<p>Otkrivanje embolusa u cerebralnoj cirkulaciji na egzaktan način moguće je samo upotrebom transkranijalnog doplera. Istraživanje je obuhvatilo 150 ispitanika, obolelih od akutnog ishemijskog cerebrovaskularnog događaja (ishemijskog moždanog udara i tranzitornog ishemijskog ataka) u zoni vaskularizacije a. cerebri medie (ACM), a lečenih na Klinici za neurologiju, Kliničkog centra Vojvodine. Ciljevi istraživanja su obuhvatili određivanje prevalence i frekvence MES kod bolesnika sa akutnim ishemijskim cerebrovaskularnim događajem (TIA, IMU) tokom serijskog monitoringa, utvrđivanje povezanost pojave MES u odnosu na etiologiju ishemijske epizode, procenjivanje efekata terapije (antiagregacione i antikoagulantne) na pojavu MES tokom serijskog monitoringa, i utvrđivanje prediktivnog značaja MES na dalji tok bolesti tj, rani povratni embolizam unutra tri meseca. Utvrdili smo da se mikroembolusi kao markeri aktivne embolizacije mogu registrovati primenom transkranijalnog doplera u akutnoj fazi moždanog udara u određenoj meri. U ispitivanom uzorku metodom transkranijalne detekcije kod 52 (34,7%) bolesnika je registrovana pojava cerebralnih mikroembolusa. Ovi ispitanici su činili MES (+) grupu pacijenata. Kod 98 (65,3%) bolesnika nisu registrovani ES, oni su činili MES (-) grupu pacijenata. Detekcija je vr&scaron;ena u prvih 72h od vremena nastanka IMU ili TIA. Zaključili smo da se serijskim monitoringom registruje smanjenje prevalence i frekvence embolijskih signala. Utvrdili smo da su starija životna dob, hipertenzija i dijabetes statistički značajno povezani sa pojavom mikroembolusnih signala. Najveća zastupljenost mikroembolusa registrovana je u aterotrombotičnom podtipu ishemijskog moždanog udara. Utvrđen je prediktivni značaj aterosklerotske bolesti velikih krvnih sudova na pojavu MES. Registrovana je statistički značajno če&scaron;ća pojava MES kod simptomatske karotidne stenoze, visokog stepena (70-90%), neravne i ulcerisane povr&scaron;ine plaka. Nije utvrđena statistički značajna povezanost pojave MES, kliničkih manifestacija bolesti i neuroradiolo&scaron;kog nalaza. Nije registrovan uticaj antitrombotičke terapije na pojavu mikroembolusnih signala. Zabeležena je veća stopa recidiva IMU i TIA kod bolesnika sa registrovanim cerebralnim mikroembolusima. Utvrđen je prediktivni značaj MES na pojavu recidiva IMU ali ne i prediktivni značaj na pojavu letalnog ishoda.</p> / <p>Detection of emboli in the cerebral circulation to the exact way it is possible only by using transcranial doppler. The study included 150 patients of acute ischemic cerebrovascular events (ischemic stroke and TIA) in a zone of vascularization a. cerebri media (ACM), and treated at the Clinic of Neurology, Clinical Center of Vojvodina Research objectives included the determination of the prevalence and frequency of MES in patients with acute ischemic cerebrovascular accident (TIA, IMU) during serial monitoring, establishing the link between the appearance MES in relation to the etiology of ischemic episodes, assessing the effects of therapy<br />(antiplatelet and anticoagulant) on the occurrence of MES during serial monitoring and determine the predictive value MES in the further course of the disease, ie. return early embolism within three months. We have found that microemboli as markers of active embolization can register by using transcranial Doppler in the acute phase of stroke in certain extent. In the examined sample using transcranial detection with 52 (34.7%) patients the occurrence of cerebral microemboli is registered. These respondents are accounted for MES (+) group of patients. With 98 patients (65.3%) is not registered EC, they account for MES (-) group of patients. Detection was performed during 72 hours from the time of occurrence of ischemic stroke or TIA. We concluded that serial monitoring registers decrease in prevalence and frequency of embolic signals. We found that older age, hypertension, and diabetes are significantly associated with the appearance of microembolic signals. The highest incidence of microemboli was registered in atherothrombotic ischemic stroke subtype. It is determined the predictive significance of atherosclerotic disease of large blood vessels on the occurrence of MES. More common MES is significantly registered with symptomatic carotid stenosis, greater degree (70-90%), uneven surfaces and ulcerated plaque. There was no statistically significant correlation between the occurrence of MES, clinical manifestations and neuroradiological findings. It is not registered impact of antithrombotic therapy on the incidence of microembolic signals. We are noticed thet the higher rate of recurrence of ischemic stroke and TIA patients with cerebral microemboli is registered. The predictive significance of MES in recurrence of ischemic stroke is determined, but not predictive significance of the occurrence of a lethal outcome.</p>

