RESUMO
We present the case of a patient with subarachnoid hemorrhage (SAH) secondary to a ruptured cerebral aneurysm and a refractory shock with high doses of vasopressors without a proven source of infection. This patient received therapy with high-volume hemofiltration plus adsorption, resolving the hemodynamic deterioration and with good neurological evolution. Our clinical case proposes that extracorporeal therapies may have a feasibility role in the management of complications of SAH.
Assuntos
Hemofiltração , Hemorragia Subaracnóidea/terapia , Hemofiltração/instrumentação , Humanos , Interleucina-6/sangue , Aneurisma Intracraniano/sangue , Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/terapia , Masculino , Pessoa de Meia-Idade , Hemorragia Subaracnóidea/sangue , Hemorragia Subaracnóidea/complicaçõesRESUMO
BACKGROUND: Intracranial aneurysms are arterial anomalies affecting 2% to 3% of the general population in the world and these ruptures are associated with a high mortality. Some risk factors, such as age, gender, smoking, alcohol, hypertension and familial history are associated with the number of aneurysms and their size. In addition, inflammatory processes within the blood vessels of the brain can activate matrix metalloproteinase-9 (MMP-9), which degrades various components of the extracellular matrix, such as elastin. Thereby, this work has aimed at evaluating the relationship between plasma MMP-9 levels and the risk factors that are associated with intracranial aneurysm, as well as investigating the aneurysm statuses (ruptured and unruptured) and comparing them with the control volunteers. METHODS: Between August 2014 to June 2016, blood samples were collected from 282 patients (204 ruptured and 78 unruptured saccular intracranial aneurysms) and 286 control volunteers. The MMP-9 plasma levels were measured by ELISA. Statistical analyzes were performed with SPSS software when using parametric or nonparametric tests, after the normality tests. RESULTS: Higher levels of MMP-9 were found in the aneurysm groups as a whole and when they were stratified by rupture status, then compared with the control group (pâ¯<â¯0.0001). When stratifying them by diameter, those smaller than 7â¯mm presented high levels of MMP-9 (pâ¯<â¯0.0001), especially in the ruptured ones. As for risk factors, hypertension and smoking were the most important. However, hypertension was mostly associated with the ruptured aneurysms (pâ¯<â¯0.0001). CONCLUSIONS: High levels of MMP-9 were found in smaller ruptured and unruptured intracranial aneurysms (<7â¯mm) with strongest statistical associations than other sizes, especially when associated with smoking and hypertension.
Assuntos
Aneurisma Roto , Aneurisma Intracraniano , Metaloproteinase 9 da Matriz/sangue , Adulto , Idoso , Aneurisma Roto/sangue , Aneurisma Roto/diagnóstico por imagem , Feminino , Humanos , Aneurisma Intracraniano/sangue , Aneurisma Intracraniano/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Fatores de RiscoRESUMO
BACKGROUND: Aspirin is a promising medical therapy for the prevention of intracranial aneurysm (IA) rupture. Recently, we found that men have a better response to aspirin than women. The purpose of this study was to determine whether a sex differential exists in the level of 15-hydroxyprostaglandin dehydrogenase (15-PGDH) in the lumen of human IAs. METHODS AND RESULTS: Consecutive patients undergoing coiling or stent-assisted coiling for a saccular IA at our institution were enrolled. Two samples (A and B) were collected from IA lumens, and the plasma level of 15-PGDH was measured using an ELISA-based method. The study included 38 patients, with 20 women and 18 men. Women and men were comparable on baseline characteristics. The mean plasma concentration of 15-PGDH did not differ statistically between sample A (62.8±16.2 ng/mL) and sample B (61.8±17.9 ng/mL; 95% confidence interval -6.6 to 9.4). The mean plasma concentration of 15-PGDH in IA lumens of samples A and B was significantly higher in men (73.8±13.5 ng/mL) than women (49.6±7.8 ng/mL; P<0.0001). CONCLUSIONS: Higher enzyme levels of 15-PGDH exist in the lumen of IAs of men compared with women. This observation could explain why aspirin confers better protection against IA rupture in men than in women. The susceptibility of an individual to aspirin may differ according to the level of 15-PGDH.
