Neurocritical care
-
The noise produced by oscillatory movements of secretions in the oropharynx, hypopharynx, and trachea during inspiration and expiration in unconscious terminal patients is often described as "the death rattle." The secretions are produced by the salivary glands and bronchial mucosa. These patients are usually too weak to expectorate or swallow the migrating secretions. Sputum usually only accumulates in these areas if there is a significant impairment of the cough reflex, as in deep coma or near death. ⋯ Death rattle was most commonly reported in patients dying from pulmonary malignancies, primary brain tumors, or brain metastases, and predicts death within 48 hours in 75% of the patients. After withdrawal of artificial ventilation from the intensive care unit, excessive respiratory secretion resulting in a rattling breathing during the last hours of life is not uncommon, especially not in pulmonary and neurological patients. The distressing experience and negative influence in the bereavement process indicates an ethical demand to treat this symptom from the perspective of others merely than that of the patient.
-
Cerebral vasospasm secondary to aneurysmal subarachnoid hemorrhage that has become refractory to maximal medical management can be treated with selective intra-arterial papaverine infusions. Papaverine is a potent vasodilator of the proximal, intermediate, and distal cerebral arteries and can improve cerebral blood flow (CBF). ⋯ Intra-arterial papaverine can be used alone or in combination with balloon angioplasty. This article reviews the mechanism of action, technique of administration, effects on CBF, clinical results, and complications of intra-arterial papaverine for the treatment of cerebral vasospasm.
-
This is a phase-2 safety trial to demonstrate the ability of frameless stereotactic aspiration and thrombolysis of ICH to safely remove blood. ⋯ Frameless stereotactic aspiration and thrombolysis (FAST) of deep spontaneous intracerebral hemorrhage is a safe therapy that is associated with reduction in ICH volume, early improvement in NIHSS and potentially could be used to improve outcome.
-
Decompressive craniectomy has demonstrated efficacy in reducing morbidity and mortality in critically ill patients with massive hemispheric cerebral infarction. However, little is known about the patterns of functional recovery that exist in patients after decompressive craniectomy, and controversy still exists as to whether craniotomy and infarct resection ("strokectomy") are appropriate alternatives to decompression alone. We therefore used functional magnetic resonance imaging (f-MRI) to assess the extent and location of functional recovery in patients after decompressive craniectomy for massive ischemic stroke. ⋯ After massive hemispheric cerebral infarction requiring decompressive craniectomy, patients may experience functional recovery as a result of activation in both the infarcted and contralateral hemispheres. The evidence of functional recovery in peri-infarct regions suggests that decompression alone may be preferable to strokectomy where the risk of damage to adjacent nonischemic brain may be greater.
-
Case Reports
Forearm compartment syndrome following intravenous thrombolytic therapy for acute ischemic stroke.
Minor and major bleeding complications have occurred following thrombolysis in acute ischemic stroke. However, compartment syndrome has not been reported among these incidences. ⋯ Patients suffering from stroke who fall are at risk of developing a compartment syndrome; the early diagnosis is often difficult, the sequelae can be devastating, and wrestling with the benefits and risks of reversing the coagulopathy in the acute phase of a cerebral infarction is a challenge.