RESUMO
OBJECTIVE: This study evaluates care-related sociodemographic, clinical, and imaging factors and influences associated with outcome at discharge in patients with aneurismal subarachnoid haemorrhage. PATIENTS AND METHOD: Retrospective cohort study in 334 patients treated at Hospital Hermanos Ameijeiras in Havana, Cuba between October 2005 and June 2014. RESULTS: Logistic regression analysis determined that the following factors were associated with higher risk of poor outcome: age older than 65 years (OR 3.51, 95% CI 1.79-5.7, P=.031), female sex (OR 2.17, 95% CI 1.22-3.84, P=.0067), systolic hypertension (OR 4.82, 95% CI 2.27-9.8, P=.0001), and hyperglycaemia at admission (OR 3.93, 95% CI 2.10-7.53, P=.0003). Certain complications were also associated with poor prognosis, including respiratory infection (OR 2.73, 95% CI 1.27-5.85, P=.0085), electrolyte disturbances (OR 3.33, 95% CI 1.33-8.28, P=.0073), hydrocephalus (OR 2.21, 95% CI 1.05-4.63, P=.0039), rebleeding (OR 16.50, 95% CI 8.24-41.24, P=.0000), symptomatic vasospasm (OR 19.00, 95% CI 8.86-41.24, P=.0000), cerebral ischaemia (OR 3.82, 95% CI 1.87-7.80, P=.000) and multiplex rebleeding (OR 6.69, 95% CI 1.35-36.39, P=.0019). Grades of iii and iv on the World Federation of Neurological Surgeons (OR 2.09, 95% CI 1.12-3.91, P=.0021) and Fisher scales (OR 5.18, 95% CI 2.65-10.29, P=.0008) were also related to poor outcome. CONCLUSIONS: Outcome of aneurysmal subarachnoid haemorrhage was related to age, sex, clinical status at admission to the stroke unit, imaging findings according to the Fisher scale, blood pressure, glycaemia and such complications as electrolyte disturbances, hydrocephalus, rebleeding, and multiplex rebleeding.
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Índice de Gravidade de Doença , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea/terapia , Fatores Etários , Cuba , Feminino , Humanos , Hiperglicemia , Hipertensão/etiologia , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Prognóstico , Estudos Retrospectivos , Fatores Sexuais , Hemorragia Subaracnóidea/diagnóstico por imagemRESUMO
INTRODUCTION: Symptomatic vasospasm in the setting of a subarachnoid hemorrhage is a complication of difficult diagnosis in some clinical situations. Objectives. Describe the clinical characteristics of cerebral vasospasm demonstrated by neurovascular studies in patients with ruptured saccular aneurysm. PATIENTS AND METHODS: 19 consecutive patients with symptomatic vasospasm, evaluated with TCD and any variant of neurovascular study with contrast injection. All these cases were in degrees between 1 and 3 of the World Federation of Neurological Surgeons Scale. RESULTS: The cognitive and behavioral manifestations were the most frequent (53%), followed by neurological focal deficits (26%). Clinical vasospasm occurred most frequently between day 9 and 10. Vasospasm is predominant in the arteries of the anterior circulation. The high mortality (42%) and the antecedent of arterial hypertension characterized the group with symptomatic vasospasm. There was no statistical relationship between the result of the scale of Fisher and the symptomatic vasospasm. All the TCD parameters had statistical significance. CONCLUSIONS: The clinical manifestations more frequently associated with symptomatic vasospasm were cognitive and behavioral. This group of patients is characterized by a high mortality. The TCD is a test of great value to predict cerebral ischemia due to vasospasm.
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Vasoespasmo Intracraniano/fisiopatologia , Adulto , Comportamento/fisiologia , Isquemia Encefálica/etiologia , Isquemia Encefálica/patologia , Isquemia Encefálica/fisiopatologia , Transtornos Cognitivos/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Vasoespasmo Intracraniano/complicações , Vasoespasmo Intracraniano/diagnóstico , Vasoespasmo Intracraniano/patologiaRESUMO
INTRODUCTION: Patients with subarachnoid haemorrhage should be referred to a tertiary hospital as early as possible. The aim of this research was to study how long these patients take to reach a tertiary care centre in Havana. PATIENTS AND METHODS: We conducted a prospective study of patients with subarachnoid haemorrhage who were admitted to the Stroke Unit at the Hospital Hermanos Ameijeiras between January 2005 and December 2007. The time of arrival at the hospital was determined and a comparison was carried out between patients who arrived after 72 hours and those who reached the hospital sooner. RESULTS: The sample studied comprised 94 patients. Only 34 (36%) arrived during the first three days, whereas 13 (13.8%) reached the hospital within the first 24 hours. None of the sociodemographic and clinical variables that were studied was associated with early remission. The length of time spent in hospital by patients admitted during the first 72 hours was 14.9 days, while in the other cases it was 17.57 days (p = 0.248). The greatest impact on early remission to the tertiary centre was on the outcome at discharge on the Rankin scale, which was lower in those who arrived early compared to the rest of the cases (p = 0.05); the same was true of mortality, which was 5.9% in those who arrived within the first 72 hours versus 11.7% in the others (p = 0.04). CONCLUSIONS: Only a third of the cases reached hospital during the first 72 hours and this group had a more favourable course.
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Diagnóstico Tardio , Hemorragia Subaracnóidea/diagnóstico , Feminino , Hospitais , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Hemorragia Subaracnóidea/epidemiologia , Fatores de TempoRESUMO
INTRODUCTION: During the clinical course of aneurysmal subarachnoid haemorrhage, cerebral vasospasm is one of the most dreaded medical complications. AIM. To determine the usefulness of transcranial Doppler (TCD) ultrasound imaging in diagnosing vasospasm in patients with subarachnoid haemorrhage (SAH) who were attended in a Stroke Unit. PATIENTS AND METHODS: The study included 89 patients with SAH of a non-traumatic origin; these patients had been admitted to a Stroke Unit and were submitted to a contrast-enhanced neurovascular study and daily monitoring with TCD. Values were determined for the sensitivity, specificity, predictive power and overall precision of the TCD ultrasound imaging, together with the differences in mean flow rate and the coefficient of correlation between the gold standard test and the results of monitoring with TCD. RESULTS: Female patients under 50 years of age with favourable initial clinical degrees were predominant. Aneurysmal SAH was prevalent and the frequency of angiographic vasospasm was 40%, in the majority of cases located in the middle cerebral arteries. Most of the patients had mean cerebral blood flow rates of or below 120 cm/s. The peaks of mean blood flow rate were obtained between the fourth and the tenth day. Overall precision, sensitivity and the predictive negative value of TCD were good. Specificity was excellent for flow rates below 130 cm/s, and the predictive positive value was low. CONCLUSIONS: Monitoring with TCD proved to be useful for diagnosing cerebral vasospasm in patients with a good initial clinical status.
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Hemorragia Subaracnóidea/diagnóstico por imagem , Hemorragia Subaracnóidea/diagnóstico , Ultrassonografia Doppler Transcraniana/estatística & dados numéricos , Vasoespasmo Intracraniano/diagnóstico por imagem , Vasoespasmo Intracraniano/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Velocidade do Fluxo Sanguíneo , Circulação Cerebrovascular , Feminino , Humanos , Pessoa de Meia-Idade , Curva ROC , Fluxo Sanguíneo Regional , Reprodutibilidade dos Testes , Hemorragia Subaracnóidea/complicações , Vasoespasmo Intracraniano/etiologiaRESUMO
INTRODUCTION: Paraneoplastic motor neuron disease are rare among patients with renal cell carcinoma. OBJECTIVE: Present the clinical and electrophysiological evolution of a patient with a motor neuron disease and hypernephrome. CASE REPORT: A 60 years old woman, affected only by high level pressure since 10 years ago. She noticed sudden palsy of the left leg and 10 months later an abdominal ultrasound showed a renal cell carcinoma, discovered without other symptoms than neurologic. After radical nephrectnomy, the patient was treated with recombinant interferon alpha 2b. The neurologic damage advanced and she has a flaccid weakness and muscle atrophy in the legs and brisk reflexes, also in wasted limbs. There is Babinski, fasciculations, light flaccid dysarthria and laryngospasm. Peripheral nerve conduction studies are within normal limits. The electromyogram show positive sharp waves in both legs and left hand. Recruitment patterns are decreased and there are fasciculations in the tongue, upper and lower limbs. The magnetic resonance of the brain and spinal cord is normal. There are not evidence of metastasis. The question of whether or not this is a paraneoplastic form of motor neuron disease remain unclear. CONCLUSION: This case suggest the need to consider a renal cell carcinoma in the course of a motor neuron disease.
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Carcinoma de Células Renais/complicações , Neoplasias Renais/complicações , Doença dos Neurônios Motores/complicações , Carcinoma de Células Renais/diagnóstico por imagem , Carcinoma de Células Renais/cirurgia , Eletromiografia , Feminino , Humanos , Neoplasias Renais/diagnóstico por imagem , Neoplasias Renais/cirurgia , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Doença dos Neurônios Motores/diagnóstico por imagem , Doença dos Neurônios Motores/cirurgia , RadiografiaRESUMO
INTRODUCTION: Thymectomy is a well established procedure in myasthenia gravis (MG). To reduce its morbidity, treatments which are effective in the short term, such as plasmapheresis and intravenous immunoglobulin (IGI) have been used. OBJECTIVE: To evaluate the efficacy and tolerability of the IGI, compared with plasmapheresis, in the preparation of myasthenic patients before thymectomy. PATIENTS AND METHODS: We compared a group of 33 prospective myasthenic patients treated with IGI with 38 clinical histories taken as controls treated by plasmapheresis during the peri operative period of thymectomy. RESULTS: The patients treated with IGI were in the intensive care unit and neurology ward for less time. The endotracheal tube was also removed sooner. However, these differences were not significant. The commonest complications of IGI were fever, shivering and phlebitis. The most frequent adverse reaction to plasmapheresis were cutaneous eruptions. One patient developed Hepatitis C after plasmapheresis. CONCLUSION: IGI is comparable in efficacy to plasmapheresis in the peri operative period of MG, but has a better profile of adverse reactions.