Assuntos
Hidroxiprostaglandina Desidrogenases/sangue , Aneurisma Intracraniano/enzimologia , Adulto , Idoso , Aspirina/uso terapêutico , Biomarcadores/sangue , Fármacos Cardiovasculares/uso terapêutico , Embolização Terapêutica/instrumentação , Feminino , Humanos , Aneurisma Intracraniano/sangue , Aneurisma Intracraniano/diagnóstico , Aneurisma Intracraniano/terapia , Masculino , Pessoa de Meia-Idade , Fatores Sexuais , Stents , Regulação para CimaRESUMO
OBJECTIVE: To evaluate if type 2 diabetes mellitus (DM) constitutes a prognostic factor for death and severe disability in patients with aneurysm clipping after subarachnoid hemorrhage (ASH), in an Intensive Care Unit (ICU). MATERIAL AND METHODS: This is a cohort study in patients who were admitted to the ICU between December-2009 and June-2010; 20 with DM (exposed group) and 40 without DM (non-exposed group). Mortality was quantified during ICU stay. At ICU discharge, severe disability was measured through the Glasgow Outcome Scale (category 2); and Glasgow Coma Scale was used to estimate the difference in consciousness level between ICU arrival and discharge. Descriptive statistics and Kaplan Meier survival curves were performed. RESULTS: Mean age was similar between groups (55.8 +/- 11 and 55.6 +/- 15 years, respectively, p = 0.40). A vegetative state was present in one patient without DM. The Glasgow Coma Scale score at ICU entry was 14.1 +/- 1.4 and at discharge, 12.0 +/- 3.6 in the exposed group (p = 0.01); and 13.9 +/- 2.0 us. 13.5 +/- 2.6, in the non-exposed group, respectively (p = 0.45). There were 3 deaths in patients with DM and 5, in patients without DM (p > 0.05); survival time was 12 (95%CI 7, 16) and 10 days (95%CI 7, 13), respectively. Mean glucose remained higher in patients who died at the ICU (p < 0.001). Hydrocephaly was present in 6 exposed patients and 2, non-exposed (p = 0.007). Additionally, 7 and 5 with and without DM, respectively registered a positive blood culture (p = 0.04). CONCLUSIONS: DM was not associated with higher mortality in ICU patients, but hyperglycemia was; thus, it is essential that the intensive care provider watches closely the glycemic control.
Assuntos
Diabetes Mellitus Tipo 2/complicações , Mortalidade Hospitalar , Aneurisma Intracraniano/cirurgia , Hemorragia Subaracnóidea/cirurgia , Idoso , Bacteriemia/complicações , Bacteriemia/epidemiologia , Glicemia/análise , Dano Encefálico Crônico/sangue , Dano Encefálico Crônico/epidemiologia , Dano Encefálico Crônico/etiologia , Estudos de Coortes , Diabetes Mellitus Tipo 2/sangue , Feminino , Escala de Coma de Glasgow , Humanos , Hidrocefalia/sangue , Hidrocefalia/epidemiologia , Hidrocefalia/etiologia , Hiperglicemia/epidemiologia , Hiperglicemia/etiologia , Unidades de Terapia Intensiva/estatística & dados numéricos , Aneurisma Intracraniano/sangue , Aneurisma Intracraniano/complicações , Estimativa de Kaplan-Meier , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estado Vegetativo Persistente/sangue , Estado Vegetativo Persistente/epidemiologia , Estado Vegetativo Persistente/etiologia , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Prognóstico , Estudos Retrospectivos , Hemorragia Subaracnóidea/sangue , Hemorragia Subaracnóidea/complicaçõesRESUMO
Hemodynamics plays an important role in the progression and rupture of cerebral aneurysms. The temporal and spatial variations in wall shear stress (WSS) within the aneurysmal sac are hypothesized to be correlated with the growth and rupture of the aneurysm. The current work describes the blood flow dynamics in 34 patient-specific models of saccular aneurysms located in the region of the anterior and posterior circulation of the circle of Willis. The models were obtained from three-dimensional rotational angiography image data and blood flow dynamics was studied under a physiologically representative waveform of inflow. The three-dimensional continuity and momentum equations for unsteady laminar flow were solved with commercial software using non-structured fine grid sizes. The vortex structure, the wall pressure, and the WSS showed large variations, depending on the morphology of the artery, size of the aneurysm, and form. A correlation existed between the mean WSS on the aneurysmal sac for lateral unruptured and ruptured aneurysms with an aneurysm surface index, which is defined as the ratio between the aneurysm area and the artery area at model inlet, respectively.
