Clinico-radiological related to early brain death factors

OBJECTIVE

To identify clinical and radiological factors associated to early evolution to brain death (BD), defined as occurring within the first 24 h.

DESIGN

A retrospective cohort study was made covering the period 2015-2017.

SETTING

An adult Intensive Care Unit (ICU).

PATIENTS/METHODS

Epidemiological, clinical and imaging (CT scan) parameters upon admission to the ICU in patients evolving to BD.

RESULTS

A total of 166 patients with BD (86 males, mean age 62.7 years) were analyzed. Primary cause: intracerebral hemorrhage 42.8%, subarachnoid hemorrhage 18.7%, traumatic brain injury 17.5%, anoxia 9%, stroke 7.8%, other causes 4.2%. Epidemiological data: arterial hypertension 50%, dyslipidemia 34%, smoking 33%, antiplatelet medication 21%, alcoholism 19%, anticoagulant therapy 15%, diabetes 15%. The Glasgow Coma Score (GCS) upon admission was 3 in 68.8% of the cases in early BD versus in 38.2% of the cases in BD occurring after 24 h (p = 0.0001). Eighty-five patients presented supratentorial hematomas with a volume of 90.9 ml in early BD versus 82.7 ml in BD > 24 h (p = 0.54). The mean midline shift was 10.7 mm in early BD versus 7.8 mm in BD > 24 h (p = 0.045). Ninety-one patients presented ventriculomegaly and 38 additionally ependymal transudation (p = 0.021). Thirty-six patients with early BD versus 24 with BD > 24 h presented complete effacement of basal cisterns (p = 0.005), sulcular effacement (p = 0.013), loss of cortico-subcortical differentiation (p = 0.0001) and effacement of the suprasellar cistern (p = 0.005). The optic nerve sheath measurements showed no significant differences between groups.

CONCLUSIONS

Early BD (>24 h) was associated to GCS < 5, midline shift, effacement of the basal cisterns, cerebral sulci and suprasellar cistern, and ependymal transudation.

Clinico-radiological related to early brain death factors

OBJECTIVE

To identify clinical and radiological factors associated to early evolution to brain death (BD), defined as occurring within the first 24 hours.

DESIGN

A retrospective cohort study was made covering the period 2015-2017.

SETTING

An adult Intensive Care Unit (ICU).

PATIENTS/METHODS

Epidemiological, clinical and imaging (CT scan) parameters upon admission to the ICU in patients evolving to BD.

RESULTS

A total of 166 patients with BD (86 males, mean age 62.7 years) were analyzed. Primary cause: intracerebral hemorrhage 42.8%, subarachnoid hemorrhage 18.7%, traumatic brain injury 17.5%, anoxia 9%, stroke 7.8%, other causes 4.2%. Epidemiological data: arterial hypertension 50%, dyslipidemia 34%, smoking 33%, antiplatelet medication 21%, alcoholism 19%, anticoagulant therapy 15%, diabetes 15%. The Glasgow Coma Score (GCS) upon admission was 3 in 68.8% of the cases in early BD versus in 38.2% of the cases in BD occurring after 24 h (p = 0.0001). Eighty-five patients presented supratentorial hematomas with a volume of 90.9 ml in early BD versus 82.7 ml in BD >24 h (p = 0.54). The mean midline shift was 10.7 mm in early BD versus 7.8 mm in BD >24 h (p = 0.045). Ninety-one patients presented ventriculomegaly and 38 additionally ependymal transudation (p = 0.021). Thirty-six patients with early BD versus 24 with BD >24 h presented complete effacement of basal cisterns (p = 0.005), sulcular effacement (p = 0.013), loss of cortico-subcortical differentiation (p = 0.0001) and effacement of the suprasellar cistern (p = 0.005). The optic nerve sheath measurements showed no significant differences between groups.

CONCLUSIONS

Early BD (>24 h) was associated to GCS < 5, midline shift, effacement of the basal cisterns, cerebral sulci and suprasellar cistern, and ependymal transudation.

Prospective multicentre study of rectal carriage of multidrug-resistant Enterobacteriaceae among health-care workers in Spain

OBJECTIVES

To investigate the rectal carriage of multidrug-resistant Enterobacteriaceae (colistin-resistant, extended-spectrum β-lactamase (ESBL) -producers and/or carbapenemase-producers) among health-care workers (HCWs) from six Spanish hospitals.

