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Background Moderate hypothermia after decompressive surgery might not be beneficial for stroke patients. However, normothermia may prove to be an effective method of enhancing neurological outcomes. The study aims were to evaluate the application of a pre-specified normothermia protocol in stroke patients after decompressive surgery and its impact on temperature load, and to describe the functional outcome of patients at 12 months after treatment. Methods We analysed patients with space-occupying middle cerebral artery (MCA) infarction treated with decompressive surgery and a pre-specified temperature management protocol. Patients treated primarily with device-controlled normothermia or hypothermia were excluded. The individual temperature load above 36.5 °C was calculated for the first 96 h after hemicraniectomy as the Area Under the Curve, using °C x hours. The effect of temperature load on functional outcome at 12 months was analysed by logistic regression. Results We included 40 stroke patients treated with decompressive surgery (mean [SD] age: 58.9 [10.1] years; mean [SD] time to surgery: 30.5 [16.7] hours). Fever (temperature > 37.5 °C) developed in 26 patients during the first 96 h after surgery and mean (SD) temperature load above 36.5 °C in this time period was 62,3 (+/− 47,6) °C*hours. At one year after stroke onset, a moderate to moderately severe disability (modified Rankin Scale score of 3 or 4) was observed in 32% of patients, and a severe disability (score of 5) in 37% of patients, respectively. The lethality in the cohort at 12 months was 32%. The temperature load during the first 96 h was not an independent predictor for 12 month lethality (OR 0.986 [95%-CI:0.967–1.002]; p < 0.12). Conclusions Temperature control in surgically treated patients with space-occupying MCA infarction using a pre-specified protocol excluding temperature management systems resulted in mild hyperthermia between 36.8 °C and 37.2 °C and a low overall temperature load. Future prospective studies on larger cohorts comparing different strategies for normothermia treatment including temperature management devices are needed.

Background: The optimal timing of surgical therapy for traumatic spinal cord injury (TSCI) remains unclear. The purpose of this study is to evaluate the impact of “ultra-early” (<4 h) versus “early” (4–24 h) time from injury to surgery in terms of the likelihood of neurologic recovery. Methods: The effect of surgery on neurological recovery was investigated by comparing the assessed initial and final values of the American Spinal Injury Association (ASIA) Impairment Scale (AIS). A post hoc analysis was performed to gain insight into different subgroup regeneration behaviors concerning neurological injury levels. Results: Datasets from 69 cases with traumatic spinal cord injury were analyzed. Overall, 19/46 (41.3%) patients of the “ultra-early” cohort saw neurological recovery compared to 5/23 (21.7%) patients from the “early” cohort (p = 0.112). The subgroup analysis revealed differences based on the neurological level of injury (NLI) of a patient. An optimal cutpoint for patients with a cervical lesion was estimated at 234 min. Regarding the prediction of neurological improvement, sensitivity was 90.9% with a specificity of 68.4%, resulting in an AUC (area under the curve) of 84.2%. In thoracically and lumbar injured cases, the estimate was lower, ranging from 284 (thoracic) to 245 min (lumbar) with an AUC of 51.6% and 54.3%. Conclusions: Treatment within 24 h after TSCI is associated with neurological recovery. Our hypothesis that intervention within 4 h is related to an improvement in the neurological outcome was not confirmed in our collective. In a clinical context, this suggests that after TSCI there is a time frame to get the right patient to the right hospital according to advanced trauma life support (ATLS) guidelines.

