Neuroleptic malignant syndrome (NMS) is a potentially fatal adverse event associated with the use of antipsychotics (AP). The objective of this study was to investigate the profile of cases of NMS and to compare our findings with those published in similar settings. A series of 18 consecutive patients with an established diagnosis of NMS was analyzed, gathering data on demography, symptoms and signs. Two thirds of all cases involved woman with a past medical history of psychiatric disorder receiving relatively high doses of AP. The signs and symptoms of NMS episodes were similar to those reported in other series and only one case had a fatal outcome, the remaining presenting complete recovery. As expected, more than two thirds of our cases were using classic AP (68%), however the clinical profile of these in comparison with those taking newer agent was similar. Newer AP also carry the potential for NMS. Key words: atypical antipsychotics, typical antipsychotics, neuroleptic malignant syndrome.Síndrome neuroléptica maligna RESUMO A síndrome neuroléptica maligna (SNM) é um evento adverso potencialmente fatal associado ao uso de antipsicóticos (AP). O objetivo deste estudo foi investigar as características clínicas de cases da SNM e comparar nossos resultados com os publicados na literatura. Uma série de 18 pacientes com diagnóstico confirmado de SNM foram analisados, associando dados demográficos, apresentação clínica, diagnóstico e tratamento. Dois terços dos casos envolveram mulheres com antecedentes psiquiátricos que recebeceram doses relativamente altas de AP. Os sinais e sintomas foram semelhantes àqueles já relatados na literatura e a maioria dos pacientes teve uma recuperação completa, exceto por um caso com desfecho fatal. Houve predomínio de pacientes que usam medicamentos neurolépticos clássicos (68%), porém não houve diferença nas manifestações destes casos em relação àqueles que usavam AP novos. AP mais novos também têm o potencial de causar SNM. Palavras-Chave: neurolépticos atípicos, neurolépticos típicos, síndrome neuroléptica maligna.

Neurological diseases are prevalent in the emergency room (ER). The aim of this study was to compare the neurological diagnoses between younger and older patients evaluated in the ER of a tertiary care hospital. Method: Patients admitted to the ER who required neurological evaluation in the first 24 hours were separated into two groups based on age, ≤50 years old and >50 years old. Results: Cerebrovascular disease (59.6% vs. 21.8%, p<0.01) was most frequent in the >50 years old group. Seizures (8.1% vs. 18.6%, p<0.01) and primary headache (3.7% vs. 11.4%, p<0.01) were most frequent in the ≤50 years old group. Conclusion: The current study demonstrated that these three neurological diagnoses represented the majority of the neurological evaluations in the ER. National guidelines for ER teams that treat these prevalent disorders must be included in clinical practice and training. Key words: nervous-system disease, stroke, headache, seizures, emergency medical services, health services epidemiology.Diagnósticos neurológicos na sala de emergência: diferenças entre pacientes jovens e idosos RESUMO Doenças neurológicas são prevalentes na sala de emergência (SE). O objetivo deste estudo é comparar a ocorrência de diagnósticos neurológicos entre pacientes jovens e idosos atendidos na SE de um hospital terciário. Método: Pacientes admitidos na SE que necessitaram avaliação neurológica nas primeiras 24 horas após a admissão foram separados em dois grupos baseados na idade, ≤50 anos de idade e >50 anos de idade. Resultados: Doença cerebrovascular foi o diagnóstico mais comum nos pacientes >50 anos (59,6% vs. 21,8%, p<0,01). Convulsões (8,1% vs. 18,6%, p<0,01) e cefaléias primárias (3,7% vs. 114%, p<0,01) foram mais frequentes no grupo ≤50 anos. Conclusão: O presente estudo demonstrou que esses três diagnósticos neurológicos representam a maioria das avaliações neurológicas na SE. Diretrizes nacionais para os profissionais emergencistas que tratam estas doenças devem ser incluídos na prática clínica e no treinamento médico. Palavras-chave: doença do sistema nervoso, AVC, cefaléia, convulsões, serviço médico de emergência, epidemiologia em serviços de saúde.