METHODS

Rectal swabs from 258 HCWs, employed in intensive care units, haematology wards and clinical microbiology laboratories from six hospitals in northern Spain were studied. They were cultured in selective media for Gram-negative resistant bacteria. Detection of antimicrobial resistance genes and multilocus sequence typing were performed by PCR and further sequencing. A questionnaire including data related to risk factors of colonization/infection by resistant bacteria (age, gender, chronic diseases, immunosuppressive therapies, invasive procedures or antimicrobial treatments) was given to each participant.

RESULTS

No carbapenemase-producing Enterobacteriaceae were recovered. However, 8/258 HCWs (3.1%) were positive for ESBL-producing isolates. This rate was not higher than the colonization rate previously reported in Spain for healthy people in the community. Five isolates showed high-level resistance to colistin (MICs ranging from 8 to 128 mg/L) but all of them were negative for the mcr genes tested. No statistically significant risk factors for gut colonization by ESBL-producing or colistin-resistant Enterobacteriaceae were identified among the HCWs participating in the study.

CONCLUSIONS

Our data suggest that working in hospitals does not represent a risk for rectal carriage of multidrug-resistant Enterobacteriaceae.

Syndrome and outcome of antibody-negative limbic encephalitis

BACKGROUND AND PURPOSE

The aim was to report the clinical characteristics of 12 patients with limbic encephalitis (LE) who were antibody-negative after a comprehensive immunological study.

METHODS

The clinical records of 163 patients with LE were reviewed. Immunohistochemistry on rat brain, cultured neurons and cell-based assays were used to identify neuronal autoantibodies. Patients were included if (i) there was adequate clinical, cerebrospinal fluid (CSF) and magnetic resonance imaging information to classify the syndrome as LE, (ii) magnetic resonance images were accessible for central review and (iii) serum and CSF were available and were confirmed negative for neuronal antibodies.

RESULTS

Twelve (7%) of 163 LE patients [median age 62 years; range 40-79; 9 (75%) male] without neuronal autoantibodies were identified. The most frequent initial complaints were deficits in short-term memory leading to hospital admission in a few weeks (median time 2 weeks; range 0.5-12). In four patients the short-term memory dysfunction remained as an isolated symptom during the entire course of the disease. Seizures, drowsiness and psychiatric problems were unusual. Four patients had solid tumors (one lung, one esophagus, two metastatic cervical adenopathies of unknown primary tumor) and one chronic lymphocytic leukemia. CSF showed pleocytosis in seven (58%) with a median of 13 white blood cells/mm³ (range 9-25). Immunotherapy included corticosteroids, intravenous immunoglobulins and combinations of both drugs or with rituximab. Clinical improvement occurred in six (54%) of 11 assessable patients.

CONCLUSIONS

Despite the discovery of new antibodies, 7% of LE patients remain seronegative. Antibody-negative LE is more frequent in older males and usually develops with predominant or isolated short-term memory loss. Despite the absence of antibodies, patients may have an underlying cancer and respond to immunotherapy.

Infectious complications related to external ventricular shunt. Incidence and risk factors

OBJECTIVE

Infectious complications related to external ventricular shunt (ICREVS) are a main problem in neurocritical intensive care units (ICU). The aim of the review is to assess the incidence of ICREVS and to analyse factors involved.

METHODS

Retrospective analysis, adult polyvalent ICU in a third level reference hospital. Patients carrying external ventricular shunt (DVE) were included. Those patients with central nervous system infection diagnosed prior DVE placement were excluded.

RESULTS

87 patients were included with 106 DVE. Most common admittance diagnosis was subarachnoid haemorrhage (49.4%). 31 patients with 32 DVE developed an ICREVS. Infection rate is 19.5 per 1000 days of shunt for ICREVS and 14 per 1000 days for ventriculitis. 31.6% of the patients developed ICREVS and 25.3% ventriculitis. Patients who developed ICREVS presented higher shunt manipulations (2.0 ± 0.6 vs. 3.26 ± 1.02, p=0.02), shunt repositioning (0.1 ± 0.1 vs. 0.2 ± 0.1) and ICU and hospital stay (29.8 ± 4.9 vs 49.8 ± 5.2, p<0.01 y 67.4 ± 18.8 vs. 108.9 ± 30.2, p=0.02. Those DVE with ICREVS were placed for longer not only at infection diagnosis but also at removal (12.6 ± 2.1 vs. 18.3 ± 3.6 and 12.6 ± 2.1 vs. 30.4 ± 7.3 days, p<0.01). No difference in mortality was found.

