Trastornos del sueño en el traumatismo craneoencefálico

The purpose of the review is to collect the most relevant current literature on the mechanisms of normal sleep and sleep disorders associated with traumatic brain injury (TBI), to discuss the most frequent conditions and the evidence on their possible treatments and future research.Sleep disorders are extremely prevalent after TBI (30-84%). Insomnia and circadian rhythm disorders are the most frequent disorders among the population that has suffered mild TBI, while hypersomnolence disorders are more frequent in populations that have suffered moderate and severe TBI. The syndrome of obstructive sleep apnea and restless leg syndrome are also very frequent in these patients; and patients exposed to multiple TBIs (war veterans) are especially susceptible to sleep disorders. The treatment of these disorders requires taking into account the particularities of these patients.In conclusion, diagnosis and treatment of sleep disorders should become part of routine clinical practice and cease to be anecdotal (as it is today) in patients with TBI. In addition, it is necessary to continue carrying out research that reveals the best therapeutic approach to these patients.     

Rehabilitación de la cognición social en el traumatismo craneoencefálico: una revisión sistemática

IntroductionMany studies have described the presence of difficulty processing and generating social behaviour in patients who have suffered a traumatic brain injury (TBI). These difficulties in social cognition (SC) deteriorate personal relationships in the family, at work, or in the community. However, therapeutic programmes aiming to improve SC continue to be an outstanding issue in clinical practice. We performed a systematic review of the existing literature on the recovery of SC in patients with TBI, assessing the methodological quality of the included studies and the therapeutic effectiveness of the rehabilitation strategies used.DevelopmentWe performed a bibliographic search of papers published before June 2018 in the Medline/PubMed, Google Scholar, PsycINFO, and ClinicalTrials.gov databases. Of the 198 potentially relevant articles, 10 met our eligibility criteria. Two of the authors independently and blindly assessed the methodological quality of these studies using the PEDro scale.ConclusionsThe articles included in this systematic review essentially studied the effect of different interventions aimed at the rehabilitation of SC in patients with chronic TBIs. The analysis showed adequate methodological quality and an acceptable level of evidence. Future research should analyse the effect of these interventions in patients with TBIs in the sub- and post-acute phases.     

Craniectomías descompresivas en el traumatismo craneoencefálico: la visión del intensivista

ObjetiveTo perform a score with early clinical and radiological findings after a TBI that identifies the patients who in their subsequent evolution are going to undergo DC.MethodObservational study of a retrospective cohort of patients who, after a TBI, enter the Neurocritical Section of the Intensive Care Unit of our hospital for a period of 5 years (2014-2018). Detection of clinical and radiological criteria and generation of all possible models with significant, clinically relevant and easy to detect early variables. Selection of the one with the lowest Bayesian Information Criterion and Akaike Information Criterion values for the creation of the score. Calibration and internal validation of the score using the Hosmer-Lemeshow and a bootstrapping analysis with 1,000 re-samples respectively.Results37 DC were performed in 153 patients who were admitted after a TBI. The resulting final model included Cerebral Midline Deviation, GCS and Ventricular Collapse with an Area under ROC Curve: 0.84 (95% IC 0.78-0.91) and Hosmer-Lemeshow p = 0.71. The developed score detected well those patients who were going to need an early DC (first 24 hours) after a TBI (2.5 ± 0.5) but not those who would need it in a later stage of their disease (1.7 ± 0.8). However, it seems to advice us about the patients who, although not requiring an early DC are likely to need it later in their evolution (DC after 24 hours vs do not require DC, 1.7 ± 0.8 vs 1 ± 0.7; p = 0.002).ConclusionWe have developed a prognostic score using early clinical-radiological criteria that, in our environment, detects with good sensitivity and specificity those patients who, after a TBI, will require a DC.     

Reflexiones sobre el uso de la hipotermia moderada en el tratamiento del paciente con un traumatismo craneoencefálico grave

