Diffuse axonal injury (DAI), a type of traumatic injury, is known for its severe consequences. However, there are few studies describing the outcomes of DAI and the risk factors associated with it. This study aimed to describe the outcome for patients with a primary diagnosis of DAI 6 months after trauma and to identify sociodemographic and clinical factors associated with mortality and dependence at this time point. Seventy-eight patients with DAI were recruited from July 2013 to February 2014 in a prospective cohort study. Patient outcome was analyzed using the Extended Glasgow Outcome Scale (GOS-E) within 6 months of the traumatic injury. The mean Injury Severity Score was 35.0 (SD = 11.9), and the mean New Injury Severity Score (NISS) was 46.2 (SD = 15.9). Mild DAI was observed in 44.9% of the patients and severe DAI in 35.9%. Six months after trauma, 30.8% of the patients had died, and 45.1% had shown full recovery according to the GOS-E. In the logistic regression model, the severity variables – DAI with hypoxia, as measured by peripheral oxygen saturation, and hypotension with NISS value – had a statistically significant association with patient mortality; on the other hand, severity of DAI and length of hospital stay were the only significant predictors for dependence. Therefore, severity of DAI emerged as a risk factor for both mortality and dependence.

RESUMOO traumatismo cranioencefálico (TCE) é a principal causa de morte e sequela em crianças e adultos jovens nos países industrializados ocidentais. A lesão encefálica definitiva que se estabelece após o TCE é o resultado de mecanismos fisiopatológicos que se iniciam com o acidente e estendem-se por dias ou semanas. As lesões encefálicas no TCE podem ser classificadas em difusas e focais. Esses dois mecanismos costumam associar-se em um mesmo paciente, embora, geralmente exista o predomínio de um tipo. O conhecimento dos mecanismos fisiopatológicos da lesão cerebral no traumatismo cranioencefálico é fundamental para o estabelecimento de medidas terapêuticas clínicas e cirúrgicas. Neste artigo, realizamos uma revisão crítica da literatura sobre os princípios fisiopatológicos da lesão cerebral no paciente com traumatismo cranioencefálico. UNITERMOS FISIOPATOLOGIAA lesão encefálica definitiva que se estabelece após o TCE é o resultado de mecanismos fisiopatológicos que se iniciam com o acidente e se estendem por dias a semanas. Assim, do ponto de vista didático, as lesões cerebrais são classificadas em primárias e secundárias 8 . As lesões primárias são aquelas que ocorrem no momento do trauma. No paciente com ferimentos por projétil de arma de fogo ou arma branca que penetram o crânio, a lesão primária ocorre em virtude do trauma direto ao parênquima encefálico. Por outro lado, nos traumatismos fechados, caracterizados quando não ocorre contato com o conteúdo intracraniano, as lesões primárias podem resultar da movimentação cerebral associada à energia cinética do acidente. Nas lesões decorrentes de forças de aceleração e desaceleração não é necessário o impacto do crânio contra estruturas externas. Como o encéfalo e a caixa craniana possuem densidades diferentes, quando submetidos às mesmas forças inerciais, respondem de forma desigual. Esse descompasso de movimentos pode promover a ruptura de veias cerebrais que desembocam nos seios durais, bem como impacto e laceração do parênquima contra as estruturas rígidas do crânio. Somado a esse mecanismo como a região central do encéfalo é relativamente fixa em virtude da presença do tronco encefálico, as regiões periféricas do cérebro e cerebelo tendem a apresentar maior amplitude de movimento. Essa diferença na amplitude dos movimentos entre a região central e a periférica do encéfalo gera o estiramento de axônios e de vasos sanguíneos cerebrais, o que pode resultar desde uma disfunção temporária até ruptura dessas estruturas 9,10 . As lesões secundárias decorrem de agressões que se iniciam após o momento do acidente, resultantes da interação de fatores intra e extracerebrais, que se somam para inviabilizar a sobrevivência de células encefálicas poupadas pelo trauma inicial. No local do acidente, intercorrências clínicas como hipotensão arterial, hipoglicemia, hipercarbia, hipóxia respiratória, hipóxia anêmica e distúrbios hidroeletrolíticos são os principais fatores de lesão secundária. Posteriormente, são somados outros distúrbios metabólicos e infecciosos sistêmi...

Decompressive craniectomy results in a significant elevation of cerebral BFV in most patients with traumatic brain swelling and transtentorial herniation syndrome. The increase in cerebral BFV may also occur in the side opposite the decompressed hemisphere; the cerebral BFV increase is significantly greater in the operated hemisphere than contralaterally. Concomitantly, PI values decrease significantly postoperatively, mainly in the decompressed cerebral hemisphere, indicating reduction in cerebrovascular resistance.

