Neurocritical care
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Recombinant activated Factor VII (rFVIIa) has recently gained popularity for rapid reversal of coagulopathy during operative neurosurgery. Patients undergoing chronic subdural hematoma (CSDH) or epidural hematoma (EDH) evacuation often have their coagulation status judged by preoperative international normalized ratio (INR). We present our experience in two patients with significant clinical coagulopathy who were successfully reversed with rFVIIa in the setting of normal INR. ⋯ These two patients are the first to be examined for the use of rFVIIa for reversal of clinical coagulopathy in the setting of normal INR. Our experience suggests that normal INR should not be a deterrent for patients to receive rFVIIa in the setting of strong neurosurgical suspicion for underlying clinical coagulopathy.
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Case Reports
Neurointensive care management of raised intracranial pressure caused by severe valproic acid intoxication.
We describe the neurointensive care (NIC) management of a patient with severe cerebral swelling and raised intracranial pressure (ICP) after severe sodium valproic acid (VPA) intoxication. A previously healthy 25-year old male with mild tonic-clonic epilepsy was found unconscious with serum VPA levels >10,000 micromol/l. The patient deteriorated to Glasgow Motor Scale score (GMS) 2 and a CT scan showed signs of raised ICP. Early ICP was elevated, >50 mm Hg, and continuous EEG monitoring showed isoelectric readings. ⋯ We conclude that NIC may be an important treatment option in cases of severe intoxication causing cerebral swelling.
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Recent and on going clinical research trials may indicate that the incidence of vasospasm is less in patients treated with lumbar drains following SAH than with patients treated with external ventricular drainage (EVD) alone. These studies have sparked interest in the more aggressive use of LDs in patients with aneurysmal SAH but some clinicians have been concerned about safety. ⋯ LDs are safe when used in the setting of aneurysmal SAH if appropriate patient selection and good technique are employed.
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Reversible cerebral vasoconstriction syndrome (RCVS) is a rare vasculopathy of unknown etiology. Ischemic stroke and intracerebral hemorrhage are well-documented sequelae, but subarachnoid hemorrhage is an uncommon complication of RCVS. ⋯ Reversible cerebral vasoconstriction syndrome may be associated with subarachnoid hemorrhage. RCVS should be included in the differential diagnosis of non-aneurysmal subarachnoid hemorrhage.
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Case Reports
Successful endovascular treatment of a ruptured mycotic intracavernous carotid artery aneurysm in an AIDS patient.
As the medical treatment for human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) continues to advance, the HIV-related aneurysms may pose a clinical problem of increasing magnitude. The authors report on a successfully treated ruptured mycotic intracavernous carotid artery aneurysm case in an AIDS patient. ⋯ The cerebral aneurysms in HIV/AIDS patients can be generally categorized into two groups: the mycotic aneurysms from bacterial or fungal infections and the HIV-associated aneurysms as a distinct entity. To plan appropriate interventions, a high degree of clinical suspicion must be exercised to promptly recognize the mycotic nature of many HIV-related aneurysms.