Both stroke and depression are major health problems in the elderly. In this study, the prevalence of major depression after stroke was investigated in a well-defined sample of acute stroke patients (n=80), followed up at 3 months, 1 year, 2 and 3 years after the stroke event. Links to biological and psychosocial factors were examined. Hypercortisolism was studied by the dexamethasone suppression test and compared with healthy elderly. Living conditions (including demographic caracteristics, economic resources, health, functional ability, activity/leisure, social network) and life satisfaction were described before and after stroke in relation to a general elderly population. Demographic caracteristics, economic resources, social network and psychiatric morbidity prestroke did not differ from the general elderly population. Already prior to the stroke, patients reported more health problems and lower functional ability in many aspects of daily life, more passive leisure time and a lower global life satisfaction. After stroke, contacts with children were maintained, whilst contacts outside the family declined and remained lower than in the general elderly population. Stroke involved a marked reduction in global life satisfaction. Poor life satisfaction at 1 year remained poor for the entire three years; these stroke victims had a higher frequency of major depression early after stroke. The prevalence of major depression was 25% at the acute stage, 31% at 3 months, decreased to 16% at 1 year, was 19% at 2 years and increased to 29% at 3 years. The most important predictors of immediate major depression were left anterior brain lesion, dysphasia, and living alone. Dependence in self-care ability and loss of social contacts outside the family were the most important predictors at 3 months. From 1 year onwards, loss of social contacts contributed most to depression and at 3 years also cerebral atrophy. Sixty percent of patients with early depression (0-3 months) had recovered at 1 year; those not recovered at 1 year had a high risk of chronicitation. Hypercortisolism as measured by the dexamethasone suppression test was associated with major depression late (3 years) but not early (0-3 months) after stroke. At 3 years, the dexamethasone suppression test had a sensitivity of 70%, a specificity of 97%, a positive predictive value of 88%, a negative predicitive value of 91%, and a diagnostic accuracy of 90%. Nonsuppression of dexamethasone at 3 months was a significant predictor of major depression at 3 years. / <p>Härtill 5 uppsatser</p> / digitalisering@umu

There are a number of links between the endocrine system and the nervous system. In this study, the impact of ischemic stroke on the endocrine system was investigated. Elderly volunteers were studied because data regarding the influence of advanced age on endocrine parameters were lacking. Only small differences in pituitary-thyroid and pituitary-adrenal hormone axes were found between two groups of elderly patients, 60 and 80 years of age. The 80-year-old age group had a lower thyrotropin response to thyrotropin releasing hormone (TRH) and a decline in dopamine excretion. Patients with acute ischemic stroke showed a pronounced hypercortisolism studied by the dexamethasone test and urine free cortisol measurements. In multiple regression analyses, postdexamethasone cortisol levels were positively correlated to proximity of the lesion to the frontal pole of the brain and disorientation. Urine cortisol levels were predicted by limb paresis, disorientation and body temperature. High cortisol excretion was associated with a worse functional outcome. Norepinephrine excretion was correlated to urine cortisol levels and to motor impairment. Patients with acute stroke had elevated free thyroxin indices. A paradoxical growth hormone response to TRH was found in the majority of stroke patients. In a multiple regression model disorientation was negatively correlated to thyrotropin response after TRH and positively correlated to prolactin response. Growth hormone response to TRH was associated with extensive paresis. In a cohort study diabetic and non-diabetic patients were prospectively studied after an initial stroke. Diabetes mellitus adversely influenced survival, the risk for a recurrent stroke and myocardial infarction. / <p>S. 1-66: sammanfattning, s. 69-190: 6 uppsatser</p> / digitalisering@umu

Diss. (sammanfattning) Linköping : Linköpings universitet, 2006. / Härtill 4 uppsatser.

The purpose of the study was to determine the long-term effects of muscle weakness secondary to strokes on the bone mineral content of the hemiparetic limb. Patients who had experienced single recent strokes were studied. The bone mineral content of each limb was measured by Dual Energy X-ray Absorptiometry using the region of interest analysis program. Muscle strength of each muscle group was ranked using the Oxford scale, and the mean was calculated for each limb. Bone and muscle parameters were measured within seven days after the stroke and repeated thereafter at monthly intervals for up to 6 mo. A repeated measures analysis of variance, Newman-Keuls pair-wise comparisons, and orthogonal contrasts were done for each parameter. Significance levels were set at P < 0.05. Sixteen patients were included in this study. Demineralization was more pronounced in the upper than lower limbs. Demineralization of bones on the paralyzed side started during the first month after the stroke and gradually progressed. By the fourth month, the bone mineral content decreased by a mean of 9.3% (P = 0.01) and 3.7% (P = 0.01) in the upper and lower limbs, respectively, for the 11 patients followed for 4 mo. In the patients we followed for more than 4 mo, there was no further significant mineral loss. No change in bone mineral content was observed in the healthy nonparetic limbs. In conclusion, after a stroke, bone demineralization occurs in the paralyzed side and reaches its maximum within 3 to 4 mo. Arms are affected more than legs.

<p>UVOD: Vilisov poligon predstavlja najznačajniju rezervu kolateralnog protoka između ekstrakranijalnih arterija koje vaskularizuju mozak i ima sposobnost razvoja kolateranih puteva kod ekstrakranijalne karotidne bolesti. Ova anatomska struktura podložna je varijacijama koje uključuju i prekid kontinuiteta i nekompletnost kolateralizacije. CILJEVI: Cilj je bio da se utvrdi da li nekompletnost Vilisovog poligona utiče na če&scaron;će pojavljivanje neurolo&scaron;ke simptomatologije i ishemijske moždane lezije kod pacijenata sa ekstrakranijalnom karotidnom bolesti. Takođe cilj je bio i da se utvrdi da li cerebrovaskularna reaktivnost kod pacijenata sa asimptomatskom ekstrakranijalnom karotidnom bolesti zavisi od kompletosti Vilisovog poligona i na koji način hirur&scaron;ki tretman utiče na parametre cerebrovaskularne rezerve kod pacijenata sa kompletnim i nekompletnim Vilisovim poligonom. METOD: U retrospektivnoj studiji analiziran je nalaz MRA kod 211 pacijenata sa ekstrakranijalnom karotidnom bolesti i 102 pacijenta iz kontrolne grupe. U prospektivnoj studiji je kod 98 pacijenata sa asimptomatskom karotidnom bolesti pored MRA nalaza određivana cerebrovaskularna reaktivnost putem određivanja &bdquo;breath hold index&ldquo;-a (BHI) pre i nakon operativnog tretmana. REZULTATI: Nekompletan Vilisov poligon nađen je kod 25% asimptomatskih, 47,5% simptomatskih pacijenata sa karotidnom bolesti i kod 59% kontrolne grupe pacijenata, pri čemu su se razlike pokazale kao statistički značajne. Kod asimptomatskih pacijenata sa nekompletnim Vilisovim poligonom BHI preoperativno iznostio je 0,62 a postoperativno 1,01 na strani lezije. U slučaju nekompletnog Vilisovog poligona preoperativna vrednost BHI iznostila je 0,88 a postoperativna 1,09 na strani lezije. Razlike su se pokazale kao statistički značajne između grupa i pre i posle operativnog tretmana. Porast je bio statistički značajno izraženiji u grupi asimptomatskih pacijenata sa nekompletnim Vilisovim poligonom. Nisu zabeležene major operativne komplikacije (perioeprativni moždani udar,smrtni ishod) a na pojavu hiperperfuzionog sindroma najvi&scaron;e su uticali kompletnost Vilisovog poligona, vrednost BHI i preoperativni tretman hipertenzije. ZAKLJUČCI: Nekompletan Vilisov poligon predstavlja faktor rizika za pojavu neurolo&scaron;ke simptomatologije ili ishemijske moždane lezije kod pacijenata sa ekstrakranijalnom karotidnom bolesti. Kod asimptomatskih pacijenata nekompletan Vilisov pologon utiče na smanjenu cerebrovaskularnu reaktivnost i veći rizik od moždanog udara. Parametri cerebrovaskularne reaktivnosti signifikantno se pobolj&scaron;avaju nakon operativnog tretmana.</p> / <p>INTRODUCTION: Circle of Willis is the most important reserve of collateral flow between the extracranial arteries that supply the brain and has the ability to develop collateral pathways in extracranial carotid disease. This anatomical structure is subject to variations which include a disruption in the continuity and incompleteness of collateralisation. OBJECTIVES: was to determine whether the incompleteness of the Circle of Willis is more often associated with neurological symptoms and ishemic cerebral lesions in patients with extracranial carotid artery disease. Also, the objective was to determine whether cerebrovascular reactivity in patients with asymptomatic extracranial carotid artery disease depends on the completeness Circle of Willis and how surgical treatment affects the parameters of cerebrovascular reserve in patients with complete and incomplete Circle of Willis. METHODS: This study analyzed the findings of MRA in 211 patients with extracranial carotid artery disease and 102 patients in the control group. In prospective study in 98 patients with asymptomatic carotid artery disease in addition to the MRA findings cerebrovascular reactivity was determined by determining the &quot;breath hold index&quot; -a (BHI) before and after surgical treatment. RESULTS: Incomplete Circle of Willis was found in 25% of asymptomatic, 47.5% of symptomatic patients with carotid artery disease, and 59% of the control group patients, where the difference proved to be statistically significant. In asymptomatic patients with incomplete Circle of Willis BHI values were 0.62 preoperatively and 1.01 postoperatively on the side of the lesion. In the case of incomplete Circle of Willis preoperative BHI values were 0.88 preopertively and 1.09 postoperatively in asymptomatic patients. The differences are shown to be statistically significant between the groups before and after surgical treatment. The increase was significantly more pronounced in the group of asymptomatic patients with incomplete Circle of Willis. There were not recorded major operative complications (perioeprativni stroke, mortality) and the occurrence hyperperfusion syndrome was most affected by completeness of the Circle of Willis, a value BHI and preoperative treatment of hypertension. CONCLUSIONS: Incomplete Circle of Willis is a risk factor for the occurrence of neurological symptoms or ischemic brain lesions in patients with extracranial carotid artery disease. In asymptomatic patients incomplete Circle of Willis affects the reduced cerebrovascular reactivity and a higher risk of stroke. The parameters of cerebrovascular reactivity significantly improved after surgical treatment.</p>

Introdução: A medida da qualidade de vida relacionada à saúde vem se tornando um modelo importante de avaliação em muitos estudos clínicos. Especial consideração deve ser dada à doença cerebrovascular por ser freqüente e de graves conseqüências físicas, sociais, familiares e econômicas. No Brasil não dispomos de um instrumento específico de avaliação da qualidade de vida validado para uso em pacientes com doença cerebrovascular isquêmica. Este estudo avaliou as medidas psicométricas do instrumento de avaliação da qualidade de vida específico para a doença cerebrovascular do tipo isquêmico, adaptado transculturalmente para a língua portuguesa (Stroke specific quality of life scale, SS-QOL). Metodologia: Foram avaliados 50 pacientes com história de doença cerebrovascular do tipo isquêmico, com idade superior a 45 anos e com evolução clínica superior a 3 meses da data do íctus, assistidos no Centro Catarinense de Reabilitação em Florianópolis, Santa Catarina. O instrumento SS-QOL foi aplicado em duas entrevistas com intervalo médio, entre elas, de 2 a 4 semanas. Paralelo a esta medida, foram aplicados, na primeira entrevista, os instrumentos: índice Barthel, inventário de depressão de Beck, escala de doença cerebrovascular do Instituto Nacional de Saúde dos Estados Unidos da América (NIHSS) e o estudo de resultados médicos - versão curta de 36 itens (SF-36). A avaliação da confiabilidade (estabilidade e consistência interna) do SS-QOL foi testada por meio da análise do coeficiente de confiabilidade, com o modelo teste-reteste, e do valor alfa de Cronbach. A validação do constructo e de critério foi estabelecida através da correlação linear entre os resultados obtidos para cada domínio e os resultados obtidos nas medidas escolhidas como padrão ouro para aquele domínio medido pelo coeficiente de correlação de Pearson (r). A capacidade discriminativa do constructo foi testada comparando o escore médio do SS-QOL entre os pacientes que referiam alteração da qualidade de vida e os pacientes que não referiram alteração da qualidade de vida em relação à época antes do infarto cerebral. Ela também foi avaliada comparando o escore médio do SS-QOL em relação à gravidade clínica da doença medida pela escala NIHSS e pelo grau de incapacidade funcional avaliado pela escala de Rankin modificado. Resultados: O SS-QOL, versão para a língua portuguesa, apresentou boa aceitabilidade, não tendo informações perdidas nem porcentagem aumentada de respostas com efeito teto ou solo. A confiabilidade do instrumento foi considerada excelente, com coeficiente de correlação intraclasse de 0,95 (p < 0,001) e o valor alfa de Cronbach de 0,98 (p < 0,001). O grau de correlação linear dos domínios do SS-QOL com as demais medidas escolhidas para cada domínio foi considerado de razoável a moderadamente elevado, com valor de r variando de 0,42 a 0,91 (p < 0,01). O SS-QOL mostrou capacidade discriminativa adequada ao detectar diferenças estatisticamente significantes no escore médio dos pacientes que referiram alteração da qualidade de vida e dos que não alegaram alteração da qualidade de vida em relação a antes de a doença ter ocorrido e no escore médio dos pacientes com doença considerada leve em relação aos pacientes com doença considerada moderada (p < 0,001). A análise de variância revelou diferenças estatisticamente significantes no escore médio dos pacientes estratificados pelo grau de incapacidade funcional (p < 0,01). Conclusão: O SS-QOL, adaptado para a língua portuguesa, apresentou medidas psicométricas consideradas satisfatórias, estando adequado para a utilização como uma ferramenta de avaliação da qualidade de vida em pacientes com doença cerebrovascular na prática médica diária ou em estudos clínicos. / Introduction: Measurement of health related quality of life has become an important evaluation model in many clinical studies. Special consideration must be given to the cerebrovascular disease because it is frequent and has serious physical, social, familial and economic consequences. We do not have, in Brazil, a specific instrument to evaluate health related quality of life validated for stroke patients. This study evaluates psychometric measures of the stroke specific quality of life scale cross-culturally adapted to Portuguese language (SS-QOL). Methodology: We evaluated 50 stroke patients, admitted to the Centro Catarinense de Reabilitação in Florianópolis, Santa Catarina, older than 45 years old with time of lesion superior to 3 months. The SS-QOL was applied in two interviews with average interval, between them, of 2 to 4 weeks. Parallel to the instrument, we applied, in the first interview, the Barthel index, Beck depression inventory, National Institute of Health stroke scale (NIHSS) and the Medical outcome study - short version of 36 items (SF-36). The SS-QOL reliability evaluation (stability and internal consistency) was tested with the analysis of the stability coefficient with test-retest model, and the Cronbach?s alpha value. The construct and criterion validation was established by comparing the linear correlation between the results for each domain and the results of the chosen gold standard measures for that domain measured with Pearson correlation coefficient (r). The discriminant capacity was tested comparing the SS-QOL mean scores of patients who referred changes in the quality of life and those that did not refer it in relation to the prestroke period. It was also evaluated comparing the SS-QOL mean score in relation to disease clinical gravity measured with the NIHSS and the degree of functional incapacity evaluated by Rankin modified scale. Results: The SS-QOL, Portuguese language version has good acceptability. It does not have missing data or increased percentage of ceiling or floor effect. The stability was considered excellent with intraclass correlation coefficient of 0,95 (p < 0.001) and the Cronbach?s alpha value of 0,98 (p < 0,001). The degree of linear correlation of the SS-QOL domains with the chosen measures for each domain was considered reasonable to moderately high with r values varying from 0,42 to 0.91 (p < 0,01). The SS-QOL presented suitable discriminant capacity detecting differences, statistically significant, in the mean score of patients who had referred changes in the quality of life and those that did not refer it in relation to the prestroke period and in the mean score of patients with mild stroke and those with moderate stroke. The variance analysis showed statistically significant differences in the mean score of patients stratified by the functional incapacity degree (p < 0.01). Conclusion: The SS-QOL, adapted to Portuguese language, had psychometric measures considered satisfactory. It is suitable to use as a tool of quality of life evaluation in patients with stroke in the daily clinical practice or clinical studies.

Introdução e Objetivos: Falha óssea craniana após craniectomia descompressiva (CD) causa alterações neurológicas que podem estar associadas a modificações da anatomia cortical e hemodinâmica encefálica. Nosso objetivo foi avaliar se essas alterações ocorrem e se estão associadas ao prognóstico neurológico. Métodos: Avaliamos prospectivamente doentes com falha craniana após CD pelo método de Tomografia com estudo de perfusão (TCP) e Doppler Transcraniano (DTC) antes e entre 15 e 30 dias após a cranioplastia. O exame neurológico sistematizado e avaliação de escalas prognósticas (mRs, MEEM, índice de Barthel) foi realizado antes e seis meses após a operação. Resultados: Nós avaliamos 30 doentes, 15 (50%) com CD relacionada a traumatismo cranioencefálico (TCE) e 15 (50%) devido a doença cerebrovascular (DCV). Observamos que houve melhora satisfatória de queixas neurológicas, além de melhora significativa da mRs (p=0,003), MEEM (p < 0,001) e índice de Barthel (p=0,002). Houve reestruturação significativa da superfície cortical, tanto anterior (p < 0,001) quanto posterior (p=0,045). A diferença cortical posterior mostrou correlação com melhora do MEEM (p=0,03; r=-0,4) e índice de Barthel (p=0,035; r=-0,39). As alterações da anatomia encefálica foram mais evidentes em doentes com antecedente de DCV do que TCE. A relação entre a radiodensidade da substância cinzenta (SC) e branca (SB) apresentou elevação (p=0,007), sem correlação com prognóstico. A TCP demonstrou redução da duração média de trânsito (DMT) de 8,23 ± 1,30 segundos(s) para 7,50 ± 1,21 s (p=0,02) e do volume sanguíneo cerebral de 2,29 ± 0,58 ml/100g para 2,00±0,59 ml/100g (p=0,037) apenas no lado operado. O fluxo sanguíneo cerebral (FSC) não demonstrou alterações significativas em nenhum dos lados. Observamos correlação moderada entre DMT (diferença entre lado operado e não operado) com força muscular contralateral (r=-0,4, p =0,034). Na divisão entre grupos, a redução da DMT ocorreu no TCE e DCV mas, foi significativa apenas no primeiro grupo. Houve aumento significativo da velocidade de fluxo na artéria cerebral média tanto homolateral de 49,89±14,79 para 62,32±14,29 (p < 0,001) quanto contralateral de 53,95 ± 11,65 para 58,84±14,17 (p < 0,002) no exame de DTC. Observamos correlação com prognóstico neurológico tanto homolateral (MEEM; p=0,033, r= 0,55) quanto contralateral (mRs; p=0,031, r= -0,48) além de evidência de aumento da velocidade de fluxo em doentes com TCE e DCV mas, significativa apenas em doentes com DVC. Conclusões: As alterações do DTC e DMT apresentam correlação com prognóstico neurológico, representam possível recuperação da hemodinâmica encefálica mas, com comportamento diferente entre doentes com TCE e DCV. Após a cranioplastia ocorre melhora neurológica que se correlaciona com as alterações da anatomia cortical / Introduction and Objectives: Cranial vault defects after decompressive craniectomy (DC) causes neurological disorders that may be associated with changes in brain anatomy and hemodynamics. Our objective was to evaluate whether these changes occur and if they were associated with neurological prognosis. Methods: We prospectively evaluated patients with bone defect after DC with computed tomography perfusion (CTP) and transcranial Doppler Sonography (TCD) before and between 15 and 30 days after cranioplasty . We performed neurological examination and prognostic scales (mRs, MMSE and Barthel index) before and after six months. Results: We studied 30 patients, 15 (50%) had DC related to traumatic brain injury (TBI) and 15 (50%) due to cerebrovascular disease (CVD). We observed a satisfactory improvement of neurological complaints, as well as significant improvement in mRs (p= 0.003), MMSE (p < 0.001) and Barthel index (p=0.002). Significant anatomical expansion of both cerebral hemispheres, including anterior (p < 0.001), posterior (p=0.045), and cortical surface. The posterior measurements was correlated with improvement in the MMSE (p=0.03; r=-0.4) and Barthel index (p=0.035; r=-0.39). Brain anatomy changes were more evident in patients with history of CVD than TBI. Increase in radiodensity relationship between gray and white matter by CT scan (p=0.007) were observed without correlation with prognosis. TCP showed mean transit time (MTT) decrease from 8.23 ± 1.30 seconds (s) to 7.50 ± 1.21 s (p=0.02) and cerebral blood volume (CBV) from 2.29 ± 0.58 ml/100g to 2.00 ± 0.59 ml/100g (p=0.037) both in operated side. Cerebral blood flow (CBF) did not show significant changes in either side. We verified moderate correlation between MTT and contralateral muscle strength (r=-0.4; p=0.034). In the sub groups analysis, MTT decrease in TBI and CVD but was significant only in TBI patients. TCD showed a significant increase in middle cerebral artery flow velocity from 49.89±14.79 to 62.32±14.29 (p < 0.001) ipsilateral and from 53.95 ± 11.65 to 58.84 ± 14.17 (p < 0.002) contralateral to cranioplasty side. There was correlation between TCD changes and neurological prognosis ipsilateral (MMSE; p=0.033, r=0.55) and contralateral (MRS; p=0.031, r=-0.48) to operated side, besides flow velocity increased in TBI and CVD but was significant only in CVD patients. Conclusions: The TCD and MTT changes were correlated with neurological prognosis, represent recovery of brain hemodynamic condition but different behavior between TBI and CVD patients. After cranioplasty occurs neurological improvement that also correlates with anatomical changes in cortical surface

Introdução e Objetivos: Falha óssea craniana após craniectomia descompressiva (CD) causa alterações neurológicas que podem estar associadas a modificações da anatomia cortical e hemodinâmica encefálica. Nosso objetivo foi avaliar se essas alterações ocorrem e se estão associadas ao prognóstico neurológico. Métodos: Avaliamos prospectivamente doentes com falha craniana após CD pelo método de Tomografia com estudo de perfusão (TCP) e Doppler Transcraniano (DTC) antes e entre 15 e 30 dias após a cranioplastia. O exame neurológico sistematizado e avaliação de escalas prognósticas (mRs, MEEM, índice de Barthel) foi realizado antes e seis meses após a operação. Resultados: Nós avaliamos 30 doentes, 15 (50%) com CD relacionada a traumatismo cranioencefálico (TCE) e 15 (50%) devido a doença cerebrovascular (DCV). Observamos que houve melhora satisfatória de queixas neurológicas, além de melhora significativa da mRs (p=0,003), MEEM (p < 0,001) e índice de Barthel (p=0,002). Houve reestruturação significativa da superfície cortical, tanto anterior (p < 0,001) quanto posterior (p=0,045). A diferença cortical posterior mostrou correlação com melhora do MEEM (p=0,03; r=-0,4) e índice de Barthel (p=0,035; r=-0,39). As alterações da anatomia encefálica foram mais evidentes em doentes com antecedente de DCV do que TCE. A relação entre a radiodensidade da substância cinzenta (SC) e branca (SB) apresentou elevação (p=0,007), sem correlação com prognóstico. A TCP demonstrou redução da duração média de trânsito (DMT) de 8,23 ± 1,30 segundos(s) para 7,50 ± 1,21 s (p=0,02) e do volume sanguíneo cerebral de 2,29 ± 0,58 ml/100g para 2,00±0,59 ml/100g (p=0,037) apenas no lado operado. O fluxo sanguíneo cerebral (FSC) não demonstrou alterações significativas em nenhum dos lados. Observamos correlação moderada entre DMT (diferença entre lado operado e não operado) com força muscular contralateral (r=-0,4, p =0,034). Na divisão entre grupos, a redução da DMT ocorreu no TCE e DCV mas, foi significativa apenas no primeiro grupo. Houve aumento significativo da velocidade de fluxo na artéria cerebral média tanto homolateral de 49,89±14,79 para 62,32±14,29 (p < 0,001) quanto contralateral de 53,95 ± 11,65 para 58,84±14,17 (p < 0,002) no exame de DTC. Observamos correlação com prognóstico neurológico tanto homolateral (MEEM; p=0,033, r= 0,55) quanto contralateral (mRs; p=0,031, r= -0,48) além de evidência de aumento da velocidade de fluxo em doentes com TCE e DCV mas, significativa apenas em doentes com DVC. Conclusões: As alterações do DTC e DMT apresentam correlação com prognóstico neurológico, representam possível recuperação da hemodinâmica encefálica mas, com comportamento diferente entre doentes com TCE e DCV. Após a cranioplastia ocorre melhora neurológica que se correlaciona com as alterações da anatomia cortical / Introduction and Objectives: Cranial vault defects after decompressive craniectomy (DC) causes neurological disorders that may be associated with changes in brain anatomy and hemodynamics. Our objective was to evaluate whether these changes occur and if they were associated with neurological prognosis. Methods: We prospectively evaluated patients with bone defect after DC with computed tomography perfusion (CTP) and transcranial Doppler Sonography (TCD) before and between 15 and 30 days after cranioplasty . We performed neurological examination and prognostic scales (mRs, MMSE and Barthel index) before and after six months. Results: We studied 30 patients, 15 (50%) had DC related to traumatic brain injury (TBI) and 15 (50%) due to cerebrovascular disease (CVD). We observed a satisfactory improvement of neurological complaints, as well as significant improvement in mRs (p= 0.003), MMSE (p < 0.001) and Barthel index (p=0.002). Significant anatomical expansion of both cerebral hemispheres, including anterior (p < 0.001), posterior (p=0.045), and cortical surface. The posterior measurements was correlated with improvement in the MMSE (p=0.03; r=-0.4) and Barthel index (p=0.035; r=-0.39). Brain anatomy changes were more evident in patients with history of CVD than TBI. Increase in radiodensity relationship between gray and white matter by CT scan (p=0.007) were observed without correlation with prognosis. TCP showed mean transit time (MTT) decrease from 8.23 ± 1.30 seconds (s) to 7.50 ± 1.21 s (p=0.02) and cerebral blood volume (CBV) from 2.29 ± 0.58 ml/100g to 2.00 ± 0.59 ml/100g (p=0.037) both in operated side. Cerebral blood flow (CBF) did not show significant changes in either side. We verified moderate correlation between MTT and contralateral muscle strength (r=-0.4; p=0.034). In the sub groups analysis, MTT decrease in TBI and CVD but was significant only in TBI patients. TCD showed a significant increase in middle cerebral artery flow velocity from 49.89±14.79 to 62.32±14.29 (p < 0.001) ipsilateral and from 53.95 ± 11.65 to 58.84 ± 14.17 (p < 0.002) contralateral to cranioplasty side. There was correlation between TCD changes and neurological prognosis ipsilateral (MMSE; p=0.033, r=0.55) and contralateral (MRS; p=0.031, r=-0.48) to operated side, besides flow velocity increased in TBI and CVD but was significant only in CVD patients. Conclusions: The TCD and MTT changes were correlated with neurological prognosis, represent recovery of brain hemodynamic condition but different behavior between TBI and CVD patients. After cranioplasty occurs neurological improvement that also correlates with anatomical changes in cortical surface

Introdução: A medida da qualidade de vida relacionada à saúde vem se tornando um modelo importante de avaliação em muitos estudos clínicos. Especial consideração deve ser dada à doença cerebrovascular por ser freqüente e de graves conseqüências físicas, sociais, familiares e econômicas. No Brasil não dispomos de um instrumento específico de avaliação da qualidade de vida validado para uso em pacientes com doença cerebrovascular isquêmica. Este estudo avaliou as medidas psicométricas do instrumento de avaliação da qualidade de vida específico para a doença cerebrovascular do tipo isquêmico, adaptado transculturalmente para a língua portuguesa (Stroke specific quality of life scale, SS-QOL). Metodologia: Foram avaliados 50 pacientes com história de doença cerebrovascular do tipo isquêmico, com idade superior a 45 anos e com evolução clínica superior a 3 meses da data do íctus, assistidos no Centro Catarinense de Reabilitação em Florianópolis, Santa Catarina. O instrumento SS-QOL foi aplicado em duas entrevistas com intervalo médio, entre elas, de 2 a 4 semanas. Paralelo a esta medida, foram aplicados, na primeira entrevista, os instrumentos: índice Barthel, inventário de depressão de Beck, escala de doença cerebrovascular do Instituto Nacional de Saúde dos Estados Unidos da América (NIHSS) e o estudo de resultados médicos - versão curta de 36 itens (SF-36). A avaliação da confiabilidade (estabilidade e consistência interna) do SS-QOL foi testada por meio da análise do coeficiente de confiabilidade, com o modelo teste-reteste, e do valor alfa de Cronbach. A validação do constructo e de critério foi estabelecida através da correlação linear entre os resultados obtidos para cada domínio e os resultados obtidos nas medidas escolhidas como padrão ouro para aquele domínio medido pelo coeficiente de correlação de Pearson (r). A capacidade discriminativa do constructo foi testada comparando o escore médio do SS-QOL entre os pacientes que referiam alteração da qualidade de vida e os pacientes que não referiram alteração da qualidade de vida em relação à época antes do infarto cerebral. Ela também foi avaliada comparando o escore médio do SS-QOL em relação à gravidade clínica da doença medida pela escala NIHSS e pelo grau de incapacidade funcional avaliado pela escala de Rankin modificado. Resultados: O SS-QOL, versão para a língua portuguesa, apresentou boa aceitabilidade, não tendo informações perdidas nem porcentagem aumentada de respostas com efeito teto ou solo. A confiabilidade do instrumento foi considerada excelente, com coeficiente de correlação intraclasse de 0,95 (p < 0,001) e o valor alfa de Cronbach de 0,98 (p < 0,001). O grau de correlação linear dos domínios do SS-QOL com as demais medidas escolhidas para cada domínio foi considerado de razoável a moderadamente elevado, com valor de r variando de 0,42 a 0,91 (p < 0,01). O SS-QOL mostrou capacidade discriminativa adequada ao detectar diferenças estatisticamente significantes no escore médio dos pacientes que referiram alteração da qualidade de vida e dos que não alegaram alteração da qualidade de vida em relação a antes de a doença ter ocorrido e no escore médio dos pacientes com doença considerada leve em relação aos pacientes com doença considerada moderada (p < 0,001). A análise de variância revelou diferenças estatisticamente significantes no escore médio dos pacientes estratificados pelo grau de incapacidade funcional (p < 0,01). Conclusão: O SS-QOL, adaptado para a língua portuguesa, apresentou medidas psicométricas consideradas satisfatórias, estando adequado para a utilização como uma ferramenta de avaliação da qualidade de vida em pacientes com doença cerebrovascular na prática médica diária ou em estudos clínicos. / Introduction: Measurement of health related quality of life has become an important evaluation model in many clinical studies. Special consideration must be given to the cerebrovascular disease because it is frequent and has serious physical, social, familial and economic consequences. We do not have, in Brazil, a specific instrument to evaluate health related quality of life validated for stroke patients. This study evaluates psychometric measures of the stroke specific quality of life scale cross-culturally adapted to Portuguese language (SS-QOL). Methodology: We evaluated 50 stroke patients, admitted to the Centro Catarinense de Reabilitação in Florianópolis, Santa Catarina, older than 45 years old with time of lesion superior to 3 months. The SS-QOL was applied in two interviews with average interval, between them, of 2 to 4 weeks. Parallel to the instrument, we applied, in the first interview, the Barthel index, Beck depression inventory, National Institute of Health stroke scale (NIHSS) and the Medical outcome study - short version of 36 items (SF-36). The SS-QOL reliability evaluation (stability and internal consistency) was tested with the analysis of the stability coefficient with test-retest model, and the Cronbach?s alpha value. The construct and criterion validation was established by comparing the linear correlation between the results for each domain and the results of the chosen gold standard measures for that domain measured with Pearson correlation coefficient (r). The discriminant capacity was tested comparing the SS-QOL mean scores of patients who referred changes in the quality of life and those that did not refer it in relation to the prestroke period. It was also evaluated comparing the SS-QOL mean score in relation to disease clinical gravity measured with the NIHSS and the degree of functional incapacity evaluated by Rankin modified scale. Results: The SS-QOL, Portuguese language version has good acceptability. It does not have missing data or increased percentage of ceiling or floor effect. The stability was considered excellent with intraclass correlation coefficient of 0,95 (p < 0.001) and the Cronbach?s alpha value of 0,98 (p < 0,001). The degree of linear correlation of the SS-QOL domains with the chosen measures for each domain was considered reasonable to moderately high with r values varying from 0,42 to 0.91 (p < 0,01). The SS-QOL presented suitable discriminant capacity detecting differences, statistically significant, in the mean score of patients who had referred changes in the quality of life and those that did not refer it in relation to the prestroke period and in the mean score of patients with mild stroke and those with moderate stroke. The variance analysis showed statistically significant differences in the mean score of patients stratified by the functional incapacity degree (p < 0.01). Conclusion: The SS-QOL, adapted to Portuguese language, had psychometric measures considered satisfactory. It is suitable to use as a tool of quality of life evaluation in patients with stroke in the daily clinical practice or clinical studies.

Abstract In the Nordic countries, event-free survival (EFS) exceeds 80% in certain groups of children treated for acute lymphoblastic leukaemia (ALL). With the improved cure rates, however, there are more children suffering from neurological late effects, especially due to therapy directed at the central nervous system (CNS). The aim of this study is to examine the changes taking place in the nervous system after leukemia treatment and to evaluate the role of treatment in these changes in patients and in an animal model. Twenty-seven ALL survivors and healthy controls were examined by means of motor evoked potentials (MEPs). ALL survivors were also examined clinically. The children with ALL continued to show decreased motor nerve conduction in the peripheral nerves, but not within the CNS, five years after the cessation of treatment. Clinical neurological findings were obtained in 33% of the cases. The MEP results indicated reversibility of the motor injury due to CNS effects. Nineteen patients underwent perfusion magnetic resonance imaging (MRI) at the cessation of treatment or 4-8 years after the treatment. Seventeen of them also underwent single-photon emission computed tomography (SPECT). The studies showed small perfusion defects in SPECT, which were not visible by perfusion MRI. Methotrexate (Mtx) neurotoxicity was studied in a swine model using functional MRI, brain perfusion SPECT, iodine-123 labelled 2β-carbomethoxy-3β-(4-iodophenyl) tropane ([123I]β-CIT) SPECT and whole-hemisphere autoradiography with [125I]β-CIT in ten Mtx-treated animals and five control animals. Mtx-related changes in the brain could be detected as reduced or negative blood-oxygen-level-dependent (BOLD) responses to somatosensory activation in BOLD contrast MRI, which indicates changes in flow metabolism coupling. Perfusion defects in brain SPECT were seen in the Mtx group and the control group, which suggests that the perfusion defects seen in brain SPECT are probably multifactorial. The change in dopamine transporter (DAT) density in the Mtx group was not different from that in the controls. The abnormalities in nerve conduction after treatment in survivors of ALL were partly reversible years after the treatment. The patients had perfusion defects in SPECT imaging which were not seen in perfusion MRI. The clinical significance of these defects remains obscure. The animal model suggested perfusion defects to be multifactorial.