<p>ZIEL:<br>Untersuchung des Auftretens von In-Stent-Restenosen (ISR) nach stentgeschützter perkutaner transluminaler Angioplastie intrakranieller Stenosen.</p><p> METHODEN:<br> In diese retrospektive Langzeit-Follow-up-Studie wurden konsekutiv 46 Patienten mit insgesamt 49 intrakraniellen Stenosen eingeschlossen, die im Zeitraum von August 2003 bis Juli 2010 mittels Stentangioplastie behandelt wurden. Der Nachbeobachtungszeitraum erstreckte sich bis Februar 2011. Die Quantifizierung der Stenosen erfolgte an angiografischen Bildern. Als ISR wurde eine erneute Stenose >50% innerhalb des Stents oder unmittelbar (d.h. innerhalb von 5mm) neben dem Stent und einem absoluten Lumenverlust von >20% definiert. Die Mittelwerte der Stenosegrade zu unterschiedlichen Zeitpunkten wurden mit dem t-Test für abhängige Stichproben verglichen. Die ISR-freie Überlebenswahrscheinlichkeit wurde mit der Kaplan-Meier-Kurve untersucht und Kurvenvergleiche für Untergruppen erfolgten mit dem Log-Rang-Test.</p><p> ERGEBNISSE:<br> Die mediane Follow-up-Dauer betrug sieben Monate (Spannweite: ein Tag-75 Monate, Interquartilsabstand: 20,25 Monate, Mittelwert: 17,4 Monate). Zwei Patienten verstarben an peri- bzw. post-prozeduralen Komplikationen (eine intrakranielle Blutung aufgrund einer Dissektion mit einem arteriovenösen Shunt und eine Reperfusionsblutung). Sechs Patienten mit sieben behandelten Stenosen verstarben innerhalb des Beobachtungszeitraums ohne bekannte Todesursache. Es gab für 57% der Stenosen mindestens eine Bildgebung im Verlauf. Die 1-Jahres-ISR-freie Überlebenswahrscheinlichkeit für das Gesamtkollektiv lag bei 69%. Insgesamt traten acht ISR auf; sieben davon innerhalb der ersten acht Monate nach Stentplatzierung. Mittels Log-Rang-Test wurde eine signifikant niedrigere 8-Monats-ISR-freie Überlebenswahrscheinlichkeit in der Gruppe der ≤55-jährigen Patienten im Vergleich zu >55-jährigen Patienten (13% versus 79%, p=0,002) ermittelt. Für Patienten ohne eine arterielle Hypertonie resultierte eine signifikant niedrigere 7-Monats-ISR-freie Überlebenswahrscheinlichkeit und eine höhere für Patienten mit einer arteriellen Hypertonie (0% versus 81%, p=0,006). Nur zwei von acht Patienten zeigten zum Zeitpunkt der ISR-Diagnose Symptome. Die Zunahme einer ISR bis zum Gefäßverschluss bei einem Patienten mit einem angiografisch dokumentierten suffizienten Kollateralkreislauf verlief ohne Symptome.</p><p> SCHLUSSFOLGERUNG:<br> Gerade innerhalb der ersten Monate nach stentgeschützter perkutaner transluminaler Angioplastie sind engmaschige Verlaufskontrollen wichtig. Die Festsetzung der Zeitpunkte für Verlaufskontrollen sollte dabei nicht allein auf einer eventuell vorhandenen klinischen Symptomatik basieren. Möglicherweise bilden ≤55-jährige Patienten und Patienten ohne eine arterielle Hypertonie mit höherer Wahrscheinlichkeit eine ISR. ISR können im zeitlichen Verlauf sowohl zu- als auch abnehmen. Der Progress einer ISR bis zum vollständigen Gefäßverschluss kann im Fall einer ausreichenden intrakraniellen Kollateralgefäßversorgung asymptomatisch verlaufen. Somit könnte der zusätzlichen Evaluation des Kollateralstatus in der Verlaufsbeurteilung von ISR ein wichtiger Stellenwert zukommen.</p>