Base teórica: O Acidente Vascular Cerebral (AVC) é a causa mais comum de novos diagnósticos de epilepsia no idoso. Embora a epilepsia pós-AVC seja um fenômeno clínico reconhecido há muito tempo, seguem muitas questões não resolvidas. Além disso, nas últimas duas décadas, o tratamento do AVC isquêmico sofreu mudanças radicais com a introdução da trombólise e da hemicraniectomia descompressiva (HD) para o tratamento do infarto maligno de artéria cerebral média (ACM). As consequências destas duas novas abordagens terapêuticas nas características da epilepsia pós-AVC ainda são pouco exploradas. Objetivo: Estudar as características e estimar fatores de risco para as crises epilépticas ou a epilepsia pós-AVC em pacientes submetidos ao tratamento agudo (Estudo 1) ou HD para infarto maligno de ACM (Estudo 2). Métodos: O estudo 1 é uma coorte de 153 pacientes submetidos a trombólise. Variáveis estudadas incluiram fatores de risco para o AVC e variáveis associadas ao AVC isquêmico agudo e trombólise. Utilizamos a análise de regressão de Cox para o estudo das variáveis que se associaram de forma independente com crises epilépticas, epilepsia pós-AVC e o desfecho do AVC. O estudo 2 é também uma coorte que retrospectivamente avaliou 36 pacientes com infarto maligno de ACM tratados com HD. Tempo, incidência e fatores de risco para crises epilépticas e desenvolvimento de epilepsia foram analisados. Resultados: Estudo 1: 74 pacientes (48,4%) eram mulheres; média de idade foi 67,2 anos (DP=13,1). Média do NIHSS na chegada foi 10,95 (DP=6,25) e 2,09 (DP=3,55) após 3 meses. Transformação hemorrágica ocorreu em 22 (14,4%) dos pacientes. Foi considerado desfecho bom classificação na escala modificada de Rankin (mRS) 0-1, sendo encontrado em 87 (56,9%) dos pacientes. Vinte e um pacientes (13,7%) tiveram crises epilépticas e 15 (9,8%) desenvolveram epilepsia após a trombólise. Crises epilépticas foram associadas de forma independente com transformação hemorrágica e desfecho não favorável (mRS ≥ 2) em três meses após o AVC. Transformação hemorrágica e mRS ≥ 2 avaliados em 3 meses, associaram-se de forma independente com epilepsia pós-AVC. Crises epilépticas surgiram como um fator de risco independente para desfecho pobre. Estudo 2. A média de seguimento dos pacientes foi de 1.086 (DP= 1.172) dias. Nove pacientes morreram antes de receberem alta hospitalar e no período de um ano, 11 pacientes haviam morrido. Quase 60% alcançaram mRS ≤ 4. Treze pacientes desenvolveram crises dentro da primeira semana após o AVC. No total, crises epilépticas ocorreram em 22 (61%) dos 36 pacientes. Dezenove pacientes (56%) dos 34, sobreviveram ao período agudo e desenvolveram epilepsia após infarto da ACM e HD. Questionamos aos pacientes ou responsáveis se eles se arrependeram de terem autorizado a HD no momento do AVC. Também foi perguntado se eles autorizariam a HD novamente. Trinta e dois (89%) não se arrependeram de ter autorizado a HD no momento do infarto agudo da ACM, e autorizaria novamente em retrospecto. Conclusão: Confirmamos que as frequências de crises ou epilepsia pós-AVC e trombolítico são comparáveis com as frequências das décadas da era pré-trombólise e confirmamos a alta incidência de crises epilépticas e epilepsia após infartos malignos de ACM submetidos a HD. Em nosso estudo, as crises epilépticas associaram-se de forma independente com pior prognóstico após terapia trombolítica. / Background: The most common cause of newly diagnosed epilepsies in the elderly is stroke. Although post-stroke epilepsy is a well-studied stroke complication, many questions remain unsolved. In addition, during the past two decades, the treatment of stroke has changed dramatically with the introduction of thrombolysis for treatment of acute ischemic stroke (AIS) and decompressive hemicraniectomy (DHC) for malignant middle cerebral artery infarction (MCA). The consequences of these two new therapeutic approaches for characteristics of post-stroke epilepsy remains poorly explored. Objective: To study characteristics and estimate risk factors for acute seizures or post-stroke epilepsy in patients submitted to thrombolysis for treatment of acute stroke (Study 1) or DHC for malignant MCA infarction. Methods: Study 1 is a cohort study of 153 patients submitted to thrombolysis. Variables studied included risk factors for stroke, and variables related to acute stroke and thrombolysis. Variables independently associated with seizures, pos-stroke epilepsy or stroke