Assuntos
Aneurisma Intracraniano/sangue , Aneurisma Intracraniano/fisiopatologia , Modelos Cardiovasculares , Análise Numérica Assistida por Computador , Reologia , Aneurisma Roto/diagnóstico por imagem , Aneurisma Roto/fisiopatologia , Angiografia Cerebral , Circulação Cerebrovascular , Círculo Arterial do Cérebro/diagnóstico por imagem , Círculo Arterial do Cérebro/fisiopatologia , Simulação por Computador , Elasticidade , Humanos , Processamento de Imagem Assistida por Computador , Imageamento Tridimensional/métodos , Aneurisma Intracraniano/diagnóstico por imagem , Estresse MecânicoRESUMO
The goal of the present study was to determine concentrations of E-selectin in both cerebrospinal fluid (CSF) and serum of patients with aneurysmal subarachnoid hemorrhage (SAH) and to evaluate the correlation between the clinical parameters and E-selectin levels. Both CSF and serum samples obtained from 12 patients with aneurysmal SAH and 8 patients with hydrocephalus (control group) without any other known central nervous system disease were assayed for E-selectin by quantitative enzyme-linked immunosorbent assay and the results were compared between the two groups. Mean levels of soluble forms of E-selectin within the first 3 days and on the 5th and 7th days of SAH were 4.0 +/- 7.9, 2.8 +/- 5.2, and 3.1 +/- 4.9 ng/ml in the patient's CSF, and 33.7 +/- 9.2, 35.1 +/- 7.0, and 35.2 +/- 8.7 ng/ml in serum, respectively. In contrast, mean E-selectin levels were 0.1 +/- 0.2 ng/ml in CSF and 8.7 +/- 5.0 ng/ml in serum of control patients. The difference between groups was statistically significant regarding both CSF and serum E-selectin levels (P < 0.05). Thus, we have demonstrated a marked increase of E-selectin concentration in both CSF and serum of patients with aneurysmal SAH compared with control and suggest that blocking the interaction between E-selectin and vascular endothelium may have a beneficial effect on vasospasms.
Assuntos
Selectina E , Aneurisma Intracraniano , Hemorragia Subaracnóidea , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Biomarcadores/líquido cefalorraquidiano , Estudos de Casos e Controles , Selectina E/sangue , Selectina E/líquido cefalorraquidiano , Ensaio de Imunoadsorção Enzimática , Feminino , Humanos , Aneurisma Intracraniano/sangue , Aneurisma Intracraniano/líquido cefalorraquidiano , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Hemorragia Subaracnóidea/sangue , Hemorragia Subaracnóidea/líquido cefalorraquidiano , Fatores de TempoRESUMO
The goal of the present study was to determine concentrations of E-selectin in both cerebrospinal fluid (CSF) and serum of patients with aneurysmal subarachnoid hemorrhage (SAH) and to evaluate the correlation between the clinical parameters and E-selectin levels. Both CSF and serum samples obtained from 12 patients with aneurysmal SAH and 8 patients with hydrocephalus (control group) without any other known central nervous system disease were assayed for E-selectin by quantitative enzyme-linked immunosorbent assay and the results were compared between the two groups. Mean levels of soluble forms of E-selectin within the first 3 days and on the 5th and 7th days of SAH were 4.0 ± 7.9, 2.8 ± 5.2, and 3.1 ± 4.9 ng/ml in the patient's CSF, and 33.7 ± 9.2, 35.1 ± 7.0, and 35.2 ± 8.7 ng/ml in serum, respectively. In contrast, mean E-selectin levels were 0.1 ± 0.2 ng/ml in CSF and 8.7 ± 5.0 ng/ml in serum of control patients. The difference between groups was statistically significant regarding both CSF and serum E-selectin levels (P < 0.05). Thus, we have demonstrated a marked increase of E-selectin concentration in both CSF and serum of patients with aneurysmal SAH compared with control and suggest that blocking the interaction between E-selectin and vascular endothelium may have a beneficial effect on vasospasms.