Few healthcare centers in Brazil perform thrombolytic therapy for acute ischemic stroke (AIS) patients. Objective: The aim of this study was to describe an interinstitutional protocol for the rapid identification and thrombolytic treatment of AIS patients at a public health hospital in a large Brazilian city. Method: Emergency medical services (EMS) personnel evaluated 433 patients with possible stroke during a six-month period. After a standard checklist, patients with suspected AIS and symptoms onset of less than two hours were evaluated at our University Hospital (UH). Results: Sixty-five (15%) patients met the checklist criteria and had a symptom onset of less than two hours, but only 50 (11%) patients were evaluated at the UH. Among them, 35 (70%) patients had ischemic stroke, 10 (20%) had hemorrhagic stroke, and 5 (10%) had other diagnoses. Of the 35 ischemic stroke patients, 15 (43%) underwent IV thrombolysis. Conclusion: The present study demonstrated that trained EMS workers could help to improve the rate of thrombolytic treatment in large Brazilian cities. Permanent training programs for EMS and hospital staff, with quality control and correct identification of AIS patients, should be implemented to increase appropriate thrombolytic therapy rates in Brazil. Key words: acute ischemic stroke, thrombolytic therapy, emergency medical services, stroke therapy, hospital management.Protocolo de AVCi agudo em Curitiba: uma iniciativa de um hospital universitário e do SAMU RESUMO No Brasil, apenas alguns hospitais realizam terapia trombolítica para o acidente vascular cerebral isquêmico agudo (AVCiA). Objetivo: O objetivo deste estudo foi descrever um protocolo inter-institucional para a rápida identificação e para o tratamento trombolítico de pacientes com AVCiA em hospital público de Curitiba, PR. Método: O Serviço de Atendimento Médico de Urgência (SAMU) avaliou 433 pacientes com possível AVC durante um período de seis meses. Depois de um check list padrão, os pacientes com suspeita de AVCiA e início dos sintomas inferior a duas horas, foram avaliados no Hospital de Clínicas (HC). Resultados: Sessenta e cinco (15%) pacientes preencheram os critérios propostos, porém apenas 50 pacientes (11%) foram avaliados no HC. Destes, 35 (70%) eram AVC isquêmico (AVCi), 10 (20%) eram hemorrágicos e 5 (10%) tiveram outros diagnósticos. Dos 35 pacientes com AVCi, 15 (43%) foram submetidos a trombólise IV. Conclusão: O presente estudo demonstrou que o treinamento do SAMU poderia auxiliar na otimização da terapia trombolítica em grandes cidades brasileiras. Programas permanentes de treinamento com controle de qualidade, caracterizados pela correta identificação de pacientes com AVCiA devem ser realizados nos hospitais em parceria com o SAMU para elevar as taxas de tratamento trombolítico no Brasil. Palavras-chave: acidente vascular cerebral isquêmico agudo, terapia trombolítica, serviços médicos de urgência, condutas hospitalares.