outcome were defined using Cox regression analysis. Study 2 is also a cohort study that retrospectively assessed 36 patients with malignant stroke of the MCA submitted to DHC. Timing, incidence and plausible risk factors for seizure and epilepsy development were analyzed in these patients. Results: Study 1. Seventy-four patients (48.4%) were female; mean age of patients was 67.2 years-old (SD=13.1). Initial NIHSS mean score was 10.95 (SD=6.25) and 2.09 (SD=3.55) after three months. Hemorrhagic transformation occurred in 22 (14.4%) patients. A good outcome, as defined by a modified Rankin Scale (mRS) of 0-1, was observed in 87 (56.9%) patients. Twenty one (13.7%) patients had seizures and 15 (9.8%) patients developed epilepsy after thrombolysis. Seizures were independently associated with hemorrhagic transformation and with mRS ≥ 2 three months after stroke. Hemorrhagic transformation and unfavorable outcome, as measured by mRS ≥ 2 after three months, were variables independently associated with post-stroke epilepsy. Seizures emerged as an independent factor for poor outcome in stroke thrombolysis. Study 2. Mean patient follow-up time was of 1.086 (SD=1.172) days. Nine patients died before being discharged and after one year eleven patients died. Almost 60% had the modified Rankin score ≤ 4. Thirteen patients developed seizures within the first week after stroke. In total, seizures occurred in 22 (61%) of 36 patients. Nineteen patients (56%) out of 34 patients who survived the acute period developed epilepsy after MCA infarcts and DHC. Also, we asked patients or the person responsible for them whether they regretted, in retrospect, having authorized DHC at the time of the stroke. It was also asked whether they would authorize DHC again. Thirty- two (89%) did not regret having authorized DHC at the time of acute MCA infarct, and would authorize DHC again in retrospect. Conclusion: We confirm that seizures or post-stroke epilepsy rates after thrombolysis are comparable with rates from pre-thrombolysis decades and a high incidence of seizures and epilepsy after malignant MCA infarcts submitted to DHC. In our study, seizures were an independent risk factor associated with worst outcome after thrombolysis therapy.

Base teórica: O Acidente Vascular Cerebral (AVC) é a causa mais comum de novos diagnósticos de epilepsia no idoso. Embora a epilepsia pós-AVC seja um fenômeno clínico reconhecido há muito tempo, seguem muitas questões não resolvidas. Além disso, nas últimas duas décadas, o tratamento do AVC isquêmico sofreu mudanças radicais com a introdução da trombólise e da hemicraniectomia descompressiva (HD) para o tratamento do infarto maligno de artéria cerebral média (ACM). As consequências destas duas novas abordagens terapêuticas nas características da epilepsia pós-AVC ainda são pouco exploradas. Objetivo: Estudar as características e estimar fatores de risco para as crises epilépticas ou a epilepsia pós-AVC em pacientes submetidos ao tratamento agudo (Estudo 1) ou HD para infarto maligno de ACM (Estudo 2). Métodos: O estudo 1 é uma coorte de 153 pacientes submetidos a trombólise. Variáveis estudadas incluiram fatores de risco para o AVC e variáveis associadas ao AVC isquêmico agudo e trombólise. Utilizamos a análise de regressão de Cox para o estudo das variáveis que se associaram de forma independente com crises epilépticas, epilepsia pós-AVC e o desfecho do AVC. O estudo 2 é também uma coorte que retrospectivamente avaliou 36 pacientes com infarto maligno de ACM tratados com HD. Tempo, incidência e fatores de risco para crises epilépticas e desenvolvimento de epilepsia foram analisados. Resultados: Estudo 1: 74 pacientes (48,4%) eram mulheres; média de idade foi 67,2 anos (DP=13,1). Média do NIHSS na chegada foi 10,95 (DP=6,25) e 2,09 (DP=3,55) após 3 meses. Transformação hemorrágica ocorreu em 22 (14,4%) dos pacientes. Foi considerado desfecho bom classificação na escala modificada de Rankin (mRS) 0-1, sendo encontrado em 87 (56,9%) dos pacientes. Vinte e um pacientes (13,7%) tiveram crises epilépticas e 15 (9,8%) desenvolveram epilepsia após a trombólise. Crises epilépticas foram associadas de forma independente com transformação hemorrágica e desfecho não favorável (mRS ≥ 2) em três meses após o AVC. Transformação hemorrágica e mRS ≥ 2 avaliados em 3 meses, associaram-se de forma independente com epilepsia pós-AVC. Crises epilépticas surgiram como um fator de risco independente para desfecho pobre. Estudo 