traumatic brain injury (TBI) is the leading cause of death and disability worldwide, especially among young adults. In Brazil, it is estimated that more than one million people live with disabilities due to TBI. Despite the high incidence of TBI and related socioeconomic burden, epidemiological studies are scarce. Objective: To discuss the available evidence regarding the epidemiological profile of Brazilian people victims of TBI. Methods: A literature review was conducted on the SciELO, LILACS and PubMed databases. The terms used were traumatic brain injury and/or epidemiology, and/or Brazil. Original, descriptive and review studies that investigated only one specific cause of TBI, only one level of severity or a specific age group were not included in the current review. Results: Eight retrospective articles published between 1993 and 2015 were included. Five studies were conducted in emergency hospitals and three studies were based on databases records. Men under 40 years old were the most affected group, and the main causes of TBI were falls and traffic accidents, especially involving motorcycle. Conclusion: Sound epidemiological studies on TBI are still rare. All studies included were retrospective and only two reported national data. In this scenario, prospective epidemiological studies that systematically investigate the profile of TBI victims in Brazil are urgently necessary. (AU)

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O trauma raquimedular (TRM) é uma importante causa de incapacidade, sendo constatado uma incidência média de 21 pacientes por milhão de habitantes por ano por uma revisão sistemática realizada nas cinco regiões do pais em. Em Belo Horizonte essa incidência chegou a 26 pacientes por milhão por ano. Trata-se de AFC, 28 anos, que foi encaminhado com urgência para o Hospital João XXIII com história de agressão por arma branca (um facão) na região supra clavicular esquerda no dia 22/10. Ao exame neurológico o paciente encontrava-se consciente, orientado e com hemiplegia á esquerda. Anestesia tátil e vibratória á esquerda (lesão do trato corticoespinhal e fascículo grácil e cuneiforme) e preservada á direita, além de anestesia térmica/dolorosa contralateral a hemissecção (lesão do trato espinotalâmico), que configuram a síndrome de Brown Sequard completa. Foi realizada tomografia computadorizada da coluna que evidenciou fratura de lâmina de T1. A ferida lacerante foi suturada e paciente manteve quadro estável por 5 dias. Após 7 dias da admissão hospitalar constatou-se anisocoria com pupila miótica à esquerda eptose de pálpebra também a esquerda, que configura a síndrome de Horner concomitantemente. Foi realizada punção lombar constatando liquor hemorrágico e com alta celularidade, iniciado antibioticoterapia com Meropenem e Vancomicina. Relata-se a correlação anátomoclínica de paciente vitima de TRM aberto, com síndromes associadas, de hemissecção medular e Horner. Ressalta-se a importância dos conhecimentos em neuroanatomia. (AU)

Spinal cord trauma is an important cause of disability, with an average incidence of 21 patients per million inhabitants per year by a systematic review in the five regions of Brazil. In Belo Horizonte, this incidence reached 26 patients per million per year. This is the AFC, 28 years old, who was referred urgently to the Hospital João XXIII with a history of white-collar aggression (a machete) in the left supraclavicular region on 22/10. At the neurological examination the patient was conscious, oriented and with left hemiplegia. Tactile and vibratory anesthesia to the left (lesion of the corticospinal tract and gracile and cuneiform fasciculus) and preserved to the right, in addition to thermal / painful anesthesia contralateral to the hemisection (lesion of the spinothalamic tract), which constitute the complete Brown Sequard syndrome. Computed tomography of the spine was performed, showing a T1 fracture. The lacerating wound was sutured and patient maintained stable frame for 5 days. After 7 days of hospital admission, anisocoria was observed with miotic pupil on the left and ptosis of the eyelid also on the left, which configures Horner syndrome concomitantly. A lumbar puncture was performed, confirming hemorrhagic and high cellularity, and antibiotic therapy with Meropenem and Vancomycin. The anatomic-clinical correlation of a patient with open MTR with associated syndromes of medullary and Horner hemisection is reported. The importance of knowledge in neuroanatomy is emphasized. (AU)

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Burkitt's lymphoma (BL) is a highly aggressive B cell non-Hodgkin lymphoma. Although dural metastases are relatively frequent in malignancies, they are rarely associated with subdural hematoma (SDH). We present a case of subdural effusion secondary to dural metastases from Burkitt's lymphoma.