Traumatic brain injury initiates several metabolic processes that can increase the primary injury. It is well established that in severe head injuries, posttraumatic secondary insults, such as brain hypoxia, hypotension or anemia, exacerbate neuronal injury and lead to a poorer outcome. Experimental and clinical evidence suggests that moderate hypothermia (32–34°C), may limit some of these deleterious secondary metabolic responses. Recent laboratory studies and prospective controlled clinical trials of induced moderate hypothermia for relatively short periods (24–48 h) in patients with severe head injury, have demonstrated good intracranial pressure control and better outcome when compared with patients maintained in normothermia and given conventional treatment. Despite its proven clinical role in neuroprotection, hypothermia research has been inconstantly followed for various reasons. In this paper we review the mechanisms of neuroprotection in hypothermia, the different preclinical and clinical studies that favor its use as a neuroprotector in severe head injury or in patients in whom high intracranial pressure is refractory to first tier measures. The evidence that favors hypothermia is discussed. We also discuss the negative results of the still unpublished multicentre trial on prophylactic moderate hypothermia developed in the USA. The main problem with moderate hypothermia is the lack of a systematic methodology to induce and maintain it. Also, optimal duration of its use and the methodology and timing for rewarming have not been determined. Consequently, the results of different trials are difficult to analyze and compare. However, most evidence suggests that hypothermia provides remarkable protection against the adverse effects of neuronal damage that is exacerbated by secondary injury. Further prospective controlled trials with clearly defined methodology are needed before this method is implemented in daily clinical practice. The most important task for the years to come may be to focus on refining this procedure, defining the optimal time of cooling and rewarming and to optimize the methods of rapidly inducing and maintaining Iow temperature. It is also essential to define the most appropriate method and velocity of the rewarming phase, in which many successfully controlled patients deteriorate and die.     

Neumoencéfalo a tensión secundario a ventilación mecánica no invasiva en paciente con traumatismo craneoencefálico grave

The presence of air inside intracranial cavity is a rare entity known as pneumocephalus and in most cases doesńt present any clinical repercussion except in case of elevated intracranial pressure that can lead to a decreasing level of consciousness, coma and even death.We present a rare case of a young male, without medical precedents of interest, hospitalized in an intensive care unit for vigilance after a traffic accident with asymptomatic crane encephalic trauma and cranial computerized tomography without meaningful findings. During the intensive care unit stay positive pressure is applied in airway with non-invasive mechanical ventilation that produces air entrance in cranial cavity (pneumocephalus) causing neurological deterioration and necessity of urgent surgery.     

Validación de la versión en español de la escala de evaluación del trastorno por déficit de atención e hiperactividad (ADHD-RS-IV.es) en una muestra española

ObjectivesThe purpose of this study is to validate a Spanish-language version of the 18-item ADHD Rating Scale-IV (ADHD-RS-IV.es) in a Spanish sample.MethodsFrom a total sample of 652 children and adolescents aged 6 to 17 years (mean age was 11.14 ± 3.27), we included 518 who met the DSM-IV-TR criteria for ADHD and 134 healthy controls. To evaluate the factorial structure, validity, and reliability of the scale, we performed a confirmatory factor analysis (CFA) using structural equation modelling on a polychoric correlation matrix and maximum likelihood estimation. The scale's discriminant validity and predictive value were estimated using ROC (receiver operating characteristics) curve analysis.ResultsBoth the full scale and the subscales of the Spanish-language version of the ADHD-RS-IV showed good internal consistency. Cronbach's alpha was 0.94 for the full scale and ≥ 0.90 for the subscales, and ordinal alpha was 0.95 and ≥ 0.90, respectively. CFA showed that a two-factor model (inattention and hyperactivity/impulsivity) provided the best fit for the data. ADHD-RS-IV.es offered good discriminant ability to distinguish between patients with ADHD and controls (AUC = 0.97).ConclusionsThe two-factor structure of the Spanish-language version of the ADHD-RS-IV (ADHD-RS-IV.es) is consistent with those of the DSM-IV-TR and DSM-5 as well as with the model proposed by the author of the original scale. Furthermore, it has good discriminant ability. ADHD-RS-IV.es is therefore a valid and reliable tool for determining presence and severity of ADHD symptoms in the Spanish population.     

Validación argentino-chilena de la versión en español del test Addenbrooke's Cognitive Examination III para el diagnóstico de demencia

BackgroundThe Addenbrooke's Cognitive Examination III (ACE-III), an adaptation of the ACE cognitive screening test, has been demonstrated to have high sensitivity and specificity in detecting cognitive impairment in patients with dementia and other neurological and psychiatric disorders. Although the Spanish-language version of the ACE-III has already been validated in Spain, it is yet to be validated in Latin America. The aim of this study was to validate the ACE-III test in an Argentinean and Chilean population.MethodsACE-III was administered to 70 patients with Alzheimer disease, 31 patients with behavioural variant frontotemporal dementia, and a control group of 139 healthy volunteers. Participants were recruited at centres in both countries.ResultsThe Spanish-language version of ACE-III was found to have good internal consistency (Cronbach's alpha = 0.87). We found significant differences in total ACE-III scores between patients with Alzheimer disease and controls (p  <  .05) and between patients with Alzheimer disease and bvFTD (p  <  .05). With a cut-off point of 86, 98.6% of AD patients, 83.9% of behavioural variant frontotemporal dementia patients, and 84.2% of controls were correctly classified.ConclusionsThis study shows that the Spanish-language version of ACE-III continues to be an effective tool for detecting cognitive dysfunction in patients with dementia.     