2. A média de seguimento dos pacientes foi de 1.086 (DP= 1.172) dias. Nove pacientes morreram antes de receberem alta hospitalar e no período de um ano, 11 pacientes haviam morrido. Quase 60% alcançaram mRS ≤ 4. Treze pacientes desenvolveram crises dentro da primeira semana após o AVC. No total, crises epilépticas ocorreram em 22 (61%) dos 36 pacientes. Dezenove pacientes (56%) dos 34, sobreviveram ao período agudo e desenvolveram epilepsia após infarto da ACM e HD. Questionamos aos pacientes ou responsáveis se eles se arrependeram de terem autorizado a HD no momento do AVC. Também foi perguntado se eles autorizariam a HD novamente. Trinta e dois (89%) não se arrependeram de ter autorizado a HD no momento do infarto agudo da ACM, e autorizaria novamente em retrospecto. Conclusão: Confirmamos que as frequências de crises ou epilepsia pós-AVC e trombolítico são comparáveis com as frequências das décadas da era pré-trombólise e confirmamos a alta incidência de crises epilépticas e epilepsia após infartos malignos de ACM submetidos a HD. Em nosso estudo, as crises epilépticas associaram-se de forma independente com pior prognóstico após terapia trombolítica. / Background: The most common cause of newly diagnosed epilepsies in the elderly is stroke. Although post-stroke epilepsy is a well-studied stroke complication, many questions remain unsolved. In addition, during the past two decades, the treatment of stroke has changed dramatically with the introduction of thrombolysis for treatment of acute ischemic stroke (AIS) and decompressive hemicraniectomy (DHC) for malignant middle cerebral artery infarction (MCA). The consequences of these two new therapeutic approaches for characteristics of post-stroke epilepsy remains poorly explored. Objective: To study characteristics and estimate risk factors for acute seizures or post-stroke epilepsy in patients submitted to thrombolysis for treatment of acute stroke (Study 1) or DHC for malignant MCA infarction. Methods: Study 1 is a cohort study of 153 patients submitted to thrombolysis. Variables studied included risk factors for stroke, and variables related to acute stroke and thrombolysis. Variables independently associated with seizures, pos-stroke epilepsy or stroke outcome were defined using Cox regression analysis. Study 2 is also a cohort study that retrospectively assessed 36 patients with malignant stroke of the MCA submitted to DHC. Timing, incidence and plausible risk factors for seizure and epilepsy development were analyzed in these patients. Results: Study 1. Seventy-four patients (48.4%) were female; mean age of patients was 67.2 years-old (SD=13.1). Initial NIHSS mean score was 10.95 (SD=6.25) and 2.09 (SD=3.55) after three months. Hemorrhagic transformation occurred in 22 (14.4%) patients. A good outcome, as defined by a modified Rankin Scale (mRS) of 0-1, was observed in 87 (56.9%) patients. Twenty one (13.7%) patients had seizures and 15 (9.8%) patients developed epilepsy after thrombolysis. Seizures were independently associated with hemorrhagic transformation and with mRS ≥ 2 three months after stroke. Hemorrhagic transformation and unfavorable outcome, as measured by mRS ≥ 2 after three months, were variables independently associated with post-stroke epilepsy. Seizures emerged as an independent factor for poor outcome in stroke thrombolysis. Study 2. Mean patient follow-up time was of 1.086 (SD=1.172) days. Nine patients died before being discharged and after one year eleven patients died. Almost 60% had the modified Rankin score ≤ 4. Thirteen patients developed seizures within the first week after stroke. In total, seizures occurred in 22 (61%) of 36 patients. Nineteen patients (56%) out of 34 patients who survived the acute period developed epilepsy after MCA infarcts and DHC. Also, we asked patients or the person responsible for them whether they regretted, in retrospect, having authorized DHC at the time of the stroke. It was also asked whether they would authorize DHC again. Thirty- two (89%) did not regret having authorized DHC at the time of acute MCA infarct, and would authorize DHC again in retrospect. Conclusion: We confirm that seizures or post-stroke epilepsy rates after thrombolysis are comparable with rates from pre-thrombolysis decades and a high incidence of seizures and epilepsy after malignant MCA infarcts submitted to DHC. In our study, seizures were an independent risk factor associated with worst outcome after thrombolysis therapy.