Assuntos
Humanos , Masculino , Feminino , Adolescente , Adulto , Pessoa de Meia-Idade , Idoso de 80 Anos ou mais , Selectina E , Aneurisma Intracraniano , Hemorragia Subaracnóidea , Aneurisma Intracraniano/sangue , Aneurisma Intracraniano/líquido cefalorraquidiano , Estudos de Casos e Controles , Ensaio de Imunoadsorção Enzimática , Biomarcadores/sangue , Biomarcadores/líquido cefalorraquidiano , Índice de Gravidade de Doença , Hemorragia Subaracnóidea , Selectina E/sangue , Selectina E/líquido cefalorraquidiano , Fatores de TempoRESUMO
We have previously reported that subarachnoid hemorrhage due to ruptured intracranial aneurysm (SH) is associated with changes in the hormonal profile in the first 24 hours after the event. We proposed that the hormonal changes observed are due to the intense stress to which the patients are exposed. However, the thyroidal hormonal profile is indicative of the presence of a nonthyroidal illness syndrome (NTIS). In this paper, we examined whether the change in the thyroid hormone profile is compatible with a NTIS. Two groups of patients were included in the study: A) 30 patients with SH (21 females and 9 males; 41.7+/-11.4 years) and B) a control group including 25 patients with benign diseases of the spine (BDS) (lumbar disc hernia or stable spinal trauma) (8 females and 17 males; 41.3+/-14.2 years). In a subgroup of eight patients of each group serum triiodothyronine (T3) and reverse T3 levels were measured. The blood samples were obtained between 8:00 and 9:00 AM. The following results were obtained: The SH group had smaller serum T3 and free T4 levels than the BDS group (p<0.05): T3 (ng/mL): SH = 58.7+/-1.1 and BDS = 74.5+/-13.9; free T4 (ng/dL): SH = 0.9+/-0.2 and BDS = 1.1+/-0.3. There was no significant difference in the serum levels of total thyroxine (T4) and thyroid-stimulating hormone (TSH) between the two groups: T4 ( microg/dL): SH = 6.9+/-1.1 and BDS = 7.4+/-2.1; TSH ( microUI/mL): SH = 1.5+/-0.8 and BDS = 1.8+/-1,0. In the sample of eight patients of each group we had the following results: T3 (ng/mL): SH = 66.8+/-3.8 and BDS = 77.2+/-1.1 (p <0.05); reverse T3 (ng/dL): SH = 32.8+/-8 and BDS = 24.7+/-2.2 (NS); T3/ reverse T3 ratio: SH = 2.6+/-0.3 and BDS = 3.3+/-0.4 (NS). Thyreoglobulin and microsomal antibodies were not detectable, except in one patient in the SH group. In conclusion, the SH patients present serum levels of T3 and free T4 significantly lower than that of BDS patients; the thyroidal hormone profile suggests that SH patients have developed the nonthyroidal illness syndrome.