Aneurysmal subarachnoid hemorrhage (SAH) is a devastating disease with mean age of 59 years. SAH accounts for 5% of all stroke and more than one quarter of potential life years lost through stroke. With the advanced neurosurgical methods of today two thirds of the patients survive. We know, however, that various cognitive, psychiatric and physical impairments are common that affect quality of life, social life, and the ability to work in the aftermath of SAH. The overall aim constituting this PhD dissertation is to better understand some of the challenges often faced by those surviving SAH. Two SAH patient cohorts have been studied. The first followed 96 consecutively included patients during the first year after ictus. Spasticity and cognitive impairment was assessed after 6 months and the Swedish stroke register follow-up form was used to investigate family support and the use of medical and social services. Return to work was assessed at 12 months. The second cohort assessed attention deficits using the test of variables of attention (T.O.V.A.) at 7 months after ictus in 19 patients with moderate to good recovery. Spasticity was just as common in our SAH patients as after other stroke, though it was rarely treated pharmacologically. By assessing cognitive impairment at 6 months after ictus using the Montreal cognitive assessment, 68% of the patients could be correctly predicted as having returned/not returned to work at 12 months. Seventeen percent of the patients had not had a follow-up appointment 6 months after ictus. These patients were older, more often living alone, had a lower quality of life, more depressive symptoms and more cognitive impairment compared to those having had a follow-up appointment. Twenty percent had had a follow-up in primary care. Seventy-eight percent of those with moderate to severe disability were living in their own accommodations. Fifty-eight percent of the patients had attention deficits. Challenges after SAH were common and often dealt with in the home environment of the patients. The results of this thesis highlight the importance of assisting the patients and their relatives in their struggle back to life after SAH.

L’habenula, un noyau épithalamique, est située au centre de la voie dorsale diencéphalique. Cette voie relie les structures limbiques et les ganglions de la base aux cellules monoaminergiques du mésencéphale. En particulier, l’habenula latérale (HbL) projette directement aux cellules dopaminergiques et GABAergiques de l’aire tegmentale ventrale (ATV). L’ATV est le site d’origine de la voie mésolimbique dopaminergique, une voie impliquée de façon cruciale dans la manifestation des comportements dirigés. L’importance de cette projection habenulaire pour le comportement demeure encore méconnue. Ainsi, l’objectif de cette étude est d’approfondir notre compréhension du rôle de régulation de l’HbL sur les comportements dépendants de la neurotransmission dopaminergique. MATÉRIEL ET MÉTHODES: Des rats adultes mâles Sprague-Dawley ont été anesthésiés avec de l’isofluorane et installés sur un appareil stéréotaxique. L’acide iboténique, une neurotoxine agoniste des récepteurs glutamatergiques, était infusée bilatéralement dans l’HbL (0,25 μg/0,25 μl/côté). Les rats du groupe contrôle recevaient des infusions NaCl 0,9%. Les rats de l’expérience d’autostimulation intracérébrale (ASIC) étaient aussi implantés d’une électrode monopolaire dans le mésencéphale postérieur. Un groupe de rats était testé pour leur réponse de locomotion à l’amphétamine (0; 0,5 ou 1 mg/kg, intrapéritonéal), dix jours suivant la lésion de l’HbL. La locomotion était mesurée dans des chambres d’activité, chacune équipée de deux faisceaux parallèles infrarouges. Le jour du test, les rats étaient pesés et placés dans la chambre d’activité puis leur activité locomotrice de base était mesurée pendant une heure. Les rats recevaient ensuite une dose d’amphétamine ou le véhicule (NaCl 0,9%) par voie intrapéritonéale et l’activité locomotrice était mesurée pendant deux heures supplémentaires. Un groupe de rats distinct a été utilisé dans l’expérience d’ASIC. Commençant sept jours suivant la lésion, les rats étaient entraînés à appuyer sur un levier afin de s’autoadministrer des stimulations électriques, au cours de sessions quotidiennes. Nous avons ensuite mesuré chacun des taux de réponses d’une série de stimulations aux fréquences décroissantes. À partir d’une courbe réponses-fréquences, le seuil de récompense était inféré par la fréquence de la stimulation nécessaire pour produire une réponse semi-maximale. Les seuils de récompense étaient stabilisés à un niveau similaire pour l’ensemble des rats. Enfin, l’effet sur la récompense de l’amphétamine était testé aux mêmes doses employées pour l’expérience de locomotion. RÉSULTATS: Une lésion neurotoxique de l’HbL n’a pas altéré les niveaux