Neurocritical care
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Decompressive hemicraniectomy in large hemispheric infarctions has been reported to lower mortality and improve the unfavorable outcomes. Hematoma volume is a powerful predictor of 30-day mortality in patients with intracerebral hemorrhage (ICH). Hematoma volume adds to intracranial volume and may lead to life-threatening elevation of intracranial pressure. ⋯ Decompressive hemicraniectomy with hematoma evacuation is life-saving and improves unfavorable outcomes in a select group of young patients with large right hemispherical ICH.
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Paradoxical embolus should be suspected in young patients with cerebrovascular events who do not have any vascular risk factors. There is significant controversy as to how best to treat his phenomenon. ⋯ This case emphasizes the potential complications of the use of central lines in ICUs, particularly in patients with diabetic ketoacidosis in whom sluggish blood flow may predispose to a procoagulant state.
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Weaning patients with myasthenic crisis (MC) from mechanical ventilation is often difficult, and the ideal time for extubation is often uncertain. However, little is known about the risk of extubation failure and the factors that may affect its occurrence. The goals of this study were to assess the risk of extubation failure in patients with MC and to determine which clinical variables may predict unsuccessful extubation. ⋯ Extubation failure may often complicate MC. Older age and development of pulmonary complications during mechanical ventilation increase the risk of extubation failure.
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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.