Assuntos
Aneurisma Roto/sangue , Aneurisma Intracraniano/sangue , Hemorragia Subaracnóidea/sangue , Hormônios Tireóideos/sangue , Adulto , Aneurisma Roto/complicações , Biomarcadores/sangue , Estudos de Casos e Controles , Feminino , Humanos , Aneurisma Intracraniano/complicações , Masculino , Hemorragia Subaracnóidea/etiologia , Síndrome , Tireotropina/sangue , Tiroxina/sangue , Tri-Iodotironina/sangueRESUMO
UNLABELLED: It is well known that the central nervous system (CNS) influences the pituitary hormone secretions and that diseases of CNS are frequently associated with an altered endocrine function. The aim of this study has been the evaluation of the serum concentrations of the pituitary and thyroid hormones in a series of patients with subarachnoid hemorrhage due to a ruptured cerebral aneurysm. Thirty-five patients (23 females and 12 males), aged 51.9 +/- 13.3 years on the mean were admitted. They were evaluated to assess the clinical severity of the subarachnoid hemorrhage by Hunt & Hess scale: nine patients were in the grade I, 14 in the grade II, and 12 in the grade III. Blood samples were obtained between 8:00 and 9:00 a.m. and serum hormones were measured by commercial kits (IRMA or MEIA methods). Cortisol serum levels (normal range (NR) = 5 to 18 micro g/dL) were increased in all the patients (mean +/- standard deviation = 31.4 +/- 12.4 micro g/dL). Mean prolactin levels (NR < 20 ng/mL) were 18.6 +/- 17.1 ng/mL and five patients (14.2%) had levels higher than normal. FSH and LH levels were normal according to age and sex: men: FSH = 4 +/- 2.9 mUI/mL (NR = 1 to 10.5 mUI/mL); LH = 6.1 +/- 6.3 mUI/mL (NR = 2 to 12 mUI/mL); premenopausa women: FSH = 2.5 +/- 1.5 mUI/mL (NR = 2.4 to 9.3 mUI/mL); LH 3.9 +/- 5.1 mUI/mL (NR =2 to 15 mUI/mL); post- menopausal women: FSH = 48.3 +/- 18.5 mUI/mL (NR =31 to 134 mUI/mL); LH = 29 +/- 13.8 mUI/mL (NR =16 to 64 mUI/mL). Mean TSH levels were 3.9 +/- 5.2 micro UI/mL (NR =0.5 to 4.7 micro UI/mL) and five patients (14.2%) had levels higher than normal. Mean triiodothyronine levels (T3) were 66.4 +/- 18.7 ng/dL (NR = 45 to 137 ng/dL) and five patients (14.2%) had levels lower than normal (33.8 +/- 9 ng/dL). Mean thyroxine levels (T4) (NR= 4.5 to 12.5 micro g/dL) were 7.4 +/- 1.7 micro g/dL and two patients (5.6%) had levels lower than normal. Thyroglobulin and microsomal antibodies were not detectable. CONCLUSIONS: In the first 24 hours following ictus, the hormonal changes may be due to the stress produced by the intracranial bleeding; thyroid hormone alterations suggest that patients with subarachnoid hemorrhage might have an euthyroid sick syndrome.
Assuntos
Aneurisma Roto/sangue , Aneurisma Intracraniano/sangue , Hormônios Hipofisários/sangue , Hemorragia Subaracnóidea/sangue , Hormônios Tireóideos/sangue , Análise de Variância , Aneurisma Roto/complicações , Biomarcadores , Feminino , Humanos , Hidrocortisona/metabolismo , Aneurisma Intracraniano/complicações , Masculino , Pessoa de Meia-Idade , Hipófise , Ruptura Espontânea , Índice de Gravidade de Doença , Hemorragia Subaracnóidea/etiologiaRESUMO
BACKGROUND: This prospective study was accomplished with 14 patients, 10 women and 4 men, where some pre-, intra- and immediate postoperative parameters of hemostasis were analyzed and compared to a control group of normal individuals. METHODS: The patients included in this study were admitted to the Hospital das Clinicas at Unicamp in the 1990-1993 period. All the accepted patients have had their latest bleeding at least 30 days before surgery, therefore, after the acute bleeding phase, because in this phase there are alterations in hemostasis. In this period only dipyrone was used in all patients as analgesics and antipyretics. Opiates were used in all the anesthetic proceedings. The following parameters were determined: coagulation; prothrombin time, (PT), thrombin time, (TT), activated partial thromboplastin time, (APTT), platelets (PQ), fibrinogen, (FG) factor V, (F V), protein C, (P C), protein S (PS), antithrombin III (AT III); fibrinolysis, plasminogen (PLG), C 1 inhibitor (C 1), alfa 2 macroglobulin (A2M), prekallikrein (PK), euglobulin lysis time (ELT), lysis area in fibrin plates (LAFP), in 5 of these 14 patients. Activity of both plasminogen tissue activator (t-PA) and plasminogen activator inhibitor (PAI-1) were also determined. For analyze the hepatic function pre-albumin (PRE ALB) was determined. RESULTS AND CONCLUSIONS: In this study, the analysis of LAFP and ELT in the different surgical times suggests that the patients submitted to cerebral aneurysm surgery are head to hypofibrinolysis from the intraoperative to the immediate postoperative period and this evidence do not related whit PAI-1.