Base teórica: O Acidente Vascular Cerebral (AVC) é a causa mais comum de novos diagnósticos de epilepsia no idoso. Embora a epilepsia pós-AVC seja um fenômeno clínico reconhecido há muito tempo, seguem muitas questões não resolvidas. Além disso, nas últimas duas décadas, o tratamento do AVC isquêmico sofreu mudanças radicais com a introdução da trombólise e da hemicraniectomia descompressiva (HD) para o tratamento do infarto maligno de artéria cerebral média (ACM). As consequências destas duas novas abordagens terapêuticas nas características da epilepsia pós-AVC ainda são pouco exploradas. Objetivo: Estudar as características e estimar fatores de risco para as crises epilépticas ou a epilepsia pós-AVC em pacientes submetidos ao tratamento agudo (Estudo 1) ou HD para infarto maligno de ACM (Estudo 2). Métodos: O estudo 1 é uma coorte de 153 pacientes submetidos a trombólise. Variáveis estudadas incluiram fatores de risco para o AVC e variáveis associadas ao AVC isquêmico agudo e trombólise. Utilizamos a análise de regressão de Cox para o estudo das variáveis que se associaram de forma independente com crises epilépticas, epilepsia pós-AVC e o desfecho do AVC. O estudo 2 é também uma coorte que retrospectivamente avaliou 36 pacientes com infarto maligno de ACM tratados com HD. Tempo, incidência e fatores de risco para crises epilépticas e desenvolvimento de epilepsia foram analisados. Resultados: Estudo 1: 74 pacientes (48,4%) eram mulheres; média de idade foi 67,2 anos (DP=13,1). Média do NIHSS na chegada foi 10,95 (DP=6,25) e 2,09 (DP=3,55) após 3 meses. Transformação hemorrágica ocorreu em 22 (14,4%) dos pacientes. Foi considerado desfecho bom classificação na escala modificada de Rankin (mRS) 0-1, sendo encontrado em 87 (56,9%) dos pacientes. Vinte e um pacientes (13,7%) tiveram crises epilépticas e 15 (9,8%) desenvolveram epilepsia após a trombólise. Crises epilépticas foram associadas de forma independente com transformação hemorrágica e desfecho não favorável (mRS ≥ 2) em três meses após o AVC. Transformação hemorrágica e mRS ≥ 2 avaliados em 3 meses, associaram-se de forma independente com epilepsia pós-AVC. Crises epilépticas surgiram como um fator de risco independente para desfecho pobre. Estudo 2. A média de seguimento dos pacientes foi de 1.086 (DP= 1.172) dias. Nove pacientes morreram antes de receberem alta hospitalar e no período de um ano, 11 pacientes haviam morrido. Quase 60% alcançaram mRS ≤ 4. Treze pacientes desenvolveram crises dentro da primeira semana após o AVC. No total, crises epilépticas ocorreram em 22 (61%) dos 36 pacientes. Dezenove pacientes (56%) dos 34, sobreviveram ao período agudo e desenvolveram epilepsia após infarto da ACM e HD. Questionamos aos pacientes ou responsáveis se eles se arrependeram de terem autorizado a HD no momento do AVC. Também foi perguntado se eles autorizariam a HD novamente. Trinta e dois (89%) não se arrependeram de ter autorizado a HD no momento do infarto agudo da ACM, e autorizaria novamente em retrospecto. Conclusão: Confirmamos que as frequências de crises ou epilepsia pós-AVC e trombolítico são comparáveis com as frequências das décadas da era pré-trombólise e confirmamos a alta incidência de crises epilépticas e epilepsia após infartos malignos de ACM submetidos a HD. Em nosso estudo, as crises epilépticas associaram-se de forma independente com pior prognóstico após terapia trombolítica. / Background: The most common cause of newly diagnosed epilepsies in the elderly is stroke. Although post-stroke epilepsy is a well-studied stroke complication, many questions remain unsolved. In addition, during the past two decades, the treatment of stroke has changed dramatically with the introduction of thrombolysis for treatment of acute ischemic stroke (AIS) and decompressive hemicraniectomy (DHC) for malignant middle cerebral artery infarction (MCA). The consequences of these two new therapeutic approaches for characteristics of post-stroke epilepsy remains poorly explored. Objective: To study characteristics and estimate risk factors for acute seizures or post-stroke epilepsy in patients submitted to thrombolysis for treatment of acute stroke (Study 1) or DHC for malignant MCA infarction. Methods: Study 1 is a cohort study of 153 patients submitted to thrombolysis. Variables studied included risk factors for stroke, and variables related to acute stroke and thrombolysis. Variables independently associated