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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La incidencia de lesiones isqu&#233;micas no se ha reducido de forma significativa en los traumatismos cranoencef&#225;licos graves &#40;TCEG&#41; a pesar de mejoras evidentes en la recogida&#44; traslado y atenciones prehospitalarias&#46; Estas lesiones secundarias&#44; sobrea&#241;adidas a la lesi&#243;n de impacto&#44; contribuyen a aumentar la tasa de morbi&#47;mortalidad que estos pacientes presentan&#46; Durante un per&#237;odo consecutivo de 6 meses hemos seleccionado 15 pacientes afectos de un TCEG &#40;Glasgow inferior o igual a 8&#41; en los cuales el examen tomodensitom&#233;trico demostraba una lesi&#243;n difusa de severidad variable&#46; La edad media de los pacientes fue de 25&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11 a&#241;os&#44; con una mortalidad del 33&#37; y unos malos resultados&#44; valorados de acuerdo con la escala de resultados de Glasgow del 53&#37;&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">En todos los casos&#44; se procedi&#243; a la colocaci&#243;n de un cateter retr&#243;grado en el bulbo de la yugular derecha para la determinaci&#243;n de diferencias arteriovenosas de ox&#237;geno &#40;AVDO 2&#41; y de lactatos &#40;AVDL&#41;&#46; A partir de estos par&#225;metros efectuamos una estimaci&#243;n del flujo sangu&#237;neo cerebral y determinamos la existencia o no de un metabolismo anaerobio incrementado dentro de las primeras 24 horas del traumatismo&#46; Dentro de este intervalo de tiempo&#44; 2 pacientes presentaban un &#237;ndice lactato-ox&#237;geno &#40;LOI&#41; superior o igual a 0&#46;08&#44; traduciendo la existencia de un metabolismo anaerobio considerablemente incrementado y por Jo tanto la existencia de una lesi&#243;n isqu&#233;mica precoz&#46; En los 13 casos en que el LOI fue inferior a 0&#46;08&#44; las AVDO2 demostraron un flujo aumentado &#40;hiperemia&#41; en 2 pacientes &#40;AVDO2 &#60; 1&#46;3<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;ml&#41;&#44; normal en 8 &#40;AVDO2 entre 1&#46;3 &#8211; 3&#46;0<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;ml&#41; y un patr&#243;n de hipoperfusi&#243;n compensada &#40;AVDO2 &#62; 3&#46;0<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;ml&#41; en 3&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se discuten los resultados&#44; haciendo &#233;nfasis en el probable desarrollo intrahospitalario de estas lesiones secundarias y en la importancia que tiene la detecci&#243;n precoz de los patrones de hipoperfusi&#243;n compensada por su potencial reversibilidad&#46; Discutimos el valor que la monitorizaci&#243;n precoz puede tener de las AVDO2 y AVDL en el manejo global de los pacientes con un TCEG y en especial en laslesiones difusas&#46;</p>"
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        "resumen" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In spite of better transportation and prehospital care of severe head injury patients&#44; recent neuropathological work has shown that the incidence of ischemic brain lesions has not been significantly reduced&#46; This type of secondary lesions contributes considerably to the poor outcome of patients with traumatic brain injuries&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">During a consecutive period of six months we selected for the study 15 patients &#40;mean age &#61;25&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11 yrs&#41; with severe head injury &#40;score of 8 points or less in the Glasgow Coma Scale&#41; showing difusse brain damage of variable importance in the admission CT scan&#46; The mortality rate in this group of patients was 33&#37; and 53&#37; of them had a poor coutcome &#40;Glasgow Outcome Scale&#41;&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">All patients had a catheter inserted in the right juguiar bulb to measure the arteriovenous differences of oxygen &#40;AVDO2&#41; and lactates &#40;AVDL&#41;&#46; Cerebral blood flow and metabolism were estimated from these data&#46; AVDO2 and AVDL allowed to evidenciate the existence of an increased anaerobic metabolism within 24 hours of impact&#46; Two patients had a lactate-oxygen index &#40;LOI&#41; above or equal to 0&#46;08 within this period of time indicating the presence of an early ischemic brain insulto In the 13 patients showing a LOI inferior to 0&#46;08 the AVDO2 revealed an increased cerebral blood flow &#40;hyperemia&#41; in 2 &#40;AVDO2 &#60; 1&#46;3<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;ml&#41;&#44; a normal cerebral blood flow in 8 &#40;AVDO2 &#61;1&#46;3-3<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;ml&#41; and a state of compensated hypoperfusion in 3 &#40;AVDO &#62; 3<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;ml&#41;&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Our results suggest that many ischemic lesions develop after admission of the patient into the neurosurgical unit&#46; The importance of an early diagnosis of the compensated hypoperfusion pattern is discussed&#44; and the value of early monitoring of AVDO2 and AVDL in the management of severe head injury patients&#44; especially in those suffering diffuse brain damage&#44; emphasized&#46;</p>"
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Vol. 2. Núm. 4.
Páginas 313-322 (enero 1991)
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Vol. 2. Núm. 4.
Páginas 313-322 (enero 1991)
Lesiones isquémicas en la fase aguda de los traumatismos craneoencefálicos graves (lesiones difusas)
Visitas
1637
J. Sahuquillo, M.A. Poca, E. Rubio
Servicio de Neurocirugía, Unidad de Vigilancia Intensiva Hospital de Traumatología. Barcelona
A. Robles+, M. Baguena+, C. Triginer+, M.C. Pelegri*
+ Servicio de Bioquímica. Barcelona
* Hospital Vall d’Hebron. Barcelona
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La incidencia de lesiones isquémicas no se ha reducido de forma significativa en los traumatismos cranoencefálicos graves (TCEG) a pesar de mejoras evidentes en la recogida, traslado y atenciones prehospitalarias. Estas lesiones secundarias, sobreañadidas a la lesión de impacto, contribuyen a aumentar la tasa de morbi/mortalidad que estos pacientes presentan. Durante un período consecutivo de 6 meses hemos seleccionado 15 pacientes afectos de un TCEG (Glasgow inferior o igual a 8) en los cuales el examen tomodensitométrico demostraba una lesión difusa de severidad variable. La edad media de los pacientes fue de 25.7±11 años, con una mortalidad del 33% y unos malos resultados, valorados de acuerdo con la escala de resultados de Glasgow del 53%.