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Anti-Inflamatórios/uso terapêutico , Imunoglobulinas Intravenosas/uso terapêutico , Miastenia Gravis/tratamento farmacológico , Miastenia Gravis/cirurgia , Plasmaferese/métodos , Cuidados Pós-Operatórios , Prednisona/uso terapêutico , Cuidados Pré-Operatórios , Timectomia/métodos , Adulto , Feminino , Humanos , Masculino , Resultado do TratamentoAssuntos
Braço , Pênfigo/epidemiologia , Polirradiculoneuropatia Desmielinizante Inflamatória Crônica/epidemiologia , Biópsia , Humanos , Masculino , Pessoa de Meia-Idade , Pênfigo/etiologia , Pênfigo/imunologia , Pênfigo/fisiopatologia , Polirradiculoneuropatia Desmielinizante Inflamatória Crônica/complicações , Polirradiculoneuropatia Desmielinizante Inflamatória Crônica/imunologia , Polirradiculoneuropatia Desmielinizante Inflamatória Crônica/fisiopatologia , Nervo Sural/patologiaRESUMO
INTRODUCTION: Myasthenia gravis is an uncommon disorder with very variable clinical findings. This often leads to errors in diagnosis. OBJECTIVE: To study the main errors leading to false negatives in the diagnosis of myasthenia gravis. PATIENTS AND METHODS: We carried out a questionnaire to determine all the doctors and diagnoses made by them in relation to symptoms of myasthenia graves in 109 patients in whom this diagnosis was later confirmed when a specialist was consulted. RESULTS: Most of the patients went to a general practitioner first. During this initial consultation the disease was only diagnosed in 10 cases (9.2%) and neurosis was the most frequent diagnosis (27.5%). Although most patients had to see from two to four doctors before diagnosis was made, there was no major delay in this. In 84 of the 109 cases the diagnosis was established within the first six months, generally by a neurologist (86.2%) and less frequently by a general physician (11.0%). CONCLUSION: General practitioners, ophthalmologists, psychiatrists and otorhinolaryngologists are often involved in the evaluation of these cases although they made little contribution to the diagnosis.
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Miastenia Gravis/diagnóstico , Adulto , Reações Falso-Negativas , Feminino , Humanos , Masculino , Valor Preditivo dos Testes , Índice de Gravidade de DoençaRESUMO
INTRODUCTION: Thymectomy is a surgical procedure which is generally accepted for treatment of myasthenia gravis. OBJECTIVE: To describe the long-term evolution of 217 myasthenic patients who had had thymectomies in the Hospital Clinico Quirurgico Hermanos Ameijeiras in La Habana, Cuba. PATIENTS AND METHODS: We determined the stage of evolution of 217 patients, followed-up periodically, with an average observation time of 83.4 months and an interval of between 5 and 155 months. We also studied the frequency of remission and the influence of a group of variables on this, as well as the mortality and its causes. RESULTS: The clinical state of the patients was: remission 77 (35.4%); pharmacological remission 45 (20.7%); significant improvement 70 (32.2%); the same or worse 5 (2.3%); deaths 11 (5%), and unknown 9 (4.1%). The cases with thymomas had a more unsatisfactory course than the other patients, with fewer remissions and greater mortality. Over the first five years of the evolution of the disease, there was a 30% rate of remission; after five years this rose to 35-40% and after ten years reached 47%. The age of the patient, duration of symptoms, histology of the thymus, age of onset of the disease and duration of follow-up did not have any significant effect (p < 0.05) on the long-term evolution of the thymectomy, in contrast to the gravity of the condition according to Osserman's scale. CONCLUSION: The results of thymectomy, in our study were good and similar to the results reported in the international literature.