CONCLUSIONS

One out of three patients with a DVE develops an infection. The risk factors are the number of manipulations, repositioning and the permanency days. Patients with ICREVS had a longer ICU and hospital average stay without an increase in mortality.

[Epidemiological surveillance for multidrug-resistant microorganisms in a general ICU]

OBJECTIVE

Multidrug resistant (MDR) microorganisms represent a threat for patients admitted in Intensive Care Units (ICUs). The objective of the present study is to analyse the results of epidemiological surveillance cultures for these microorganisms in one of these units.

METHODS

General ICU. Retrospective analysis, descriptive statistics. Analysis of epidemiological surveillance cultures for MDR microorganisms in 2015. Studied microorganisms: Methicillin-resistant Staphylococcus aureus (MRSA), ESBL-and/or carbapenemase-producing Klebsiella pneumoniae (CESBL-KP) and MDR Acinetobacter baumannii (MDRAB).

RESULTS

One thousand, two hundred and fifty nine patients admitted. A total of 2,234 specimens from 384 patients were analysed (690, 634, 62 and 286 were rectal, throat, nasal and skin swabs respectively). Global APACHE II was 18.3 ± 8 versus 21.7 ± 7.8 in patients colonized/infected on admission. Global mortality was 19.7% versus 22.3% in patients colonized/infected on admission. The higher sensitivities achieved with the different samples for the different microorganism detection were as follows. MRSA: 79% and 90% for nasal and nasal + throat swabs, respectively. MDRAB: 80% and 95% for throat and throat + rectal swabs, respectively. CESBL-KP: 95% and 98% for rectal and rectal + throat swabs, respectively. 94 out of the 384 patients (24.4%) were colonized/infected with MDR at admission. 134 patients (10.6% of the total patients admitted) were colonized/infected with a total of 169 MMR during the hospital stay. MRSA has the earliest colonization/infection (9.2 ± 6.4days) and ESBL-producing Enterobacteriaceae, the latest (18.7± 16.4 days).

CONCLUSIONS

24.4% of patients were colonized/infected by MDR at admission. Nasal, throat and rectal swabs were the most effective specimens for recovering MRSA, MDRAB and CESBL-KP, respectively. The combination of two specimens improves MDR detection except for CESBL-KP. Skin swabs are worthless. The most prevalent MDR at admission were ESBL-producing Enterobacteriaceae while the most frequent hospital acquired MDR was MDRAB..

Evaluation of a real-time PCR assay for rectal screening of OXA-48-producing Enterobacteriaceae in a general intensive care unit of an endemic hospital

Carbapenemase-producing Enterobacteriaceae are increasing worldwide. Rectal screening for these bacteria can inform the management of infected and colonized patients, especially those admitted to intensive care units (ICUs). A laboratory developed, qualitative duplex real-time polymerase chain reaction assay for rapid detection of OXA-48-like and VIM producing Enterobacteriaceae, performed on rectal swabs, was designed and evaluated in an intensive care unit with endemic presence of OXA-48. During analytical assay validation, no cross-reactivity was observed and 100% sensitivity and specificity were obtained for both bla_OXA-48-like and bla_VIM in all spiked clinical samples. During the clinical part of the study, the global sensitivity and specificity of the real-time PCR assay for OXA-48 detection were 95.7% and 100% (P=0.1250), respectively, in comparison with culture; no VIM-producing Enterobacteriaceae were detected. Clinical features of patients in the ICU who were colonized or infected with OXA-48 producing Enterobacteriaceae, including outcome, were analyzed. Most had severe underlying conditions, and had risk factors for colonization with carbapenemase-producing Enterobacteriaceae before or during ICU admission, such as receiving previous antimicrobial therapy, prior healthcare exposure (including long-term care), chronic disease, immunosuppression and/or the presence of an intravascular catheter and/or mechanical ventilation device. The described real-time PCR assay is fast (~2-3hours, if DNA extraction is included), simple to perform and results are easy to interpret, features which make it applicable in the routine of clinical microbiology laboratories. Implementation in endemic hospitals could contribute to early detection of patients colonized by OXA-48 producing Enterobacteriaceae and prevention of their spread.

Anti-Ma and anti-Ma2-associated paraneoplastic neurological syndromes

OBJECTIVE

Analyse the clinical profile, associated tumour types, and response to treatment of paraneoplastic neurological syndromes associated with antibodies against Ma proteins.