Validación del instrumento Montreal Cognitive Assessment en español en adultos mayores de 60 años

IntroductionFew studies have validated the Spanish-language version of the Montreal Cognitive Assessment (MoCA-S) test in Latin American populations.ObjetiveTo evaluate the psychometric properties and discriminant validity of the MoCA-S in elderly patients in Santiago de Chile.Methods172 individuals were grouped according to their clinical diagnosis based on the Clinical Dementia Rating (CDR) scale as follows: amnestic mild cognitive impairment (aMCI; n ± 24), non-amnestic MCI (naMCI; n ± 24), mild dementia (n ± 20), and cognitively normal (n ± 104). Participants were evaluated with both the MoCA-S and the Mini–Mental State Examination (MMSE) to determine the discriminant validity of the MoCA-S.ResultsMean age and years of schooling were 73 ± 6 and 11 ± 4 years, respectively, with no significant intergroup differences. The MoCA-S displayed good internal consistency (Cronbach's α: 0.772), high inter-rater reliability (Spearman correlation coefficient: 0.846; P<.01), and high intra-rater reliability (test-retest reliability coefficient: 0.922; P<.001). The MoCA-S was found to be an effective and valid test for detecting aMCI (AUC ± 0.903) and mild dementia (AUC ± 0.957); its effectiveness for detecting naMCI was lower (AUC ± 0.629). The optimal cut-off points for aMCI and mild dementia were < 21 and < 20, respectively, with sensitivity and specificity rates of 75% and 82% for aMCI and 90% and 86% for mild dementia. The level of education had a great impact on scores: as a result, 2 points were added for patients with less than 8 years of schooling and one point for patients with 8-12 years of schooling (MoCA-S1-2). The MoCA-S1-2 showed significantly greater discriminant validity than the MMSE for differentiating aMCI from dementia.ConclusionsThe MoCA-S1-2 is a short, easy-to-use, and useful test for diagnosing aMCI and mild dementia.     

Premio Sixto Obrador SENEC 2019: el uso de la secuencia tensor de difusión como herramienta pronóstica en los pacientes con traumatismo craneoencefálico grave y moderado. Parte I. Análisis de las características del tensor de difusión realizado durante la fase subaguda precoz

Background and objectivesTraumatic axonal injury (TAI) contributes significantly to mortality and morbidity after traumatic brain injury (TBI). Its identification is still a diagnostic challenge because of the limitations of conventional imaging techniques to characterized it. Diffusion tensor imaging (DTI) can indirectly identify areas of damaged white matter integrity by detecting water molecule diffusion alterations. Our main objective is to characterize the TAI using DTI at the early subacute stage in our series of moderate to severe TBI patients and to evaluate if there is a relationship between the information provided by the DTI and patient's outcome.Materials and methodsWe have obtained DTI data from 217 patients with moderate to severe TBI acquired at a median of 19 days after TBI, and patient DTI metrics were compared with data obtained from 58 age-matched healthy controls. Region of interest method was applied to obtain mean fractional anisotropy (FA) value in 28 white matter fiber bundles susceptible to TAI.ResultsOur main results were that when we compared patients with controls, patients, regardless of TBI severity, showed significantly reduced mean FA in almost all region of interest measured. We found statistically significant correlation between FA metrics and some clinical characteristics. Additionally, the FA values of the three portions of Corpus callosum, Cingulum and cerebral peduncles measured at the early subacute stage were highly associated with outcome assessed at hospital discharge and at 6 and 12 months after TBI.ConclusionsWe conclude that DTI is a useful tool to characterize TAI and the detection of FA reduction in the subacute stage after TBI is associated with long-term unfavorable outcome.     

Aproximación al conocimiento de las bases genéticas del ictus. Consorcio español de genética del ictus

This article provides an overview of stroke genetics studies ranging from the candidate gene approach to more recent studies by the genome wide association. It highlights the complexity of stroke owing to its different aetiopathogenic mechanisms, the difficulties in studying its genetic component, and the solutions provided to date. The study emphasises the importance of cooperation between the different centres, whether this takes places occasionally or through the creation of lasting consortiums. This strategy is currently essential to the completion of high-quality scientific studies that allow researchers to gain a better knowledge of the genetic component of stroke as it relates to aetiology, treatment, and prevention.