de base de l’activité locomotrice dans chaque groupe. Cependant, une telle lésion a potentialisé l’effet de locomotion de l’amphétamine (1 mg/kg) pendant la première heure suivant son administration, et une tendance similaire était observable pendant la seconde heure. À l’inverse, nous n’avons observé aucune interaction entre une lésion à l’HbL et l’effet amplificateur sur la récompense de l’amphétamine. CONCLUSION: Nos résultats révèlent une importante contribution fonctionnelle de l’HbL à la locomotion induite par l’activation de la voie mésolimbique dopaminergique avec une dose de 1 mg/kg d’amphétamine. À l’opposé, aucun effet sur la récompense n’a été observé. Ces résultats suggèrent que l’activation psychomotrice et l’amplifiation de la récompense produite par l’amphétamine dépendent de substrats dissociables, chacun étant différentiellement sensible à la modulation provenant de l’HbL. / The habenula, an epithalamic nucleus, is centrally located within the dorsal diencephalic conduction system. This dorsal pathway connects the limbic forebrain and basal ganglia to midbrain monoaminergic cell groups intricately involved in the control of behavior. In particular, the lateral habenula (LHb) projects to, among other sites, the ventral tegmental area (VTA). Indeed, recent work has revealed direct LHb innervation of VTA dopamine as well as GABA cells. Little is known, however, about the behavioral relevance of this innervation but this knowledge is of potential importance, since the VTA gives rise to the mesolimbic dopamine pathway, a system critically involved in goal-directed behavior. Our aim here was to begin to understand the contribution of the LHb to dopamine-dependent behaviors. To do this, we produced neurotoxic lesions of the LHb and measured amphetamine-enhanced locomotion and intracranial self-stimulation (ICSS), two behaviors highly sensitive to mesolimbic dopamine neurotransmission. METRIALS AND METHODS: Adult male Sprague-Dawley rats were anesthetised with isoflurane and mounted onto a stereotaxic apparatus. Ibotenic acid, an excitatory neurotoxin at glutamatergic receptors, was infused bilaterally into the LHb (0.25 μg/0.25 μl/side). Sham-lesioned rats received infusions of 0.9% sterile saline. Rats in the ICSS experiment were additionally implanted with a monopolar stimulation electrode in the posterior mesencephalon. One group of rats was tested for their locomotor response to amphetamine (0, 0.5 or 1 mg/kg, i.p.), ten days after LHb lesion. Locomotion was measured in rectangular activity chambers, each equipped with two parallel infrared photobeams. On test day, rats were weighed, placed in the activity chamber and baseline locomotor activity was measured for 1 hour. Rats then received amphetamine or vehicle (0.9% saline) and locomotor activity was measured for 2 more hours. A separate group of rats was used in the ICSS experiment. Beginning seven days post-lesion, rats were trained to press a lever in order to self-administer trains of stimulation pulses. We then measured response rates at each of a series of pulse frequencies during daily sessions. From these response-frequency curves, we obtained estimates of reward thresholds, defined as the pulse frequency necessary for half-maximal responding. Baseline reward thresholds were matched across all rats and once stable, we tested the reward-enhancing effect of amphetamine, at the same doses tested in the locomotion experiment. RESULTS: Neurotoxic lesions of the LHb did not alter baseline locomotor activity in either group. Amphetamine enhanced locomotor activity throughout the entire 2 hour test. Importantly, the locomotor stimulant effect of amphetamine (1 mg/kg) was significantly greater in lesioned rats during the first hour, and a similar tendency was observed during the second hour. On the other hand, we did not observe any difference in amphetamine-induced enhancement of reward between lesioned and sham rats, at any dose or any time post-injection. CONCLUSION: Our findings reveal an important functional contribution of the LHb to dopamine-mediated locomotion. On the other hand, the clear dissociation between the locomotor-stimulant and rewarding effects of amphetamine suggests that the neural substrates mediating these two are dissociable and differentially sensitive to LHb modulation.