METHODS

A retrospective study of patients with antibodies against Ma proteins identified in a neuroimmunology laboratory of reference.

RESULTS

Of the 32 patients identified, 20 showed reactivity against Ma2 only (anti-Ma2 antibodies), 11 against Ma1 and Ma2 (anti-Ma antibodies), and 1 with reactivity against Ma1 only (anti-Ma1 antibodies). The most common clinical presentations were limbic encephalopathy, diencephalic dysfunction, or brainstem encephalopathy, frequently appearing as a combination of these features. Three patients had isolated cerebellar dysfunction with anti-Ma antibodies, and 2 exhibited peripheral nervous system syndrome with anti-Ma2 antibodies. Testicular tumours were the most common neoplasms (40%) in the anti-Ma2 cases. In the group associated with anti-Ma1 antibodies, the most common were lung tumours (36%), followed by testicular tumours. All idiopathic cases were reactive to Ma2. The clinical outcome was significantly better in the anti-Ma2 group. The patient with anti-Ma1 presented with limbic encephalitis and brainstem dysfunction associated with lymphoepithelioma of the bladder.

CONCLUSIONS

Specifically determining the different reactivities of anti-Ma protein antibodies in order to differentiate between Ma1 and Ma2 antibodies is important because anti-Ma2-associated paraneoplastic syndromes have a better outcome. Lastly, this study is the first to confirm that there may be cases that react exclusively to antibodies against Ma1.

Quantitative prediction of photoluminescence quantum yields of phosphors from first principles

The first quantitative prediction of the photoluminescence quantum yields (PLQY) of a series of blue-to-green Ir(iii) complexes is presented.

Optimizing the photoluminescence quantum yields of Ir(iii) complexes is the key to their application as phosphors in organic light-emitting diodes (OLEDs). This work demonstrates for the first time that quantitative predictions of photoluminescence quantum yields (PLQY) in a series of blue-to-green Ir(iii) complexes can be derived exclusively from electronic structure calculations.

[Visitation policy, design and comfort in Spanish intensive care units]

OBJECTIVE

To determine the design and comfort in the Intensive Care Units (ICUs), by analysing visiting hours, information, and family participation in patient care.

DESIGN

Descriptive, multicentre study.

SETTING

Spanish ICUs.

METHODS

A questionnaire e-mailed to members of the Spanish Society of Intensive Care Medicine, Critical and Coronary Units (SEMICYUC), subscribers of the Electronic Journal Intensive Care Medicine, and disseminated through the blog Proyecto HU-CI.

RESULTS

A total of 135 questionnaires from 131 hospitals were analysed. Visiting hours: 3.8% open 24h, 9.8% open daytime, and 67.7% have 2 visits a day. Information: given only by the doctor in 75.2% of the cases, doctor and nurse together in 4.5%, with a frequency of once a day in 79.7%. During weekends, information is given in 95.5% of the cases. Information given over the phone 74.4%. Family participation in patient care: hygiene 11%, feeding 80.5%, physiotherapy 17%. Personal objects allowed: mobile phone 41%, computer 55%, sound system 77%, and television 30%. Architecture and comfort: all individual cubicles 60.2%, natural light 54.9%, television 7.5%, ambient music 12%, clock in the cubicle 15.8%, environmental noise meter 3.8%, and a waiting room near the ICU 68.4%.

CONCLUSIONS

Visiting policy is restrictive, with a closed ICU being the predominating culture. On average, technological communication devices are not allowed. Family participation in patient care is low. The ICU design does not guarantee privacy or provide a desirable level of comfort.

Intensive care practices in brain death diagnosis and organ donation

We conducted a multicentre study of 1844 patients from 42 Spanish intensive care units, and analysed the clinical characteristics of brain death, the use of ancillary testing, and the clinical decisions taken after the diagnosis of brain death. The main cause of brain death was intracerebral haemorrhage (769/1844, 42%), followed by traumatic brain injury (343/1844, 19%) and subarachnoid haemorrhage (257/1844, 14%). The diagnosis of brain death was made rapidly (50% in the first 24 h). Of those patients who went on to die, the Glasgow Coma Scale on admission was ≤ 8/15 in 1146/1261 (91%) of patients with intracerebral haemorrhage, traumatic brain injury or anoxic encephalopathy; the Hunt and Hess Scale was 4-5 in 207/251 (83%) of patients following subarachnoid haemorrhage; and the National Institutes of Health Stroke Scale was ≥ 15 in 114/129 (89%) of patients with strokes. Brain death was diagnosed exclusively by clinical examination in 92/1844 (5%) of cases. Electroencephalography was the most frequently used ancillary test (1303/1752, 70.7%), followed by transcranial Doppler (652/1752, 37%). Organ donation took place in 70% of patients (1291/1844), with medical unsuitability (267/553, 48%) and family refusal (244/553, 13%) the main reasons for loss of potential donors. All life-sustaining measures were withdrawn in 413/553 of non-donors (75%).