En todos los casos, se procedió a la colocación de un cateter retrógrado en el bulbo de la yugular derecha para la determinación de diferencias arteriovenosas de oxígeno (AVDO 2) y de lactatos (AVDL). A partir de estos parámetros efectuamos una estimación del flujo sanguíneo cerebral y determinamos la existencia o no de un metabolismo anaerobio incrementado dentro de las primeras 24 horas del traumatismo. Dentro de este intervalo de tiempo, 2 pacientes presentaban un índice lactato-oxígeno (LOI) superior o igual a 0.08, traduciendo la existencia de un metabolismo anaerobio considerablemente incrementado y por Jo tanto la existencia de una lesión isquémica precoz. En los 13 casos en que el LOI fue inferior a 0.08, las AVDO2 demostraron un flujo aumentado (hiperemia) en 2 pacientes (AVDO2 < 1.3μmol/ml), normal en 8 (AVDO2 entre 1.3 – 3.0μmol/ml) y un patrón de hipoperfusión compensada (AVDO2 > 3.0μmol/ml) en 3.

Se discuten los resultados, haciendo énfasis en el probable desarrollo intrahospitalario de estas lesiones secundarias y en la importancia que tiene la detección precoz de los patrones de hipoperfusión compensada por su potencial reversibilidad. Discutimos el valor que la monitorización precoz puede tener de las AVDO2 y AVDL en el manejo global de los pacientes con un TCEG y en especial en laslesiones difusas.

Palabras clave:
Traumatismo craneoencefálico
Lesión difusa
Isquemia
Diferencias arteriovenosas de oxígeno
Metabolismo cerebral
Abstract

In spite of better transportation and prehospital care of severe head injury patients, recent neuropathological work has shown that the incidence of ischemic brain lesions has not been significantly reduced. This type of secondary lesions contributes considerably to the poor outcome of patients with traumatic brain injuries.

During a consecutive period of six months we selected for the study 15 patients (mean age =25.7±11 yrs) with severe head injury (score of 8 points or less in the Glasgow Coma Scale) showing difusse brain damage of variable importance in the admission CT scan. The mortality rate in this group of patients was 33% and 53% of them had a poor coutcome (Glasgow Outcome Scale).

All patients had a catheter inserted in the right juguiar bulb to measure the arteriovenous differences of oxygen (AVDO2) and lactates (AVDL). Cerebral blood flow and metabolism were estimated from these data. AVDO2 and AVDL allowed to evidenciate the existence of an increased anaerobic metabolism within 24 hours of impact. Two patients had a lactate-oxygen index (LOI) above or equal to 0.08 within this period of time indicating the presence of an early ischemic brain insulto In the 13 patients showing a LOI inferior to 0.08 the AVDO2 revealed an increased cerebral blood flow (hyperemia) in 2 (AVDO2 < 1.3μmol/ml), a normal cerebral blood flow in 8 (AVDO2 =1.3-3μmol/ml) and a state of compensated hypoperfusion in 3 (AVDO > 3μmol/ml).

Our results suggest that many ischemic lesions develop after admission of the patient into the neurosurgical unit. The importance of an early diagnosis of the compensated hypoperfusion pattern is discussed, and the value of early monitoring of AVDO2 and AVDL in the management of severe head injury patients, especially in those suffering diffuse brain damage, emphasized.

Key words:
Head injury
Diffuse brain injuy
Ischemia
Brain metabolismo Arteriovenous differences of oxygen
Jugular bulbo

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