La contribution de la neurotransmission dopaminergique dans le noyau accumbens à l’effet de récompense induit par la stimulation électrique du cerveau a été l’objet de plusieurs années de recherche. Cependant, d’autres sites recevant des terminaisons dopaminergiques pourraient contribuer à moduler la récompense dans d’autres régions cérébrales. Parmi elles, on retrouve l’habenula qui reçoit des projections dopaminergiques de l’aire tegmentale ventrale. La contribution de cette voie au phénomène de récompense en général et à l’effet de recompense induit par l’autostimulation intracrânienne est peu connue. Le but de cette recherche était d’étudier la contribution de la dopamine mésohabenulaire à l’effet de recompense induit par la stimulation électrique du raphé dorsal. Des rats ont été implantés d’une bicanule dans l’Hb et d’une électrode dans le raphé dorsal. Le paradigme du déplacement de la courbe a été utilisé pour évaluer les changements dans l’effet de récompense à la suite de l’injection intra-habenulaire d’amphétamine (10-40 μg). À titre de contrôles positifs, des rats ont reçu l’amphétamine dans le core et dans le shell (1-20 μg) du noyau accumbens. Les injections d’amphétamine dans l’habenula n’ont pas changé l’effet de récompense induit par la stimulation électrique. Dans le noyau accumbens, les injections dans le shell et le core provoquent des augmentations dans l’effet de récompense comme il a déjà été démontré. Nos résultats suggèrent que la neurotransmission dopaminergique dans l’habenula latérale ne contribue pas significativement au circuit soutenant l’effet renforçant de la stimulation électrique du cerveau. / The contribution of nucleus accumbens dopamine neurotransmission to reward and reinforcement has been the focus of many years of study. Other terminal sites have received comparatively less research attention, but may be potentially important. One of these sites is the lateral habenula, which receives dopaminergic innervation from cells arising from the ventral tegmental area. Very little is known about the contribution of this pathway to reward in general and to the rewarding effect of electrical brain stimulation in particular. The goal of this study was to study the contribution of mesohabenular dopamine to reward induced by electrical stimulation of the dorsal raphe. Male Sprague-Dawley rats were implanted with bilateral cannulae in the lateral habenula and a stimulation electrode aimed at the dorsal raphe nucleus. Using the curveshift paradigm, we measured the rewarding effect of intra-habenular infusions of amphetamine (10-40 μg). Control rats received amphetamine infusions into nucleus accumbens core or shell subregions (1-20 μg). Our findings show that regardless of concentration, intra-habenular amphetamine did not alter brain stimulation reward. Infusions into the nucleus accumbens enhanced the rewarding effectiveness of the stimulation, as previously shown. Our findings suggest that dopaminergic neurotransmission within the lateral habenula does not contribute significantly to the circuitry that mediates the rewarding effect of electrical brain stimulation.

Pain is a significant health problem. Mu opioid receptor agonists are used clinically as analgesics, but their use is constrained by high abuse liability. Intracranial self-stimulation (ICSS) is a preclinical behavioral procedure that has been used to assess abuse potential of opioids, and drug-induced facilitation of ICSS is interpreted as an abuse-related effect. ICSS can also be used as a behavioral baseline to detect affective dimensions of pain. Specifically, pain-related depression of ICSS can model pain-related depression of behavior and mood, and drug-induced blockade of pain-related ICSS depression can serve as a measure of affective analgesia. This dissertation used mu agonists that vary in efficacy at the mu receptor (methadone> fentanyl> morphine> hydrocodone> buprenorphine> nalbuphine) and compared their effects on ICSS in the absence (phase one) or presence (phase 2) of pain. Adult male Sprague-Dawley rats were equipped with intracranial electrodes targeting the medial forebrain bundle and trained to lever press for brain stimulation. Different frequencies of stimulation maintained a frequency-dependent increase in ICSS rates, and permitted detection of both rate-increasing and rate-decreasing treatment effects. During phase 1, medium- and high-efficacy mu agonists produced initial rate-decreasing effects, followed by abuse-related rate-increasing effects at later time points. Repeated morphine administration produced tolerance to its own rate-decreasing effects, cross-tolerance to rate-decreasing effects of other mu agonists, and enhanced expression of rate-increasing effects. Low efficacy mu agonists only produced rate-increasing effects, which were enhanced after repeated morphine. These results suggest that previous opioid exposure increases expression of abuse-related facilitation of ICSS by mu agonists regardless of efficacy. During phase 2, intraperitoneal administration of lactic acid (1.8%) served as a noxious stimulus to depress ICSS. All mu agonists blocked acid-induced depression of ICSS at doses similar to those that facilitated ICSS in the absence of pain. A higher intensity noxious stimulus (5.6 % acid) produced further depression of ICSS and reduced the antinociceptive potency of both methadone and nalbuphine. Morphine antinociception was resistant to tolerance in the assay of acid-depressed ICSS. Overall, these results provide a basis for comparing determinants of abuse-related opioid effects in the absence of pain with their affective analgesic effects in the presence of pain.