with seizures, pos-stroke epilepsy or stroke outcome were defined using Cox regression analysis. Study 2 is also a cohort study that retrospectively assessed 36 patients with malignant stroke of the MCA submitted to DHC. Timing, incidence and plausible risk factors for seizure and epilepsy development were analyzed in these patients. Results: Study 1. Seventy-four patients (48.4%) were female; mean age of patients was 67.2 years-old (SD=13.1). Initial NIHSS mean score was 10.95 (SD=6.25) and 2.09 (SD=3.55) after three months. Hemorrhagic transformation occurred in 22 (14.4%) patients. A good outcome, as defined by a modified Rankin Scale (mRS) of 0-1, was observed in 87 (56.9%) patients. Twenty one (13.7%) patients had seizures and 15 (9.8%) patients developed epilepsy after thrombolysis. Seizures were independently associated with hemorrhagic transformation and with mRS ≥ 2 three months after stroke. Hemorrhagic transformation and unfavorable outcome, as measured by mRS ≥ 2 after three months, were variables independently associated with post-stroke epilepsy. Seizures emerged as an independent factor for poor outcome in stroke thrombolysis. Study 2. Mean patient follow-up time was of 1.086 (SD=1.172) days. Nine patients died before being discharged and after one year eleven patients died. Almost 60% had the modified Rankin score ≤ 4. Thirteen patients developed seizures within the first week after stroke. In total, seizures occurred in 22 (61%) of 36 patients. Nineteen patients (56%) out of 34 patients who survived the acute period developed epilepsy after MCA infarcts and DHC. Also, we asked patients or the person responsible for them whether they regretted, in retrospect, having authorized DHC at the time of the stroke. It was also asked whether they would authorize DHC again. Thirty- two (89%) did not regret having authorized DHC at the time of acute MCA infarct, and would authorize DHC again in retrospect. Conclusion: We confirm that seizures or post-stroke epilepsy rates after thrombolysis are comparable with rates from pre-thrombolysis decades and a high incidence of seizures and epilepsy after malignant MCA infarcts submitted to DHC. In our study, seizures were an independent risk factor associated with worst outcome after thrombolysis therapy.

Background Moderate hypothermia after decompressive surgery might not be beneficial for stroke patients. However, normothermia may prove to be an effective method of enhancing neurological outcomes. The study aims were to evaluate the application of a pre-specified normothermia protocol in stroke patients after decompressive surgery and its impact on temperature load, and to describe the functional outcome of patients at 12 months after treatment. Methods We analysed patients with space-occupying middle cerebral artery (MCA) infarction treated with decompressive surgery and a pre-specified temperature management protocol. Patients treated primarily with device-controlled normothermia or hypothermia were excluded. The individual temperature load above 36.5 °C was calculated for the first 96 h after hemicraniectomy as the Area Under the Curve, using °C x hours. The effect of temperature load on functional outcome at 12 months was analysed by logistic regression. Results We included 40 stroke patients treated with decompressive surgery (mean [SD] age: 58.9 [10.1] years; mean [SD] time to surgery: 30.5 [16.7] hours). Fever (temperature > 37.5 °C) developed in 26 patients during the first 96 h after surgery and mean (SD) temperature load above 36.5 °C in this time period was 62,3 (+/− 47,6) °C*hours. At one year after stroke onset, a moderate to moderately severe disability (modified Rankin Scale score of 3 or 4) was observed in 32% of patients, and a severe disability (score of 5) in 37% of patients, respectively. The lethality in the cohort at 12 months was 32%. The temperature load during the first 96 h was not an independent predictor for 12 month lethality (OR 0.986 [95%-CI:0.967–1.002]; p < 0.12). Conclusions Temperature control in surgically treated patients with space-occupying MCA infarction using a pre-specified protocol excluding temperature management systems resulted in mild hyperthermia between 36.8 °C and 37.2 °C and a low overall temperature load. Future prospective studies on larger cohorts comparing different strategies for normothermia treatment including temperature management devices are needed.