O linfoma de Burkitt é um linfoma Linfoma não Hodgkin de células B altamente agressivo. Embora a presença de infiltração meninges seja relativamente comum no contexto de neoplasias malignas o surgimento de hematoma subdural secundários é evento raro. Será relatado caso de coleção subdural secundaria a metástases dural de linfoma de Burkitt que apresentou-se radiologicamente semelhante a hematoma subdural em fase subaguda.

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Medulloblastoma is the most common central nervous system tumor in children. Extraaxial medulloblastomas, especially tumors with no connection to the brain stem or cerebellum are extremely rare. We report a case of a 3-year-old patient, who presented with a history of subacute headache and vomiting. After performing a head computed tomography scan, a mass was detected in the left cerebello-pontine angle, along with concomitant hydrocephalus. The treatment was total resection of the tumor. Despite the fact that extra-axial medulloblastomas are extremely rare, this differential diagnosis should be included in the management of pediatric patients who present with posterior fossa tumors.

Meduloblastoma é o tumor do sistema nervoso central mais comum em crianças. Meduloblastomas extra-axiais, especialmente tumores sem conexão com o tronco encefálico ou cerebelo, são extremamente raros. Relatamos o caso de uma paciente de 3 anos de idade, que apresentou um histórico de cefaleia subaguda e vômitos. Por meio de um exame de tomografia computadorizada, foi identificada uma massa no ângulo ponto-cerebelar esquerdo, acompanhada de hidrocefalia. O tratamento foi resseção total do tumor. Apesar de meduloblastomas extra-axiais serem extremamente raros, este diagnóstico diferencial deve ser incluído no manejo de pacientes pediátricos que apresentem tumores da fossa posterior.

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A punção liquórica cervical lateral no espaço C1-C2 foi descrita a partir de uma modificação da técnica utilizada para cordotomia percutânea anterolateral. Neste artigo, é descrita uma série de 14 pacientes vítimas de trauma, submetidos à punção liquórica cervical lateral. Todos os procedimentos foram realizados para pesquisa de meningite bacteriana. Presença de escara lombar e occipital, fratura instável de coluna vertebral, tração ou imobilização ortopédica e ventilação mecânica controlada foram os principais motivos para se optar pela punção liquórica cervical lateral. A taxa de sucesso foi de 93%. Não foram evidenciadas maiores complicações per ou pósprocedimento. A punção liquórica cervical lateral se mostrou um método eficaz para obtenção de líquor em pacientes vítimas de trauma, pois não requer mudança de decúbito ou angulação da cabeceira, o que evita complicações em pacientes entubados e com fratura instável de coluna vertebral. Estudos prévios sugerem que a punção liquórica cervical lateral deve ser o método de escolha em pacientes vítimas de trauma com restrição de mobilização.

The lateral cervical spinal puncture at C1-C2 was described from a modification of the technique used for percutaneous anterolateral cordotomy. In this article, we describe a series of 14 patients of multiple trauma victims who underwent lateral cervical spinalpuncture. All procedures were performed as a screening for bacterial meningitis. Low back and occipital ulcer, unstable spinal fractures, orthopedic traction or immobilization and ventilated patients were the main reasons to opt for the lateral cervical spinal puncture over standard techniques of liquor puncture. The success rate was 93%. There was not major complication per or post procedural. The lateral cervical spinal puncture proved to be an effective method of obtaining liquor in victims of trauma because it does not requires changing position or rotation of the head, preventing complications in patients with orotraqueal tube and unstable spinal fractures. Previous studies suggest that the lateral cervical spinal puncture should be the method of choice in trauma patients with restriction of mobilization.

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