No description available.

Introdução: A doença aterosclerótica intracraniana é uma das principais causas de acidente vascular cerebral isquêmico (AVCI) no mundo, porém sua prevalência parece estar subestimada na população brasileira pela carência de estudos na área. O objetivo principal deste estudo foi descrever a frequência e gravidade da estenose intracraniana nos pacientes com AVCI ou ataque isquêmico transitório (AIT), utilizando a ultrassonografia transcraniana colorida (UTC). O objetivo secundário foi correlacionar os achados deste exame com a angiotomografia de crânio (AngioTC). Métodos: estudo observacional e prospectivo, onde foram avaliados pacientes consecutivos com o diagnóstico de AVCI ou AIT admitidos no período de fevereiro de 2014 a dezembro de 2014. A avaliação inicial consistiu na coleta de dados demográficos, epidemiológicos e clínicos e em seguida os pacientes foram submetidos ao exame de UTC através das janelas transtemporais e suboccipital, com o intuito de avaliar a presença de estenose intracraniana. Estenose intracraniana foi graduada em moderada (50- 70%), grave (70-99%) e suboclusão/oclusão (>= 99%). Foram considerados sintomáticos os casos em que houve uma associação entre os novos sinais e sintomas e uma nova área de infarto ao exame de neuroimagem no território da artéria envolvida ou quando o quadro neurológico correspondeu ao território da artéria envolvida. Os pacientes que possuíam UTC e AngioTC em sua avaliação foram comparados de forma cega quanto ao grau de estenose intracraniana seguindo a mesma classificação. Resultados: Foram avaliados 271 pacientes com o diagnóstico de AVCI ou AIT agudos (149 homens, com média de idade de 65,8 ± 12,5), 263 (97%) foram submetidos a exame de circulação intracraniana, sendo a ultrassonografia transcraniana colorida realizada em 168 casos (61,9%). Apenas 25 indivíduos (14,9%) foram excluídos devido a janela transtemporal insuficiente. Dentre os 143 pacientes que puderam ser avaliados adequadamente pela ultrassonografia transcraniana, a prevalência de estenose arterial intracraniana foi de 38,5% (55 casos); sendo sintomática em 25,2% dos casos. A média de idade dos pacientes era de 64 ± 11 anos, 26,9 % eram brancos e 29,4% hipertensos. Os pacientes com estenose intracraniana apresentaram maior pontuação na escala do NIH: 10 (IQ 4 - 19) vs 6 (IQ 3 - 13), maiores níveis de pressão arterial sistólica na admissão: 160 (IQ 145-170) vs 140 (IQ 130 - 155) e menores taxas de HDL: 32 (IQ 27 - 39) vs 36 (IQ 30 - 45). Após análise multivariada, o fator de risco independentemente associado à estenose intracraniana foi a hipertesão arterial sistêmica na admissão (p=0,006). Nos 100 pacientes com ambos os exames, a sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo da UTC comparada a AngioTC para detecção de estenoses intracranianas moderadas-graves foi de 60%, 73%, 73% e 60%, respectivamente. Conclusões: Encontramos alta frequência de estenose arterial intracraniana entre os pacientes com AVCI agudo e AIT na nossa população, especialmente entre indivíduos portadores de hipertensão arterial sistêmica. A UTC é uma ferramenta não-invasiva que pode ser utilizada para investigação da doença moderada-grave com acurácia moderada quando comparada a AngioTC / Background: Intracranial atherosclerotic disease is a major cause of ischemic stroke in the world, but its prevalence seems to be underestimated in our population by the lack of studies in the area. The aim of this study was to describe the frequency and severity of intracranial stenosis in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA), using the transcranial color-coded sonography (TCCS). The secondary objective was to correlate the TCCS test results with the findings on CT angiography on the same patients. Methods: Prospective observational study that evaluated consecutive patients admitted with a diagnosis of ischemic stroke or TIA during the period February 2014 to December 2014. The initial evaluation consisted of collection of demographic, epidemiological and clinical data and then the patients underwent the examination TCCS through transtemporal and suboccipital windows, in order to assess the presence of intracranial stenosis. Intracranial stenosis was graded moderate (50-70%), severe (70-99%) and subocclusion/occlusion (>= 99%). The cases were considered symptomatic when there was an association between new symptoms and signs and a new infarct area on neuroimaging in the territory of the