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Miastenia Gravis/cirurgia , Timo/cirurgia , Adulto , Idoso , Cuba/epidemiologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Miastenia Gravis/mortalidade , Prognóstico , Remissão Espontânea , Resultado do TratamentoRESUMO
INTRODUCTION AND OBJECTIVE: To study hemorheological factors in patients with ischemic cerebrovascular disease (not secondary to embolic cardiopathy). PATIENTS AND METHODS: We assessed 40 patients with an average age of 64.5 years; 26 had cerebral infarcts due to alterations in major blood vessels and 14 had lacunar infarcts. Forty persons with no cerebrovascular disease acted as controls. The hematological studies were done between three weeks and six months after the initial ictus. RESULTS: Blood viscosity and plasma fibrinogen concentrations were significantly higher in the patients than in the controls. However, hematocrit values were similar in all three groups studied. With regard to the hematocrit, fibrinogen levels and blood viscosity, no differences were seen between the group with damage to the great vessels and those with lacunar infarcts.
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Isquemia Encefálica/sangue , Doença Aguda , Adulto , Viscosidade Sanguínea/fisiologia , Feminino , Fibrinogênio/análise , Hematócrito , Hemorreologia , Humanos , MasculinoRESUMO
OBJECTIVE: To study the blood levels of a group of lipids and lipoproteins in patients with ischemic cerebrovascular disease which was not secondary to cardiac embolic disease. PATIENTS AND METHODS: We assessed 40 patients of an average age of 64.5 years. Of these, 26 had cerebral infarcts due to disease of the great vessels and 14 had lacunar infarcts. Forty persons with no cerebrovascular disease were used as controls. We excluded patients diagnosed as having renal failure, liver, hematological, neoplastic and acute febrile disorders. Plasma was analyzed for total cholesterol, triglycerides, lipoproteins (a), HDL, LDL, VLDL and apoprotein B between 3 weeks and 6 months after the initial stroke. RESULTS AND CONCLUSIONS: Levels of triglycerides and of lipoprotein (a) were significantly greater in patients than in controls. We found no differences between the levels of total cholesterol, HDL, LDL, VLDL in the three groups studied. However, apoprotein B was greater in the controls than in the patients. There were no significant differences between the groups with lacunar ictus and those with infarcts secondary to disease of the great vessels.
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Isquemia Encefálica/sangue , Lipídeos/sangue , Lipoproteínas/sangue , Idoso , Idoso de 80 Anos ou mais , Apolipoproteínas B/sangue , Isquemia Encefálica/epidemiologia , Infarto Cerebral/sangue , Infarto Cerebral/epidemiologia , Comorbidade , Cuba/epidemiologia , Diabetes Mellitus/epidemiologia , Feminino , Humanos , Hipertensão/epidemiologia , Masculino , Pessoa de Meia-Idade , Grupos Raciais , Estudos Retrospectivos , Fatores de Risco , Fumar/epidemiologiaRESUMO
INTRODUCTION AND CLINICAL CASE: A case of pure alexia, secondary to an occipital cerebral infarct, is presented, which initially appearing with bilateral amaurosis of two hours of duration, following by a significant difficulty to read, and according to patient, was a deficit to near vision and by criteria of ophthalmologists and optometrists was a presbyopia. Authors identified a lack of P-300 wave in study of endogenous component of events related potentials (ERP), to task of phonetic discrimination, and its normal registry to task of graphic discrimination. CONCLUSION: Therefore, we confirm the cliniconeurophysiologic diagnosis of a pure alexia without agraphia, by means of this non-invasive method studying cerebral cognitive process.
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Dislexia Adquirida/diagnóstico , Infarto Cerebral/complicações , Infarto Cerebral/diagnóstico , Dislexia Adquirida/etiologia , Potenciais Evocados , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-IdadeRESUMO
INTRODUCTION: At the beginning of 1992 an epidemic neuropathy was seen in Cuba. MATERIAL AND METHODS: To determine the clinical characteristics we studied the clinical and neurological features, cerebrospinal fluid, and did neurophysiological investigations and sural nerve biopsies. RESULTS: Sixty patients were studied. Of these, 42 (70%) had polyneuropathy which was predominantly peripheral and 18 (30%) had combined forms. Most patients had asthenia and weight loss. The polyneuropathic effects were mainly in the legs. In 33.3% of the patients there were distal autonomic effects and sphincter disorders. Only 7 patients had hypoacusia. However, subclinical neurosensorial hypoacusia was seen in 33.3%. Optic neuropathy affected central vision bilaterally and symmetrically with temporal pallor of the papilla in half the cases. In 3 patients there was loss of ganglionar nerve fibres of the papillo-macula bundle. The contrast sensitivity visual test was abnormal in some patients with peripheral polyneuropathy, showing subclinical optic neuropathy in these cases. Sensory neuroconduction suggested axonal neuropathy in 30 patients, demyelinating neuropathy in 5 patients, while the remainder were normal. Motor neuroconduction was normal in most patients. Sural nerve biopsy of 27 patients showed axon damage in 96.2% of cases. CONCLUSIONS: The clinical picture is similar to that seen in nutritional deficiencies and toxic processes.