Neurocritical care
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Case Reports
Multimodal neuromonitoring in a patient with aneurysmal subarachnoid hemorrhage associated with aortic coarctation.
Aortic coarctation (AC) rarely remains undiagnosed until adulthood. Intracranial aneurysms and spontaneous subarachnoid hemorrhage (SAH) are more frequent in patients with AC than in the general population. ⋯ Cerebral aneurysm rupture associated with coarctation of the aorta is rare. The aim of this report is to call attention to AC in, particularly, young patients presenting with SAH and to discuss advanced multimodal neuromonitoring techniques used to optimize intensive care management.
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Delirium is defined by a fluctuating level of attentiveness and has been associated with increased ICU mortality and poor cognitive outcomes in both general ICU and neurocritical care populations. Sedation use in the ICU can contribute to delirium. Limiting ICU sedation allows for the diagnosis of underlying acute neurological insults associated with delirium and leads to shorter mechanical ventilation time, shorter length of stay, and improved 1 year mortality rates. Identifying the underlying etiology of delirium is critical to developing treatment paradigms.
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Case Reports
The challenges with brain death determination in adult patients on extracorporeal membrane oxygenation.
To identify a reliable method of performing apnea testing as part of brain death determination in adult patients who develop loss of brainstem reflexes while receiving extracorporeal membrane oxygenation (ECMO). ECMO provides extracirculatory support to patients in cardiorespiratory failure who would otherwise be expected to die. Many studies have reported brain death as a potential complication of adult ECMO, but none have cited how apnea testing was performed in these patients. ⋯ Apnea testing is essential in the determination of brain death, but may not be employed in ECMO-treated adult patients. Apnea testing using the above protocol may assist in better decision making for adult ECMO patients at risk of brain death.
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Case Reports
Emergent, controlled lumbar drainage for intracranial pressure monitoring during orthotopic liver transplantation.
Measurement of intracranial pressure (ICP) is recommended in comatose acute liver failure (ALF) patients due to risk of rapid global cerebral edema. External ventricular drains (EVD) can be placed to drain cerebrospinal fluid and monitor ICP simultaneously although this remains controversial in the neurosurgical community given the risk of hemorrhagic complications. We describe a patient with ALF and global cerebral edema whose EVD failed immediately before orthotopic liver transplantation (OLT) in which a lumbar drain (LD) was used temporarily to monitor ICP. ⋯ Controlled CSF drainage using a lumbar drain can be used to monitor ICP when leveled at the foramen of Monro if EVD failure occurs perioperatively. The LD can temporarily guide ICP management until the EVD flow can be re-established after OLT.
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Intensivist staffing of intensive care units (ICUs) has been associated with a reduction in in-hospital mortality. These improvements in patient outcomes have been extended to neurointensivist staffing of neuroscience ICUs for patients with intracranial hemorrhage and traumatic brain injury. ⋯ The implementation of a neurointensivist-led neurocritical care team is associated with improved hospital discharge disposition for patients with aneurysmal subarachnoid hemorrhage.