Neurocritical care
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The management of Dysautonomia following severe traumatic brain injury (TBI) remains problematic, primarily due to an inadequate understanding of the pathophysiology of the condition. While the original theories inferred an epileptogenic source, there is greater support for disconnection theories in the literature. Disconnection theories suggest that Dysautonomia follows the release of one or more excitatory centres from higher centre control. ⋯ This article presents a critical review of the competing theories against the available observational, clinical and neurotransmitter evidence. Following this process, it is suggested that the EIR Model more readily explains pathophysiological and treatment data compared to conventional disconnection models. In particular, the EIR Model provides an explanatory model that encompasses other acute autonomic emergency syndromes, accommodates 'triggering' of paroxysms and provides a rationale for all known medication effects.
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Thrombolysis heralded a new era of acute intervention for ischemic stroke, accompanied by an increasing need for comprehensive acute critical care support. There remains the prospect of novel cerebral protection strategies. Cerebral ischemia initiates a complex cascade of events at genomic, molecular, and cellular levels, and inflammation is important in this cascade, both in the CNS and in the periphery. ⋯ A promising novel therapeutic approach is the interleukin-1 receptor antagonist (IL-1ra), which limits the action of the cytokine IL-1, a pivotal mediator in the pathophysiology of acute neurodegeneration. Critical care has much to offer some patients after acute ischemic stroke, including the delivery of acute interventions, often with very short therapeutic time windows, physiological support, and the management of complications. We discuss inflammation and its mediators in acute ischemic stroke, the systemic stress, and acute phase protein responses to acute ischemic stroke, how inflammation is relevant in deteriorating ischemic stroke, the impact of physiological variables, and both current and emerging interventions for acute ischemic stroke.
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In various surgical procedures, evidence for racial/ethnic disparities has continued to grow in recent years. Our purpose was to review the current literature regarding racial/ethnic disparities in the United States in the surgical treatment and outcome of three different cerebrovascular disease entities: carotid stenosis, intracranial aneurysm, and cerebral arteriovenous malformation (AVM). ⋯ Results of this comprehensive literature review suggest that racial disparities in cerebrovascular disease are understudied. Race-associated differences in neurosurgical outcomes must be documented and vigorously investigated to determine the basis of any observed differences and ensure that we are providing the best care possible to all of our patients.
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Decompressive Craniectomy (DC) is used to treat elevated intracranial pressure that is unresponsive to conventional treatment modalities. The underlying cause of intracranial hypertension may vary and consequently there is a broad range of literature on the uses of this procedure. Traumatic brain injury (TBI), middle cerebral artery (MCA) infarction, and aneurysmal subarachnoid hemorrhage (SAH) are three conditions for which DC has been predominantly used in the past. ⋯ We conclude that at the time of this review, there still remains insufficient data to support the routine use of DC in TBI, stroke or SAH. There is evidence that early and aggressive use of DC in good-grade patients may improve outcome, but the notion that DC is indicated in these patients is contentious. At this point, the indication for DC should be individualized and its potential implications on long-term outcomes should be comprehensively discussed with the caregivers.
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Review Case Reports
Spontaneous spinal epidural hematoma of unknown etiology: case report and literature review.
Our objective is to emphasize the importance of recognizing and rapidly treating spontaneous spinal epidural hematoma (SSEH). SSEH is a pathologic entity traditionally thought to be exceptionally rare but which, in the era of MR imaging, is becoming increasingly prevalent, and which if treated with sufficient rapidity can be completely curable. ⋯ As evidenced in the literature, outcome depends on time to operation and prognosis is impacted by age and preoperative deficit. Because of the high risk of poor outcome without treatment, SSEH should always be a diagnostic consideration in patients whose presentation is even slightly suggestive. Rapid, appropriate treatment of these patients can often lead to complete recovery of function, whereas any delay in appropriate treatment can be catastrophic.