Neurocritical care
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Transcranial Doppler (TCD) ultrasonography to demonstrate cerebral circulatory arrest (CCA) is a confirmatory test for brain death (BD). The primary aim of this retrospective study was to evaluate the practical utility of TCD to confirm BD when clinical diagnosis was not feasible due to confounding factors. Secondary aims were to evaluate the reasons for inability of TCD to confirm BD and to assess the outcome of patients not brain dead according to the TCD criteria. ⋯ Using the conventional criteria, TCD confirmed BD in a large proportion, of patients where clinical diagnosis could not be made. The presence of CCA pattern in one or more major cerebral artery may be prognostic of unfavorable outcome, even when BD criteria are not satisfied.
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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.
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Cerebral vasospasm has become the most concerning complication in patients with aneurysmal subarachnoid hemorrhage (aSAH) seen in the neurosciences intensive care unit (NSICU). Hemodynamic augmentation is frequently used to treat cerebral ischemia from vasospasm. In the last 5 years, posterior reversible encephalopathy syndrome (PRES) has been reported in three single case reports as a complication of hemodynamic augmentation. We describe an additional three patients seen in our institution. ⋯ PRES can be a cause of deterioration in patients with aSAH treated with hemodynamic augmentation. PRES should be differentiated from evolving infarctions due to cerebral vasospasm. Clinical manifestations and neuroimaging findings are reversible after gradual normalization of blood pressure.
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There is limited information on the incidence and effect of acute kidney injury (AKI) in patients with severe traumatic brain injury (TBI), although AKI may affect outcome. Recently, acute kidney injury network (AKIN) classification has been widely accepted as a consensus definition for AKI. The aim of this study is to estimate the frequency and level of severity of AKI in patients with severe TBI by using AKIN criteria and to study whether AKI affects outcome. ⋯ It is demonstrated using the newly defined AKIN criteria for renal dysfunction that AKI is a relatively common feature in patients with severe TBI, and even seemingly insignificant decrease in renal function may be associated with worse outcome. This study highlights the importance of close surveillance of renal function and stresses the value of renal hygiene in the severe TBI population.
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Patients with poor grade (World Federation of Neurosurgeons (WFNS) Grades 4 and 5) subarachnoid hemorrhage (SAH) were historically considered to have a poor neurological outcome and therefore not traditionally offered aggressive treatment. In recent years there has been increasing evidence that early aggressive treatment of this patient group can result in a good outcome. Aim of this study is to identify the outcome of patients with WFNS Grade-4 and -5 SAH treated acutely with endovascular detachable coil embolization (DCE) and aggressive neurocritical care within our institution. ⋯ Potentially, more than half the patients with WFNS Grade-4 and -5 SAH who are treated aggressively with coil embolization in association with supportive neurocritical care can achieve a good quality neurological outcome. However, it should be anticipated that these patients will spend a significant period of time in neurocritical care.