Intensive care medicine and organ donation: exploring the last frontiers?

The main, universal problem for transplantation is organ scarcity. The gap between offer and demand grows wider every year and causes many patients in waiting list to die. In Spain, 90% of transplants are done with organs taken from patients deceased in brain death but this has a limited potential. In order to diminish organ shortage, alternative strategies such as donations from living donors, expanded criteria donors or donation after circulatory death, have been developed. Nevertheless, these types of donors also have their limitations and so are not able to satisfy current organ demand. It is necessary to reduce family denial and to raise donation in brain death thus generalizing, among other strategies, non-therapeutic elective ventilation. As intensive care doctors, cornerstone to the national donation programme, we must consolidate our commitment with society and organ transplantation. We must contribute with the values proper to our specialization and try to reach self-sufficiency by rising organ obtainment.

Cranioplasty with bandaging. New forms of limitation of life support and organ donation

Most of transplanted organs are obtained from brain death (BD) donors. In neurocritical patients with catastrophic injuries and decompressive craniectomy (DC), which show a dreadful development in spite of this treatment, DC could be a futile tool to avoid natural progress to BD. We propose if cranial compressive bandage (cranioplasty with bandage) could be an ethically correct practice, similar to other life-sustaining treatment limitation (LSTL) common methods. Based on a clinical case, we contacted with the Assistance Ethics Committee and some bioethics professionals asking them two questions: 1) Is ethically correct to perform a cranioplasty with bandage in those patients with LSTL indication? 2) Thinking in organ donation possibility, is this option preferable? Conclusions 1) Cranioplasty with bandage could be considered an ethically acceptable LSTL practice, similar to other procedures. 2) It facilitates organ donation for transplant, which provides value-added because of its own social good. 3) In these cases, it is necessary to know previous patient's will or, in absentia, to obtain family consent after a detailed procedure report.

Continuously evaluating performance in deceased donation: the Spanish quality assurance program

The Spanish Quality Assurance Program applied to the process of donation after brain death entails an internal stage consisting of a continuous clinical chart review of deaths in critical care units (CCUs) performed by transplant coordinators and periodical external audits to selected centers. This paper describes the methodology and provides the most relevant results of this program, with information analyzed from 206,345 CCU deaths. According to the internal audit, 2.3% of hospital deaths and 12.4% of CCU deaths in Spain yield potential donors (clinical criteria consistent with brain death). Out of the potential donors, 54.6% become actual donors, 26% are lost due to medical unsuitability, 13.3% due to refusals to donation, 3.1% due to maintenance problems and 3% due to other reasons. Although the national pool of potential donors after brain death has progressively decreased from 65.2 per million population (pmp) in 2001 to 49 pmp in 2010, the number of actual donors after brain death has remained at about 30 pmp. External audits reveal that the number of actual donors could be 21.6% higher if all potential donors were identified and preventable losses avoided. We encourage other countries to develop similar comprehensive approaches to deceased donation performance.

Is there progressive cognitive dysfunction in Sjögren Syndrome? A preliminary study

OBJECTIVE

The aim of this study was to determine the progression of cognitive dysfunction in primary Sjögren Syndrome (SS).

METHODS

Twelve subjects with SS were compared with ten subjects with migraine and ten healthy controls on neuropsychological, mood and fatigue tests at baseline and 8 years later.

RESULTS

At follow-up, SS subjects performed below subjects with migraine on the Continuous Performance Test (CPT) but did not differ on other tasks. Compared with controls, both clinical groups obtained lower scores on simple reaction time, patients with SS obtained lower scores on the Wisconsin Card Sorting Test (WCST) and patients with migraine performed below controls on the Benton's Judgment of Line Orientation Test (JOLO). Clinical groups did not differ on cognitive changes over time, except that migraine subjects improved on verbal fluency. Compared with baseline, both SS and migraine patients were more impaired on simple reaction time, Trail Making Test part B, Stroop and JOLO. However, they showed higher scores on verbal and visual memory, WCST and CPT reaction time. SS also showed higher levels of depression and fatigue than migraine and controls, with no significant changes over time.