stenotic artery or when the neurological status corresponded to the territory of that artery. Patients who had TCCS and intracranial angiography in their assessment were blindly compared for the degree of intracranial stenosis following the same classification. Results: We evaluated 271 patients with diagnosis of acute ischemic stroke and TIA (149 men, mean age 65.8 ± 12.5), 263 (97%) underwent examination of intracranial circulation, with the TCCS held in 168 cases (61.9%). Only 25 individuals (14.9%) were excluded due to insufficient transtemporal window. Among the 143 patients who could be evaluated properly by transcranial ultrasound, the prevalence of intracranial arterial stenosis was 38.5% (55 cases); with 25,2% symptomatic cases. The average age of patients was 64 ± 11 years, 26.9% were white and 29.4% hypertensive. Patients with intracranial stenosis had higher scores on the NIHSS: 10 (IR 4-19) vs 6 (IR 3- 13), higher levels of systolic blood pressure at entry: 160 (IR 145-170) vs 140 (IR 130 - 155) and lower HDL rates: 32 (IR 27-39) vs 36 (IR 30-45). After multivariate analysis, the risk factor independently associated with intracranial stenosis was systemic arterial hypertension at admission (p = 0.006). In the 83 patients with both tests, the sensitivity, specificity, positive predictive value and negative predictive value of TCCS compared to CT angiography for detection of intracranial stenosis moderate-severe was 60%, 73%, 73% e 60%, respectively, Conclusions: We found a high frequency of intracranial artery stenosis in patients with acute ischemic stroke and TIA in our population, especially among individuals with hypertension. TCCS is a non-invasive tool that can be used to study moderate-severe disease with moderate accuracy compared to CT angiography

Para desenvolver e avaliar a aplicabilidade de uma escala técnica prognostica das dificuldades no tratamento microcirúrgico dos aneurismas gigantes e complexos da circulação anterior do polígono de Willis, 50 lesões foram operadas. Um valor numérico foi dado a cada uma das 8 variáveis da escala. Somando-se os valores para cada variável, uma nota (de 1 a 14) foi obtida, para cada uma das 50 cirurgias. Dois grupos, portanto, foram definidos: cirurgia difícil (nota de 1 a 8) e cirurgia extremamente difícil (nota de 9 a 14). Foi feita análise estatística comparando-se os 2 grupos em relação a diversas variáveis demográficas e clínicas. Concluiu-se que a escala proposta é útil no planejamento pré-operatório, intra-operatório e prognóstico neste tipo de aneurisma / In order to develop and verify the applicability of a technical and prognostic scale of the difficulties in the microsurgical treatment of giant and complex aneurysms of the anterior circulation of the Cicle of Willis, 50 lesions were operated. A numeric amount was given for each of 8 variants of the scale. By adding each amount for each variant a score(from 1 to 14) was achieved, for each of the 50 surgeries. Two groups, therefore, were established: difficult surgery (scores from 1 to 8) and extremely difficult surgery (scores from 9 to 14). Statistical assessment comparing both groups in relation to several demographic and clinical variants was done. It was concluded that the proposed scale is useful in preoperative, intraoperative and prognostic planning in microsurgery for this kind of aneurysms

INTRODUÇÃO: A craniotomia pterional é uma das técnicas mais utilizadas em neurocirurgia. É uma craniotomia que tem constantemente sido comparada com técnicas alternativas utilizadas para acessar alvos anatômicos similares. Esta craniotomia, contudo, apresenta desvantagens, necessitando de dissecção completa do músculo temporal. Prognósticos estéticos desfavoráveis são comuns e atribuídos à atrofia do músculo temporal e do tecido adiposo adjacente ou à lesão do ramo frontal do nervo facial. A neurocirurgia moderna busca equilibrar o balanço entre o traumatismo cirúrgico tecidual e a exposição microcirúrgica. Algumas modificações técnicas têm sido sugeridas para reduzir o tamanho da craniotomia pterional, visando reduzir o traumatismo tecidual e melhorar os resultados estéticos. Entretanto, estas modificações não permitem exposição cirúrgica suficiente nem garante resultados cosméticos melhores. Esta tese descreve uma nova técnica, denominada craniotomia minipterional, e compara a exposição anatômica por ela proporcionada com a da craniotomia pterional convencional. MATERIAL E MÉTODOS: A exposição