RESUMO: As alterações do nível de consciência podem variar entre dois extremos, desde uma desorientação têmporo-espacial até um estado de coma profundo. Na prática clínica é extremamente comum o médico se deparar frente a um paciente com alteração do nível de consciência. Em hospitais gerais, estudos indicam o alcoolismo, o traumatismo cranioencefálico e as doenças cardiovasculares como as principais causas de coma (82%). O médico deve saber reconhecer as principais causas de alteração da consciência, seus diagnósticos diferenciais, identifi car o paciente grave e tratar as possíveis alterações emergenciais que possam levar a um dano neurológico secundário. Nesta revisão destacamos os principais pontos no exame neurológico para determinar as diferentes alterações do nível de consciência. DESCRITORES: Coma/diagnóstico. Coma/fi siopatologia. Traumatismos encefálicos/etiologia. Consciência/classifi cação. Diagnóstico diferencial.

BackgroundPneumocephalus (PNC) is defined as a pathological collection of gas within the cranial cavity. The authors studied the effects of hyperbaric oxygenation (HBO2) therapy on a group of patients with PNC, comparing them with a control group to determine the relative impact on pneumocephalus volume, clinical symptoms, and duration of hospitalization.MethodsTwenty-four patients with PNC treated at our hospital were consecutively studied. These patients were divided into a treated group (n=13) and a control group (n=11). Thirteen patients (treated group) were treated with HBO2 therapy sessions in a monoplace hyperbaric chamber at 2.5 atmospheres with 100% oxygen concentration. The control group was treated with normobaric oxygenation.ResultsClinical improvement was seen in all patients. In the treated group, a decrease of the gas bubble was observed on the computerized tomography scan after each session of HBO2. The treated group also experienced a lower rate of meningitis compared with the control group. The length of hospital stay was significantly higher in the control group compared with the treated group.ConclusionsHBO2 therapy in selective cases may lead to clinical and radiological improvement in patients with PNC.

Object The authors present their experience in the management of posterior fossa epidural hematoma (PFEDH), which involved an aggressive diagnostic approach with the extensive use of head computerized tomography (CT) scanning. Methods The authors treated 43 cases of PFEDH in one of the largest health centers in Brazil. Diagnosis was established in all patients with the aid of CT scanning because the clinical manifestations were frequently nonspecific. Cases were stratified by clinical course, Glasgow Coma Scale score, and their radiological status. Based on clinical and radiological parameters the patients underwent surgical or conservative management. Conclusions Compared with outcomes reported in the available literature, good outcome was found in this series. This is primarily due to the broad use of CT scanning for diagnostic and observational purposes, which, in the authors' opinion, led to early diagnosis and prompt treatment.

Abstract:The evaluation of patients in the emergency room department (ER) through more accurate imaging methods such as computed tomography (CT) has revolutionized their assistance in the early 80s. However, despite technical improvements seen during the last decade, surgical planning in the ER has not followed the development of image acquisition methods. The authors present their experience with DICOM image processing as a navigation method in the ER. The authors present 18 patients treated in the Emergency Department of the Hospital das Clínicas of the University of Sao Paulo. All patients were submitted to volumetric CT. We present patients with epidural hematomas, acute/subacute subdural hematomas and contusional hematomas. Using a specific program to analyze images in DICOM format (OsiriX ® ), the authors performed the appropriate surgical planning. The use of 3D surgical planning made it possible to perform procedures more accurately and less invasively, enabling better postoperative outcomes. All sorts of neurosurgical emergency pathologies can be treated appropriately with no waste of time. The three-dimensional processing of images in the preoperative evaluation is easy and possible even within the emergency care. It should be used as a tool to reduce the surgical trauma and it may dispense methods of navigation in many cases.

Results: Overall mortality at 14 days was 22.8%. Models had a high prediction performance, with the best prediction for overall mortality achieved through Naive Bayes (area under the curve = 0.906). The most significant predictors were the GCS at admission and prehospital GCS, age, and pupil reaction. When predicting the length of stay at the intensive care unit, the Conditional Inference Tree model had the best performance (root mean square error = 1.011), with the most important variable across all models being the GCS at scene.Conclusions: Models for early mortality and hospital length of stay using Machine Learning can achieve high performance when based on registry data even in LMICs. These models have the potential to inform treatment decisions and counsel family members.Level of evidence: This observational study provides a level IV evidence on prognosis after TBI.