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Featured Program: Neurocritical Care at the Paulo Niemeyer State Brain Institute (IECPN) in Rio de Janeiro, Brazil

By Currents Editor posted 03-29-2018 23:00

  

Pedro_Kurtz__MD__PhD.bmpBy Pedro Kurtz, MD, PhD

Paulo Niemeyer State Brain Institute (IECPN) was inaugurated in 2013 as Brazil’s first public hospital/institute entirely dedicated to the treatment of patients with neurological and neurosurgical diseases, and to research and teaching in the field. The hospital’s infrastructure includes state-of-the-art operating rooms, two MRIs (including one inside the OR), two CT scans (one “mobile” for brain CT of severe patients), a neurovascular laboratory and a 44-bed neuro ICU, including eight beds of pediatric neuro ICU. Its privileged location, within the heart of Rio de Janeiro, has allowed IECPN to rapidly become a tertiary center, which receives a great number of referrals from a statewide network of public hospitals.

Since its opening four years ago, IECPN has received more than 50,000 patients and performed more than 4,500 neurosurgeries. The main pathologies treated were cerebral aneurysms (including subarachnoid hemorrhage), malignant brain tumors and pituitary adenomas, but other treatments such as the advanced neurosurgical management of epileptic disorders, Parkinson’s disease and other brain tumors or vascular malformations also play a key role in the institute’s daily activities. The institute’s medical director and leader of the neurosurgical team is Dr. Paulo Niemeyer Filho.

The neurocritical care team is led by Dr. Fabio Miranda, Dr. Pedro Kurtz and Dr. Nestor Charris, along with a faculty of seven attending physicians with large experience in the neuro ICU and a mixed background of intensive care, neurology and cardiology. A multidisciplinary approach is a crucial part of the institute’s philosophy, and the daily rounds includes a team of neurointensivists, neurosurgeons, nurses, physical therapists, pharmacists, speech therapists and psychologists. This allows us to provide patients with 24/7 bedside availability of transcranial Doppler examination, point-of-care ultrasound, echocardiography, continuous EEG interpretation and intracranial pressure monitoring, as well as early rehabilitation and progressive mobilization, and is essential to define therapeutic goals and meet the challenges that our patients offer.  

Featured_Program_March_2018.bmpThe Neuroendocrinology Service, headed by Dr. Monica Gadelha, performs approximately 200 consultations per month. A multidisciplinary pituitary team meets every week to discuss all surgical cases, and dynamic tests for evaluation of pituitary hormone deficiencies and simultaneous bilateral petrosus sinus sampling for investigation of the etiology of hypercortisolism are also performed in a regular basis. The team is also very active in research activities, and in the few years since its opening, IECPN has already become a neuroendocrinology reference center for the diagnosis and treatment of pituitary diseases, receiving residents and postgraduate students from seven other hospitals located in the city of Rio de Janeiro to develop their projects.

As a major part of its research, the institute’s Neuropathology and Molecular Genetics Laboratory develops a translational research focusing on the molecular basis of pituitary adenomas and on the establishment of biomarkers of response to different treatments for pituitary tumors.
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In the Laboratory of Neuropathology, all neurosurgical specimens are processed for histopathological analysis and diagnosis and when necessary, immuno-histochemistry is performed to help in the classification and grading of the tumors. In selected tumors, particularly diffuse gliomas, IDH1, P53 and ATRX mutations are investigated with immuno-histochemistry, and, if necessary, molecular methods can also be used. Besides that, the status of hormonal receptors in meningiomas, pituitary adenomas, the presence of infectious agents and inflammatory cells, as well as malformations causing epilepsy, can also be detected.

Our clinical research group in neurocritical care is led by Dr. Cassia Righy, focusing mainly in Subarachnoid Hemorrhage (SAH) and Sepsis in neurocritically ill patients. In cooperation with other high-volume centers in Brazil, our group has already developed a prospective online based registry of SAH patients, which includes more than 300 patients from IECPN. Early analysis of our data has allowed us to evaluate functional outcomes and compare our results to other high-volume, high-quality centers in the world, and our goal for the next few years is to have multicenter epidemiological data on SAH, which has not been reported in Brazil.

Other of our main research areas involve molecular biology, neuropathology and neuroendocrinology. Translational research projects, such as the investigation of microcephaly and the effects of ZIKA virus on normal glial cells and glioma cells, are being conducted in the institute’s laboratories in cooperation with other federal universities. Other example involves the Department of Epilepsy that focuses on the mRNA and protein profile of the corpus callosum and its epileptogenic potential. Moreover, the Laboratory of Biomedicine studies the dynamic transition between glioblastoma stem cells and non-stem glioblastoma cells, in order to better understand tumor progression in such an aggressive disease. This line of research employs a spectral approach to: 1) identify new biomarkers such as microRNAs that could provide additional diagnostic information; and 2) understand the mitochondrial metabolism of glioma stem cells (GSC), with a focus on IDH 1-2 gene polymorphism, in collaboration with our Neuropathology Laboratory. More recently, IECPN started a line of research on liquid biopsy, with a network involving three different universities in Rio de Janeiro. The objective is to compare the diagnostic accuracy of this method to detect other tumors and gliomas.

In reference to teaching activities, the main initiative of our group is the Neurocritical Care Post Graduate Course, which was designed as a one-year (240-hour) program, coordinated by Dr. Ricardo Turon and Dr. Darwin Prado and is now about to host our second class of trainees. The course was developed for physicians who work in the ICU and are looking for an in-depth knowledge of neurocritical care. Since Brazil does not yet offer any formal training in neurocritical care, our postgraduate course stands out as a rare opportunity physicians have to specialize in the area without leaving the country.

The opening of IECPN is definitely a milestone in the history of Brazil’s public health. This visionary initiative has brought cutting edge treatment and state-of-the-art technology to a great number of patients who had never had access to private healthcare, as well as forefront research in critical areas of neuroscience and education for future generations of healthcare professionals training in neurocritical care and neurosurgery.

Author’s Note: I would like to thank Dr Vivaldo Moreira Neto, Dr Leila Chimelli and Dr Monica Gadelha for their contributions for this article.

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