DISCUSSION

Preliminary evidence indicates some cognitive deficits in both SS and migraine following a pattern of fronto-subcortical dysfunction without a significant cognitive decline over time.

Liver transplantation complications in the intensive care unit and at 6 months

OBJECTIVE

This study sought to determine the factors that influence the 6-month outcomes of liver transplants.

PATIENTS AND METHODS

One hundred ninety-six variables (donor, recipient, operation, intensive care unit [ICU], evolution at 3 and 6 months) were collected from the first 74 consecutive liver transplantation performed from 2002 to 2004. The primary endpoint was patient survival at 6 months. The statistical analysis included a screening univariate analysis followed by a stepwise logistic regression with forward inclusion to test independent associations and finally generation of receiver-operator characteristic (ROC) curves to evaluate predictive factors.

RESULTS

Patient survival at 6 months was 86%, namely 10 deaths, including 4 intraoperatively and 6 postoperatively due to sepsis. Complications in the ICU were classified as reoperations due to biliary problems, vascular complications, and peritonitis. Late complications included 51% rejection episodes, 24% infections, 11% pleural effusions, and 16% diabetes mellitus. Logistic regression analysis showed independent negative predictors of survival were the number of packed red cells during transplantation, the number of fresh frozen plasma units administered in the ICU, blood urea nitrogen (BUN) concentration in the ICU, and graft complications. The odds ratios of these variables were 10.2, 5.2, 42.1, and 36.9, respectively. The area under the curve (AUC) of the ROC was 0.99; the sensitivity was 94%; and the specificity was 100%. The independent predictors of surgical complications were the length of the operation, the need for pressor support, and the number of fresh frozen plasma units administered in the operating room, with odds ratios of 1.0, 7.7, and 1.1, respectively.

CONCLUSION

This study revealed specific operative and ICU variables that correlated with the evolution of our patients.

Metabolic syndrome and resistance to IV thrombolysis in middle cerebral artery ischemic stroke

OBJECTIVE

The metabolic syndrome (MetS) is a cluster of vascular risk factors associated with a prothrombotic state. We aimed to evaluate the impact of MetS on the response to systemic tPA treatment in patients with acute middle cerebral artery (MCA) ischemic stroke.

METHODS

We studied 100 consecutive patients with ischemic stroke with MCA occlusions on prebolus transcranial Doppler (TCD) examination treated with tPA following SITS-MOST criteria. MetS was diagnosed following AHA/NHLBI-2005 criteria. Resistance to thrombolysis was defined as the absence of TCD-assessed complete MCA recanalization 24 hours after tPA infusion. Infarct volume was measured on CT scans. Long-term clinical outcome was evaluated by the modified Rankin scale (mRS) score at day 90.

RESULTS

Fifty-eight (58%) patients fulfilled MetS criteria. Median prebolus NIH Stroke Scale score was 17. Forty (42%) patients showed resistance to clot dissolution, and 53 (53%) had poor clinical outcomes (mRS > 2). A multivariable-adjusted logistic regression model identified MetS as independently associated with resistance to thrombolysis (OR 4.7, 95% CI [1.7-13.6], p = 0.004). In the whole sample, MetS was associated with mRS > 2 (OR 2.4 [1.1-5.4], p = 0.03), although this association was no longer significant after multivariable adjustment. However, in patients with atherothrombotic stroke, MetS emerged as an independent predictor of poor long-term outcome (adjusted OR 13.9 [1.3-148.7], p = 0.02).

CONCLUSION

In our series, the metabolic syndrome was associated with a poor response to thrombolysis in patients with acute middle cerebral artery occlusions, as reflected by a higher resistance to clot dissolution.

