The Treatment of Super-Refractory Status Epilepticus

Super-refractory status epilepticus is defined as status epilepticus that continues or recurs 24 h or more after the onset of anaesthetic therapy, including those cases where status epilepticus recurs on the reduction or withdrawal of anaesthesia. It is an uncommon but important clinical problem with high mortality and morbidity rates. This article reviews the treatment approaches. There are no controlled or randomized studies, and so therapy has to be based on clinical reports and opinion. The published world literature on the following treatments was critically evaluated: anaesthetic agents, anti-epileptic drugs, magnesium infusion, pyridoxine, steroids and immunotherapy, ketogenic diet, hypothermia, emergency resective neurosurgery and multiple subpial transection, transcranial magnetic stimulation, vagal nerve stimulation, deep brain stimulation, electroconvulsive therapy, drainage of the cerebrospinal fluid and other older drug therapies. The importance of treating the identifying cause is stressed. A protocol and flowchart for managing super-refractory status epilepticus is suggested. In view of the small number of published reports, there is an urgent need for the establishment of a database of outcomes of individual therapies.

NIH STROKE SCALE (booklet)

Administer stroke scale items in the order listed. Record performance in each category after each subscale exam. Do not go back and change scores. Follow directions provided for each exam technique. Scores should reflect what the patient does, not what the clinician thinks the patient can do. The clinician should record answers while administering the exam and work quickly. Except where indicated, the patient should not be coached (i.e., repeated requests to patient to make a special effort). >>> NIHSS Booklet >>>

Assessment of Current Diagnostic Criteria for Guillain-Barré Syndrome

Diagnostic criteria for Guillain-Barré syndrome (GBS) were devised in 1978 at the request of the National Institute of Neurological and Communicative Disorders and Stroke (NINCDS, now NINDS). The basis for issuing diagnostic criteria related to the swine flu vaccine incident of 1976-1977, which is reviewed in more detail elsewhere in the proceedings of this symposium. At the previous conference on Guillain-Barré syndrome in 1981, clarification of these diagnostic criteria was offered. In the intervening eight years it has become apparent that further comments and elaboration on the diagnostic criteria first stated in 1978 are in order. The reader should recognize that the suggestions made are solely the opinions of the authors and are not officially sanctioned by the NINDS or any neurological societies. The definition of GBS and criteria for diagnosis are reproduced below as they were first published in the Annals of Neurology in 1978. These are followed by a series of comments and suggested modifications.  >>> leia o artigo >>>

Seizure versus syncope

One of the most common but difficult management problems in medicine is that of patients who present with a paroxysmal loss of consciousness. All too often the underlying diagnosis remains elusive. This has a cost both in terms of mortality and ongoing morbidity and in terms of the financial burden associated with hospitalisation and repeated investigations. We describe a practical approach to this clinical dilemma, which is rooted in adherence to basic principles of history talcing and examination, formulation of a reasonable differential diagnosis, followed by an intelligent use of specific investigations and selection of an appropriate treatment. We also discuss the effect of sudden unexpected deadi in epilepsy and sudden cardiac dead». Despite a careful and thorough approach to the patient with a “seizure versus syncope” problem, many will require repeated assessment before a diagnosis is made. >>> leia o artigo >>>

Manuseio crítico de pacientes com hemorragia subaracnóide

Subarachnoid hemorrhage (SAH) is an acute cerebrovascular event which can have devastating effects on the central nervous system as well as a profound impact on several other organs. SAH patients are routinely admitted to an intensive care unit and are cared for by a multidisciplinary team. A lack of high quality data has led to numerous approaches to management and limited guidance on choosing among them. Existing guidelines emphasize risk factors, prevention, natural history, and prevention of rebleeding, but provide limited discussion of the complex critical care issues involved in the care of SAH patients. The Neurocritical Care Society organized an international, multidisciplinary consensus conference on the critical care management ofSAHto address this need. Experts from neurocritical care, neurosurgery, neurology, interventional neuroradiology, and neuroanesthesiology from Europe and North America were recruited based on their publications and expertise. A jury of four experienced neurointensivists was selected for their experience in clinical investigations and development of practice guidelines. Recommendations were developed based on literature review using the GRADE system, discussion integrating the literature with the collective experience of the participants and critical review by an impartial jury. Recommendations were developed using the GRADE system. Emphasis was placed on the principle that recommendations should be based not only on the quality of the data but also tradeoffs and translation into practice. Strong consideration was given to providing guidance and recommendations for all issues faced in the daily management of SAH patients, even in the absence of high quality data.        >>> Leia o artigo

Hemorragia cerebral

Introdução: A hemorragia cerebral intraparenquimatosa é com frequência um dos aspectos mais esquecidos da doença vascular cerebral. Objetivo: Rever a hemorragia intracerebral em diversos aspectos desde a sua epidemiologia e etiologia, assim como a patogenia, clínica, diagnóstico e prognóstico. Métodos. Realizamos uma revisão rigorosa da literatura existente, com especial atenção à publicada nos últimos anos. Foram analisadas as tendências atuais no tratamento médico e cirúrgico da hemorragia intraparenquimatosa e à luz destes dados depreende-se algumas ideias que podem resultar úteis para o seu tratamento. Conclusões: É evidente que existem nestes momentos lacunas importantes no tratamento de vários aspectos da hemorragia cerebral e que deve ser este um campo em que no futuro abundem estudos terapêuticos que venham resolver as grandes incertezas que existe no tratamento desta patologia. [REV NEUROL 2002; 35: 1056-66]  >>> Leia o artigo

Classificação TOAST

A etiologia de AVC isquêmico (AVCI) afeta o prognóstico e seu manuseio. Estudos clínicos de terapias para pacientes com AVCI agudo devem incluir avaliações por subtipo de AVC. Um sistema para classificação dos subtipos de AVCI principalmente com base na etiologia foi desenvolvido para o “Trial of Org 10172 in Acute Stroke Treatment” (TOAST). A classificação dos subtipos foi preparada a partir das características clínicas e resultados de estudos complementares. Diagnósticos “possíveis” e “prováveis” foram feitos com base no grau certeza dos médicos. A concordância inter-observador foi testada por dois neurologistas que não participaram na elaboração dos critérios. Os neurologistas, de forma independente, utilizaram o sistema de classificação TOAST na avaliação de 20 pacientes, primeiramente apenas em aspectos clínicos e, em seguida, depois de analisar os resultados dos exames complementares. A classificação TOAST estabelece cinco subtipos de AVCI: 1) aterosclerose de grande artéria, 2) cardioembolismo, 3) oclusão de pequenos vasos, 4) AVCI de outras etiologias determinadas, e 5) AVCI de etiologia indeterminada. Usando esta classificação, a concordância inter-observador foi muito alta. Na verdade, os dois médicos discordaram em apenas um paciente. Ambos foram capazes de chegar a um diagnóstico etiológico específico nos demais 11 pacientes, enquanto a causa de acidente vascular cerebral não foi determinada em nove. Concluem os autores que a Classificação TOAST é fácil de usar e tem boa concordância entre observadores. A partir deste estudo a Classificação TOAST passou a ser utilizada em diversos estudos sobre AVCI. Leia o artigo na íntegra

 

 

Unidade de AVC – artigos para leitura

Destacado

Artigos importantes que devem ser lidos durante o estágio na Unidade de AVC: