INTRODUÇÃO: Houve uma epidemia de infecção pelo vírus Zika (ZIKV) no Brasil, entre 2015 e 2016, que refletiu no aumento de casos de microcefalia neonatal secundária à infecção congênita pelo ZIKV. Para compreensão do padrão de acometimento neurológico dessas crianças foi realizado um projeto de pesquisa pelo Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), conhecido como ZIG, e realizado seguimento neurológico desses pacientes por meio do Exame Neurológico de Hammersmith Neonatal (HINE-N). OBJETIVOS: Avaliar pacientes com microcefalia secundária à infecção congênita pelo ZIKV por meio do HINE- N, descrever as características clínicas e de neuroimagem dos pacientes estudados e identificar fatores pré-natais, perinatais e demográficos potencialmente relacionados ao grau de comprometimento do exame neurológico. METODOLOGIA: O presente estudo faz parte do Núcleo de Estudos sobre Infecção Materna, Perinatal e Infantil (NEIMPI) do HCFMRP-USP e trata-se de um estudo não experimental, transversal, com intuito de correlacionar variáveis qualitativas e quantitativas. Participaram do estudo crianças com microcefalia secundária à infecção congênita pelo ZKV nascidas no município de Ribeirão Preto e seu Departamento Regional de Saúde (DRS XIII), no período de outubro de 2015 a dezembro de 2016. Os dados foram coletados no período de outubro de 2015 a janeiro de 2017. Realizou-se avaliação do perímetro craniano (PC), aplicação do HINE e coleta de dados em prontuário. Os dados foram processados e analisados com a utilização do Pacote Estatístico Statistical Package for the Social Sciences (SPSS), versão 22.0. RESULTADOS: Foram avaliadas 18 crianças, sendo predomínio do sexo feminino (55,6%), nascidas a termo, com exceção de uma que nasceu com 32 semanas, maioria originária de Ribeirão Preto (66,7%), via de parto normal (72,2%), ocorrido no Centro Obstétrico do HCFMRP - USP (83,3%), todas as crianças tiveram APGAR maior que 7. O peso de nascimento foi entre 1228 e 3200 gramas, com PC entre 26 e 31,5 cm. 72,2% das crianças fizeram ultrassom transfontanela e 100% fizeram ressonância magnética de encéfalo, com associação entre os resultados encontrados neles (ambos com p<ou=0,001). O score HINE-N foi baixo, porém não foram encontradas associações entre o score e as variáveis clínicas (ambos com p>0,05). Evidenciou-se associação entre a realização de pré-natal e a cidade de residência, local de nascimento, diagnóstico de microcefalia e de infecção pelo ZIKV no pré-natal, tipo de parto (p< ou = 0,001). A medida do PC apresentou associação direta com a presença de crise convulsiva (p<0,05) e houve associação entre crise convulsiva, ventriculomegalia e calcificação (p< ou= 0,001). CONCLUSÃO: O padrão de acometimento neurológico das crianças com microcefalia secundária à infecção congênita pelo ZIKV é muito severo, com presença de sinais precoces de paralisia cerebral desde o exame neonatal. Este estudo sugere seguimento prospectivo desses pacientes para melhor avaliação prognóstica e associação do score HINE com condições clínicas pré e perinatais / INTRODUCTION: There was an epidemic of Zika virus infection (ZIKV) in Brazil between 2015 and 2016, which reflected the increase in cases of neonatal microcephaly secondary to congenital ZIKV infection. A study was carried out for the Hospital das Clínicas of the University of São Paulo at Ribeirão Preto Medical School (HCFMRP-USP), and the followup of these patients was performed using the Neonatal Hammersmith Neurological Exam (HINE-N) aiming to understand the neurological involvement pattern of these children. OBJECTIVES: To evaluate patients with microcephaly secondary to ZIKV congenital infection using HINE-N, to describe the clinical and neuroimaging characteristics of the patients studied, and to identify prenatal, perinatal and demographic factors potentially related to the degree of impairment of neurological examination. METHODOLOGY: This study is part of the Center for Studies on Maternal, Perinatal and Child Infection (NEIMPI) of the HCFMRP-USP. It is a non-experimental, cross-sectional study aimed at correlating qualitative and quantitative variables. Children with microcephaly secondary to congenital ZKV infection born in the city of Ribeirão Preto and its Regional Health Department (DRS XIII), from October 2015 to December 2016, participated in the study. Data were collected in the period of October 2015 to January 2017. An evaluation of the cranial perimeter (PC), the application of HINE and data collection in medical records were performed. Data were processed and analyzed using the Statistical Package for Social Statistical Package (SPSS), version 22.0. RESULTS: A total of 18 children were evaluated, being 55,6% female, all to term with the exception of one who was born at 32 weeks, most of them from Ribeirão Preto (66.7%), normal delivery (72.2%), occurred in the Obstetric Center of the HCFMRP - USP (83.3%), all children had APGAR greater than 7. The birth weight was between 1228 and 3200 grams, with PC between 26 and 31.5 cm. 72.2% of the children had transfontanel ultrasonography and 100% had brain magnetic resonance imaging, with an association between the results found in them (both with p <or = 0.001). The HINE-N score was low, but no associations were found between the score and the clinical variables (both with p> 0.05). It was evidenced an association between prenatal and city of residence, place of birth, diagnosis of microcephaly and ZIKV infection in the prenatal period, type of delivery (p <or = 0.001). The PC measurement presented a direct association with the presence of seizures (p <0.05) and there was an association between seizure, ventriculomegaly and calcification (p <or = 0.001). CONCLUSION: The pattern of neurological involvement of children with microcephaly secondary to congenital ZIKV infection is very severe, with early signs of cerebral palsy since the neonatal examination. This study suggests a prospective follow-up of these patients for better prognostic evaluation and association of the HINE score with pre and perinatal clinical conditions

Concussions are the injury and symptoms that can result from transmission of a biomechanical force to the brain. They represent a significant global health burden, and are the subject of a growing body of medical research. A concussion can only be definitively diagnosed by a medical professional based on symptoms, although advanced neuroimaging and biomarker-based approaches are promising future diagnostic tools. There is no treatment for concussion beyond following return-to-work or -play guidelines, which recommend avoiding strenuous physical and cognitive activities until they no longer exacerbate symptoms. Preclinical models of concussion have been used to examine pathophysiological processes underlying symptoms, which is an important step in developing tools for diagnosis and treatment. Historically the clinical translation of preclinical concussion research has been limited, and the use of anaesthesia, and preference for adult male rats may contribute to this. These means of reducing variability are justified, but preclinical research moving forward should address these limitations to translatability by including more clinically relevant subjects and avoiding anaesthesia. To this end, we developed a new preclinical model for pediatric concussion. Our awake closed head injury (ACHI) model is well-suited to this purpose because it produces a helmeted closed-head injury involving vertical and rotational displacement of the head, and does not require anaesthesia. Before the ACHI model can be used to investigate concussion mechanism, diagnosis, and treatment, it needs to be characterized to demonstrate that it produces clinically relevant neurobehavioral and pathological changes. We developed a modified neurologic assessment protocol to test neurologic function immediately after each injury. The Barnes maze, elevated plus maze, open field, and Rotarod were used to measure injury-related changes in cognition, anxiety, and motor function. The Barnes maze reversal task was used to detect more subtle cognitive impairments of executive function. Structural MRI was used to search for visible lesion, hemorrhage, or atrophy; and silver-stain histology was used to detect neurodegeneration. We determined repeated ACHI produced acute neurologic impairment with the NAP, and a mild spatial learning deficit potentially mediated impaired cognitive flexibility in the Barnes maze and reversal training. These were accompanied by neurodegeneration in the optic tract, hippocampus, and ipsilateral cortex during the first week of recovery. Thus, following the internationally recognised definition developed by the concussion in sport group, we demonstrated 1) an “impulsive” force transmitted to the head results in 2) the rapid onset of short-lived neurologic impairment that resolves spontaneously. This occurs 3) with normal structural neuroimaging, and 4) produces cognitive impairment, and LOC in a subset of cases. The ACHI model is the first in Canada to forego anaesthesia, and this is the first demonstration of neurocognitive impairment accompanied by diffuse neurodegeneration in the absence of structural MRI abnormalities after mild traumatic brain injury in juvenile male and female rats. / Graduate

Introdução: As mucopolissacaridoses (MPSs) são doenças de deposito lisossômico causadas por deficiências enzimáticas envolvidas na degradação das glicosaminoglicanas. O catabolismo das glicosaminoglicanas pode ser bloqueado isoladamente ou em combinações, podendo ocorrer o acúmulo de dermatan sulfato, heparan sulfato, queratan sulfato, e o acido hialurônico. Existem sete tipos de MPSs (tipos I, II, III, IV, VI, VII e IX) causados por onze deficiências enzimáticas conhecidas; o comprometimento multissistêmico progressivo é uma característica comum à maioria dos tipos. O espectro de manifestações neurológicas é amplo e o diagnóstico precoce de tais manifestações é fundamental para um melhor prognóstico. A terapia de reposição enzimática (TRE) é atualmente disponível para o tratamento de alguns tipos de MPS, entretanto não há evidências de melhorias dos sintomas neurológicos com o uso da TRE. Objetivo: O objetivo deste estudo foi descrever as alterações neurológicas e de neuroimagem nos diversos tipos de MPSs. Métodos: Vinte pacientes com diagnóstico de mucopolissacaridoses (MPS) foram incluídos no estudo e avaliados conforme o protocolo clínico e de neuroimagem pré-estabelecido. Os pacientes foram submetidos à ressonância magnética (RM) de crânio e coluna em aparelhos de 1,5 Tesla. Resultados: Dentre os 20 pacientes da amostra, dois pacientes apresentavam MPS I (10%), três MPS II (15%), nove MPS IV (45%) e seis MPS VI (30%). As idades variaram de três a 26 anos (12,5 ± 6,1) e 13 (65%) pacientes eram do sexo masculino. Os pacientes com MPSs tipo I e II apresentaram uma ampla diversidade clínica e de neuroimagem. Desde casos oligossintomáticos com exame neurológico normal até um atraso significativo do desenvolvimento neuropsicomotor (DNPM), com alterações cognitivas, motoras e sensitivas persistentes foram encontrados. Os exames de RM dos pacientes com MPSs I e II apresentaram alterações tais como espessamento da díploe, alargamento dos espaços perivasculares, dilatação ventricular e comprometimento da substância branca. Alterações degenerativas na coluna vertebral estiveram presentes em todos os pacientes com MPSs I e II, a despeito da maioria estar em regime de TRE. Compressão medular foi observada em apenas um paciente com MPS I e em nenhum paciente MPS II. Dos nove pacientes com MPS IV, dois apresentaram atraso do DNPM, um deles com alterações cognitivas persistentes; em todos os pacientes encontramos déficits motores e seis dentre os nove apresentaram alterções de sensibilidade profunda. Na RM dos pacientes com MPS IV, observamos hipoplasia do processo odontóide em todos os pacientes, e em oito foram encontrados sinais de compressão medular. Subluxação atlanto-axial foi vista em seis pacientes. Estenose do canal e lipomatose epidural também contribuíram para compressão medular, e três pacientes apresentaram dois níveis de compressão. Na RM do crânio, dois pacientes com MPS IV apresentaram alterações da substância branca. Nos pacientes com MPS VI, a cognição esteve preservada e alterações de reflexos e sensibilidade profunda foram encontradas. Além das alterações clássicas encontradas em outros pacientes com outros tipos de MPSs, a RM dos pacientes com MPS VI mostrou alterações morfológicas dos diâmetros do crânio e da fossa média. Mesmo apresentando força muscular normal, todos os pacientes com MPS VI apresentaram algum grau de compressão medular. Em quatro pacientes encontramos subluxação atlanto-axial e em três estenose do canal medular. Conclusões: A heterogeneidade clínica e de neuroimagem foram marcantes nos pacientes com MPSs tipos I e II. Alterações degenerativas do coluna vertebral estiveram presentes em todos os pacientes destes grupo, a despeito da TRE. Os achados clínicos e de neuroimagem nos pacientes com MPS IV reforçam o comprometimento primário do sistema nervoso central neste tipo de MPS. Além disso, os efeitos secundários da doença sobre o medula requerem avaliação neurológica e RM da coluna total periodicamente. Nos pacientes com MPS VI, apesar do exame clínico mostrar apenas alterações sutis, o comprometimento do neuroeixo foi um achado universal pela RM, demonstrando a necessidade de seguimento radiológico mesmo em pacientes oligossintomáticos em regime de TRE / Introduction: Mucopolysaccharidosis (MPS) are lisosomal storage disorders caused by deficiencies of glycosaminoglycans catabolism enzymes, leading to deposition of mucopolysaccharides; over time, there is cellular damage affecting several organs and systems. There are seven distinct phenotypes of MPS (types I, II, III, IV, VI, VII e IX) with eleven known enzymatic defects, which may result in accumulation of dermatan sulfate, heparan sulfate, queratan sulfate, and hyaluronic acid. Neurological manifestations are broad, and an early detection of these manifestations is essential to ensure a better prognosis of MPS patients. Enzymatic replacement therapy (ERT) is currently available to treat some types of MPS, albeit there is no evidence of direct neurological improvement with ERT. Objective: The objective of this study was to describe the clinical neurological abnormalities and neuroimaging findings in a sample of patients with diagnosis of MPS. Methods: Twenty patients previously diagnosed with distinct types of MPS were enrolled in the clinical and MRI protocol. Brain and spinal cord MRI were performed in 1.5 Tesla machines. Results: Amongst the 20 patients, two had diagnosis of MPS I (10%), three had MPS II (15%), nine had MPS type IV (45%), and six had MPS type VI (30%). The ages ranged between three and 26 years-old (mean 12,5 ± 6,1) and 13 pacients (65%) were male. Clinical findings in patients with MPS I and II were broad, ranging from an unremarkable neurologic examination to severe milestones delay, and cognitive, motor, and sensitive impairment. Neuroimaging features in patients with MPS I and II showed diploe thickness, enlargement of perivascular spaces, hydrocephalus and white matter abnormalities. Degenerative abnormalities in the spine were present in all patients with MPS I and MPS II. On the other hand, spinal cord compression was found in only one patient with MPS I and in none of the MPS II patients. Among the nine MPS IV patients, two had delayed milestones and one of those exhibited persistent cognitive impairment. All patients with MPS IV had motor deficits and six of them presented impairment of deep sensory modalities. Neuroimaging of patients with MPS IV showed white matter abnormalities in two and spinal cord compression in eight patients, with three of them presenting two levels of spinal cord compression. The main mechanism of compression was atlantoaxial subluxation; in addition, other abnormalities such as spinal stenosis and epidural lipomatosis also contributed to spinal cord compression in MPS IV patients. Patients with MPS VI had preserved cognition, but sensory exam and deep tendon reflex were abnormal. Other than classical brain MRI abnormalities, patients with MPS type VI also presented with changes in the middle cranial fossa and increased anteroposterior skull diameter. Even though all six patients with MPS VI presented normal muscle strength, all of them had some degree of spinal cord compression; four patients had atlantoaxial subluxation and three had spinal stenosis. Conclusions: Clinical and neuroimaging heterogeneity was remarkable in patients with MPS types I and II. Degenerative features in vertebrae were found in all patients with MPS I and II, despite ERT. Our clinical and neuroimaging findings in patients with MPS IV support the central nervous system impairment in these patients; additionally, it was possible to understand the underlying spinal cord compression mechanisms in MPS. Although clinical abnormalities were not meaningful in patients with MPS VI, they presented significant MRI abnormalities despite ERT. Routine assessments including neurologic examination and spinal cord MRI is extremely important in MPS patients

Introdução: As mucopolissacaridoses (MPSs) são doenças de deposito lisossômico causadas por deficiências enzimáticas envolvidas na degradação das glicosaminoglicanas. O catabolismo das glicosaminoglicanas pode ser bloqueado isoladamente ou em combinações, podendo ocorrer o acúmulo de dermatan sulfato, heparan sulfato, queratan sulfato, e o acido hialurônico. Existem sete tipos de MPSs (tipos I, II, III, IV, VI, VII e IX) causados por onze deficiências enzimáticas conhecidas; o comprometimento multissistêmico progressivo é uma característica comum à maioria dos tipos. O espectro de manifestações neurológicas é amplo e o diagnóstico precoce de tais manifestações é fundamental para um melhor prognóstico. A terapia de reposição enzimática (TRE) é atualmente disponível para o tratamento de alguns tipos de MPS, entretanto não há evidências de melhorias dos sintomas neurológicos com o uso da TRE. Objetivo: O objetivo deste estudo foi descrever as alterações neurológicas e de neuroimagem nos diversos tipos de MPSs. Métodos: Vinte pacientes com diagnóstico de mucopolissacaridoses (MPS) foram incluídos no estudo e avaliados conforme o protocolo clínico e de neuroimagem pré-estabelecido. Os pacientes foram submetidos à ressonância magnética (RM) de crânio e coluna em aparelhos de 1,5 Tesla. Resultados: Dentre os 20 pacientes da amostra, dois pacientes apresentavam MPS I (10%), três MPS II (15%), nove MPS IV (45%) e seis MPS VI (30%). As idades variaram de três a 26 anos (12,5 ± 6,1) e 13 (65%) pacientes eram do sexo masculino. Os pacientes com MPSs tipo I e II apresentaram uma ampla diversidade clínica e de neuroimagem. Desde casos oligossintomáticos com exame neurológico normal até um atraso significativo do desenvolvimento neuropsicomotor (DNPM), com alterações cognitivas, motoras e sensitivas persistentes foram encontrados. Os exames de RM dos pacientes com MPSs I e II apresentaram alterações tais como espessamento da díploe, alargamento dos espaços perivasculares, dilatação ventricular e comprometimento da substância branca. Alterações degenerativas na coluna vertebral estiveram presentes em todos os pacientes com MPSs I e II, a despeito da maioria estar em regime de TRE. Compressão medular foi observada em apenas um paciente com MPS I e em nenhum paciente MPS II. Dos nove pacientes com MPS IV, dois apresentaram atraso do DNPM, um deles com alterações cognitivas persistentes; em todos os pacientes encontramos déficits motores e seis dentre os nove apresentaram alterções de sensibilidade profunda. Na RM dos pacientes com MPS IV, observamos hipoplasia do processo odontóide em todos os pacientes, e em oito foram encontrados sinais de compressão medular. Subluxação atlanto-axial foi vista em seis pacientes. Estenose do canal e lipomatose epidural também contribuíram para compressão medular, e três pacientes apresentaram dois níveis de compressão. Na RM do crânio, dois pacientes com MPS IV apresentaram alterações da substância branca. Nos pacientes com MPS VI, a cognição esteve preservada e alterações de reflexos e sensibilidade profunda foram encontradas. Além das alterações clássicas encontradas em outros pacientes com outros tipos de MPSs, a RM dos pacientes com MPS VI mostrou alterações morfológicas dos diâmetros do crânio e da fossa média. Mesmo apresentando força muscular normal, todos os pacientes com MPS VI apresentaram algum grau de compressão medular. Em quatro pacientes encontramos subluxação atlanto-axial e em três estenose do canal medular. Conclusões: A heterogeneidade clínica e de neuroimagem foram marcantes nos pacientes com MPSs tipos I e II. Alterações degenerativas do coluna vertebral estiveram presentes em todos os pacientes destes grupo, a despeito da TRE. Os achados clínicos e de neuroimagem nos pacientes com MPS IV reforçam o comprometimento primário do sistema nervoso central neste tipo de MPS. Além disso, os efeitos secundários da doença sobre o medula requerem avaliação neurológica e RM da coluna total periodicamente. Nos pacientes com MPS VI, apesar do exame clínico mostrar apenas alterações sutis, o comprometimento do neuroeixo foi um achado universal pela RM, demonstrando a necessidade de seguimento radiológico mesmo em pacientes oligossintomáticos em regime de TRE / Introduction: Mucopolysaccharidosis (MPS) are lisosomal storage disorders caused by deficiencies of glycosaminoglycans catabolism enzymes, leading to deposition of mucopolysaccharides; over time, there is cellular damage affecting several organs and systems. There are seven distinct phenotypes of MPS (types I, II, III, IV, VI, VII e IX) with eleven known enzymatic defects, which may result in accumulation of dermatan sulfate, heparan sulfate, queratan sulfate, and hyaluronic acid. Neurological manifestations are broad, and an early detection of these manifestations is essential to ensure a better prognosis of MPS patients. Enzymatic replacement therapy (ERT) is currently available to treat some types of MPS, albeit there is no evidence of direct neurological improvement with ERT. Objective: The objective of this study was to describe the clinical neurological abnormalities and neuroimaging findings in a sample of patients with diagnosis of MPS. Methods: Twenty patients previously diagnosed with distinct types of MPS were enrolled in the clinical and MRI protocol. Brain and spinal cord MRI were performed in 1.5 Tesla machines. Results: Amongst the 20 patients, two had diagnosis of MPS I (10%), three had MPS II (15%), nine had MPS type IV (45%), and six had MPS type VI (30%). The ages ranged between three and 26 years-old (mean 12,5 ± 6,1) and 13 pacients (65%) were male. Clinical findings in patients with MPS I and II were broad, ranging from an unremarkable neurologic examination to severe milestones delay, and cognitive, motor, and sensitive impairment. Neuroimaging features in patients with MPS I and II showed diploe thickness, enlargement of perivascular spaces, hydrocephalus and white matter abnormalities. Degenerative abnormalities in the spine were present in all patients with MPS I and MPS II. On the other hand, spinal cord compression was found in only one patient with MPS I and in none of the MPS II patients. Among the nine MPS IV patients, two had delayed milestones and one of those exhibited persistent cognitive impairment. All patients with MPS IV had motor deficits and six of them presented impairment of deep sensory modalities. Neuroimaging of patients with MPS IV showed white matter abnormalities in two and spinal cord compression in eight patients, with three of them presenting two levels of spinal cord compression. The main mechanism of compression was atlantoaxial subluxation; in addition, other abnormalities such as spinal stenosis and epidural lipomatosis also contributed to spinal cord compression in MPS IV patients. Patients with MPS VI had preserved cognition, but sensory exam and deep tendon reflex were abnormal. Other than classical brain MRI abnormalities, patients with MPS type VI also presented with changes in the middle cranial fossa and increased anteroposterior skull diameter. Even though all six patients with MPS VI presented normal muscle strength, all of them had some degree of spinal cord compression; four patients had atlantoaxial subluxation and three had spinal stenosis. Conclusions: Clinical and neuroimaging heterogeneity was remarkable in patients with MPS types I and II. Degenerative features in vertebrae were found in all patients with MPS I and II, despite ERT. Our clinical and neuroimaging findings in patients with MPS IV support the central nervous system impairment in these patients; additionally, it was possible to understand the underlying spinal cord compression mechanisms in MPS. Although clinical abnormalities were not meaningful in patients with MPS VI, they presented significant MRI abnormalities despite ERT. Routine assessments including neurologic examination and spinal cord MRI is extremely important in MPS patients