anatômica proporcionada pelas craniotomias pterional e minipterional foram comparadas em oito lados de cabeça de espécimes anatômicas usando um sistema computadorizado de localização estereotáxica (Optotrak 3020, Nothern Digital, Waterloo, ON, Canada) para medir uma área hexagonal pré-definida de exposição cirúrgica, um microscópio robótico (Surgiscope; Elekta Instruments, Inc, Atlanta, GA) para quantificar a exposição angular de três alvos anatômicos (bifurcações das artérias carótida interna e da artéria cerebral e o ponto médio da artéria comunicante anterior), e um sistema de neuronavegação (Medtronic Surgical Navigation Technologies, Louisville, CO) para avaliar os limites da exposição cirúrgica de cada craniotomia. Os dados foram submetidos à análise estatística utilizando análise de variância (ANOVA) RESULTADOS: Não houve diferenças estatísticas na área de exposição cirúrgica total entre as duas craniotomias (pterional=1524,7 +/- 305,0 mm2; minipterional = 1469,7 +/- 380,3 mm2; p>0,05) ou entre os componentes ipsilateral, intermédio e contralaterais da área total (p>0,05). Nenhuma diferença foi observada na exposição angular ao longo dos eixos longitudinal e transversal para os três alvos anatômicos considerados (bifurcações das artérias carótida interna e da artéria cerebral média e o ponto médio da artéria comunicante anterior) (p>0,05). Exceto para o segmento distal do compartimento opérculo-insular da cisterna sylviana, nenhuma diferença significativa nos limites da exposição cirúrgica das duas craniotomias foi evidenciada pelo sistema de neuronavegação. CONCLUSÃO: A craniotomia minipterional propicia exposição cirúrgica comparável àquela oferecida pela craniotomia pterional. / INTRODUCTION: Pterional craniotomy is one of the most used and versatile approaches in neurosurgery. It constitutes a standard against which alternative surgical techniques to the same anatomic targets have been compared for years. This technique, however, is not without disadvantages. It requires complete dissection of the temporalis muscle. Poor outcomes are common and can be attributed to atrophy of the temporalis muscle and superficial temporal fat pad or to injury of the frontal branch of the facial nerve. Contemporary neurosurgical techniques strive to balance the need to minimize tissue trauma and to maximize anatomic exposure. Many surgical modifications have been described to minimize the size of the pterional craniotomy in an effort to decrease tissue trauma and improve cosmetic outcomes. In many instances, however, these modifications neither ensure a sufficient anatomic exposure nor guarantee satisfactory aesthetic outcomes. This thesis describes a novel technique, the minipterional craniotomy, and compares its anatomic exposure with that provided by the pterional technique. MATERIALS AND METHODS: The anatomic exposure offered by the minipterional and pterional techniques were compared in eight sides of cadaver heads using a computerized tracking system (Optotrak 3020, Nothern Digital, Waterloo, ON, Canada) to measure a predefined hexagonal area of surgical exposure, a robotic microscope (Surgiscope; Elekta Instruments, Inc, Atlanta, GA) to quantify angular exposure in the transverse and longitudinal axis for three anatomic targets (bifurcations of internal carotid and middle cerebral arteries and the middle point of the anterior communicating artery), and an image-guidance system (Medtronic Surgical Navigation Technologies, Louisville, CO) to evaluate the limits of exposure for each craniotomy. Data were submitted to statistical analysis using ANOVA. RESULTS: There were no statistical differences in the total area of surgical exposure between the two craniotomies (pterional=1524.7 +/- 305.0 mm2; minipterional = 1469.7 +/- 380.3 mm2; p>0.05) or among the ipsilateral, middle, and contralateral components of the area (p>0.05). There were no differences in angular exposure along the longitudinal and transverse axis angles for the three selected targets, the bifurcations of internal carotid and middle cerebral arteries, and the anterior communicating artery (p> 0.05). Except for the distal portion of the operculoinsular compartment of the sylvian fissure, no significant differences in the limits of the surgical exposure through the pterional and minipterional were apparent on the image-guidance system. CONCLUSION: The minipterional craniotomy provides comparable surgical exposure to that offered by the pterional technique.