Arquivos de neuro-psiquiatria
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A 36 year-old black female, complaining of headache of one month's duration presented with nausea, vomiting, somnolence, short memory problems, loss of weight, and no fever history. Smoker, intravenous drugs abuser, promiscuous lifestyle. ⋯ left homonimous hemianopsia, left hemiparesis, no papilledema, diffuse hyperreflexia, slowness of movements. Brain CT scan: tumor-like lesion in the splenium of the corpus calosum, measuring 3.5 x 1.4 cm, with heterogeneous enhancing pattern, suggesting a primary CNS tumor. Due to the possibility of CNS infection, a lumbar puncture disclosed an opening pressure of 380 mmH(2)0; 11 white cells (lymphocytes); glucose 18 mg/dl (serum glucose 73 mg/dl); proteins 139 mg/dl; presence of Trypanosoma parasites. Serum Elisa-HIV tests turned out to be positive. Treatment with benznidazole dramatically improved clinical and radiographic picture, but the patient died 6 weeks later because of respiratory failure. T. cruzi infection of the CNS is a rare disease, but we have an increasing number of cases in HIV immunocompromised patients. Diagnosis by direct observation of CSF is uncommon, and most of the cases are diagnosed by pathological examination. It is a highly lethal disease, even when properly diagnosed and treated. This article intends to include cerebral trypanosomiasis in the differential diagnosis of intracranial space-occupying lesions, especially in immunocompromised patients from endemic regions.
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In recent years, noncomprehensive "guidelines" were proposed for the management of severe acute brain injuries, focusing strictly on two approaches: 1) to maintain cerebral perfusion pressure anywhere above 70 mm Hg; and 2) to maintain arterial carbon dioxide tension levels above 30 torr. Strictly following these propositions, a recently reported prospective controlled study addressed mortality rates of no less than 75-76%, far worse than mortality rates reported before those "guidelines" were published. As a humanitarian alternative, the present comprehensive guidelines are aimed at addressing practical bedside strategies to manage no only intracranial pressure and cerebral perfusion pressure but also cerebral extraction of oxygen, based on solid previously reported papers which revealed the lowest mortality rates (below 15%) in the pertinent literature, in recent years.