Diagnóstico de muerte encefálica mediante tomografía computarizada multicorte: angio-TC y perfusión cerebral

BD was diagnosed by clinical examination, electroencephalogram (EEG), Transcranial Doppler (TCD) and multislice CT of 64 detectors. Initially, a brain perfusion study was performed. This was followed by supra-aortic trunk and brain artery angiography with acquisition of images using 0.5 mm slices, from the origin of the aortic root to the vertex. In all the patients, BD diagnosis was verified by clinical examination, EEG and TCD. Brain perfusion never detected brain blood flow. The angioCT through internal carotid arteries and vertebral arteries demonstrated complete absence of intracranial circulation, observing circulation of the external carotid artery branches. Sensitivity and specificity of the method compared with clinical examination was 100%. These findings demonstrate that the study of brain perfusion and brain angiography by multislice CT scan is a rapid and minimally invasive technique, that is easily available and that shows the absence of brain blood flow through the four vascular trunks. This technique makes it possible to made the diagnosis of BD with high diagnostic safety. Its use has special interest in patients with clinical diagnostic difficulty due to treatment with sedative drugs and serious metabolic alterations.

The Bispectral Index Scale: Its Use in the Detection of Brain Death

OBJECTIVE

To evaluate the Bispectral Index Scale (BIS) monitor as a method of brain death (BD) detection.

PATIENTS AND METHODS

We performed an observational prospective study in an intensive care unit (ICU) of a university hospital of 19 patients hospitalized nonconsecutively in the ICU with serious neurologic pathology and evolution toward BD. A BIS monitor, XP model, and the sensor "BIS Quatro" were used to continuously record values: suppression ratio (SR), quality of the signal index, and electromyographic (EMG) activity.

RESULTS

The BD diagnosis was made through neurological clinical exploration and electroencephalogram (EEG) in all the cases. Additionally, transcranial Doppler was used in 13 patients. Coincident with clinical worsening, it was observed that there was a gradual decrease of the BIS value, together with a rise in the SR. In all the patients in which the BD diagnosis was confirmed, the BIS showed values of 0 and suppression rates of 100. Only one patient showed interferences, due to EMG activity, the same problem was detected when a conventional EEG was performing. After using a neuromuscular blocker, the values of BIS and SR were 0 and 100, respectively.

CONCLUSIONS

The BIS is a noninvasive, simple, and easy to interpret method. All the patients with BD diagnosis except for one had a BIS value of 0 and TS of 100, showing a perfect correlation with the other diagnostic methods. The BIS cannot be used on its own for the confirmation of the BD, but it is a useful tool to detect the beginning of brain herniation.

[Diffusion-weighted magnetic resonance in deep cerebral venous thrombosis]

Changes in the apparent diffusion coefficient (ADC) are well established in acute ischemic stroke of arterial origin. However, ADC behaviour and its prognostic significance in cerebral venous thrombosis (CVT) are not fully understood. Diffusion-weighted imaging (DWI) findings in a 34-year old woman with deep cerebral venous thrombosis are described. Recent literature concerning DWI and cerebral venous thrombosis is also reviewed. A MRI performed within 7 hours from onset revealed hyperintensities in deep grey matter bilaterally (FLAIR/T2), without changes in ADC maps, suggesting vasogenic edema. After anticoagulation a new MRA disclosed complete recanalization of venous thrombosis. Despite her good clinical outcome the MRI showed hemorrhagic lesions suggesting venous infarct. Lesions detected in acute CVT with DWI may have normal ADC values. There is no good correlation between the acute ADC values and clinical and radiological evolution. The prognostic value of ADC in the acute phase of CVT remains unsettled.

[Angioplasty for intracranial internal carotid artery stenosis]

INTRODUCTION

Percutaneous transluminal angioplastia has in recent years become an alternative to surgery and increasingly used for revascularization of the extracranial arteries in patients with cerebral ischemia. However, intracranial angioplasty is a technique which is still not widely used since it is technically more difficult and until now endoprotheses (stents) have not been available specifically designed for intracranial territory.

CLINICAL CASE

A 73 year old patient with extensive extracranial and intracranial atheromatous lesions, multiple vascular risk factors and cardiac ischemia which contraindicated surgical treatment which was treated consecutively by angioplasty and angioplasty with implantation of stents in both carotid bifurcations. Subsequently, he was treated by angioplasty for a stenosing lesion of 90% of the right carotid siphon with clinical and hemodynamic repercussions. Following the procedure, which was well-tolerated by the patient, there was clinical and angiographic improvement and return to normal of the hemodynamic parameters measured by transcranial Doppler.

CONCLUSIONS

Angioplasty is a technique which may be used in intracranial stenosing atheromatous lesions. Even without perfect angiographic correction, adequate blood flow is established in the hemodynamically affected lesions. As far as we know this is the first case of intracranial angioplasty of a lesion of the carotid siphon reported in Spain.