Solvent abuse is a public health problem in Brazil particularly among young adults and children. Inhalation of toluene-based products is popular with solvent sniffers because of the euphoric effect and easy availability of these substances. Chronic inhalation of toluene may result in a variety of neurologic complications like cerebellar dysfunction, optic atrophy, pyramidal tract signs, cranial nerve abnormalities. Also, personality changes, emotional instability and general cognitive decline have been attributed to its abuse 1 . We report an unusual case of acute optic neuritis induced by thinner sniffing. caseA 34-year-old man presented with an acute visual loss. He was admitted to the hospital reporting a sudden and progressive loss of visual acuity after sniffing a hole can of thinner during uninterrupted 48 hours. This homeless patient had a history of chronic solvent abuse for five years, moderate alcohol ingestion and tabagism, but denied other substances abuse. At the moment of the admission, 4 days after the beginning of the symptoms, he related to see only countenances. The physical examination and vital data were normal. The neurological examination was normal except for presenting bilateral mydriasis with severe reduction of the photomotor and consensual responses. Visual acuity was worse than 20/200. Ophthalmological examination demonstred bilateral papilledema, with normal ocular pressure and ocular movements. Other cranial nerves were normal. Laboratory examinations are listed in Table. Lumbar puncture showed 130 mmH 2 O opening pressure, 27 red blood cells/mm³, 1 leucocyte/mm³, glucose concentration 75 mg/dL, protein 39 mg/ dL and VDRL was negative. Magnetic resonance imaging (MRI) showed bilateral symmetric hyperintense lesions in the deep white matter, corpus callosum (splenium), centrum semiovale (Fig 1) and pons (Fig 2). EEG was irregular without specific pathological meanings. The patient was treated with methylprednisolone 1 gr/day for three days associated with replacement of B complex vitamins. Six days after the admission, the patient ran away from the hospital and one month later returned in the neurology clinic relating important improvement of the visual acuity. discussiOn Today, organic solvents contained in industrial and domestic products are the most commonly abused volatile substances. Formerly, benzene was the major organic solvent in paints, lacquers, and thinners. However, benzene is toxic to bone marrow and liver and has been replaced by n-hexane or toluene (methyl benzene), which are neuro-

-NMDA and non-NMDA receptors are involved in spinal transmission of nociceptive information in physiological and pathological conditions. Our objective was to study the influence of NMDA and non-NMDA receptor antagonists on pain control in the trigeminal system using a formalin-induced orofacial pain model. Motor performance was also evaluated. Male Rattus norvegicus were pre-treated with topiramate (T) (n=8), memantine (M) (n=8), divalproex (D) (n=8) or isotonic saline solution (ISS) (n=10) intraperitoneally 30 minutes before the formalin test. Formalin 2.5% was injected into the right upper lip (V2 branch) and induced two phases: phase I (early or neurogenic) (0-3 min) and phase II (late or inflammatory) (12-30 min). For motor behavior performance we used the open-field test and measured latency to movement onset, locomotion and rearing frequencies, and immobility time. Pre-treatment of animals with M and D only attenuated nociceptive formalin behavior for phase II. T increased locomotion and rearing frequencies and reduced immobility time. Treatment with M increased immobility time and with D reduced locomotion frequency. Our results showed that the NMDA antagonist (M) is more potent than the non-NMDA antagonists (D and T) in the control of pain in the inflammatory phase. The non-NMDA topiramate improved motor performance more than did D and M, probably because T has more anxiolytic properties.Key wOrDS: divalproex, formalin test, memantine, NMDA and non-NMDA receptors, topiramate.Influência dos antagonistas dos receptores NMDA e não-NMDA sobre a dor aguda e inflamatória ao nível do território do trigêmeo: um estudo placebo controlado Resumo -receptores NMDA e não-NMDA estão envolvidos na transmissão das informações nociceptivas em condições fisiológicas e patológicas. Com o objetivo de estudar a influência dos antagonistas dos receptores NMDA e não-NMDA sobre o controle de dor no sistema trigeminal utilizamos modelo de dor orofacial induzida pela formalina. Testes de desempenho motor foram também avaliados. ratos machos da espécie Rattus norvegicus foram tratados com topiramato (T) (n=8), memantina (M) (n=8), divalproato de sódio (D) (n=8) ou solução salina isotônica (SSI) (n=10), por via intraperitoneal, 30 minutos antes dos testes com a formalina. Formalina 2.5% foram injetadas na região do lábio superior dos animais (segundo ramo do trigêmeo) induzindo comportamento em duas fases distintas: fase I (precoce ou neurogênica) (0-3 min ) e fase II (tardia ou inflamatória) (12-30 min). Para avaliação da atividade motora utilizou-se o teste do campo aberto mensurando-se a latência para o início dos movimentos, número de casas andadas, freqüência de levantamentos e tempo de imobilidade. Animais pré-tratados com M e D atenuaram a fase inflamatória do teste da formalina. O T aumenta o número de casas andadas, freqüência de levantamentos e reduz o tempo de imobilidade. Nossos resultados mostram que o antagonista NMDA é mais potente do que os antagonistas não-NMDA para o controle da fase inflamatória da dor....