Neurocritical care
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Intracranial pressure (ICP) remains a pivotal physiological signal for managing brain injury and subarachnoid hemorrhage (SAH) patients in neurocritical care units. Given the vascular origin of the ICP, changes in ICP waveform morphology could be used to infer cerebrovascular changes. Clinical validation of this association in the setting of brain trauma, and SAH is challenging due to the multi-factorial influences on, and uncertainty of, the state of the cerebral vasculature. ⋯ Since the dilation/constriction of the cerebral vasculature resulted in detectable consistent changes in ICP MOCIAP metrics, by an extended monitoring practice of ICP that includes characterizing ICP pulse morphology, one can potentially detect cerebrovascular changes, continuously, for patients under neurocritical care.
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Randomized Controlled Trial Comparative Study
Randomized controlled trial comparing the effect of 8.4% sodium bicarbonate and 5% sodium chloride on raised intracranial pressure after traumatic brain injury.
Hypertonic sodium chloride solutions are routinely used to control raised intracranial pressure (ICP) after traumatic brain injury but have the potential to cause a hyperchloremic metabolic acidosis. Sodium bicarbonate 8.4% has previously been shown to reduce ICP and we have therefore conducted a randomized controlled trial to compare these two solutions. ⋯ An equiosmolar infusion of 8.4% sodium bicarbonate is as effective as 5% sodium chloride for reduction of raised ICP after traumatic brain injury when infused over 30 min.
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Percutaneous transluminal angioplasty (PTA) has been introduced for treatment of symptomatic cerebral vasospasm in patients with subarachnoid hemorrhage (SAH). While angiographic improvement is consistently reported, clinical improvement following the procedure varies, and limited data is available regarding overall impact on outcome. ⋯ A non significant trend was noted with reduced rate of severe disability and mortality at discharge and 1-year mortality after the introduction of PTA for cerebral vasospasm associated with SAH without increasing the length of hospital stay.
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Case Reports
Surgical treatment of space occupying edema and hemorrhage due to cerebral venous thrombosis during pregnancy.
During late pregnancy and the puerperium cerebral venous and sinus thrombosis (CVST) is a rare but important cause of stroke. Despite adequate anticoagulation some patients deteriorate, which may warrant the use of more aggressive treatment modalities. ⋯ While previous reports have demonstrated the feasibility of decompressive hemicraniectomy in selected patients with CVST and beginning herniation due to space occupying brain edema, venous infarction and congestional bleeding with mass effect, our rare case supports the notion that this procedure can also be life-saving in pregnant women.
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Review
Intraventricular fibrinolysis for intracerebral hemorrhage with severe ventricular involvement.
Intraventricular hemorrhage (IVH) has been associated with poor prognosis in patients with spontaneous intracerebral hemorrhage. Several factors contribute to the deleterious effects of IVH, including direct mass effects of the ventricular blood clot on ependymal and subependymal brain structures, mechanical and inflammatory impairment of the Pacchioni granulations by blood and its breakdown products, and disturbance of physiological cerebrospinal fluid (CSF) circulation. Acute obstructive hydrocephalus represents a major life-threatening complication of IVH and is usually treated with an external ventricular drainage (EVD). ⋯ Unfortunately, there is no prospective, randomized controlled trial addressing the effect of IVF on clinical outcome. The available data on IVF consist of small retrospective case series, case reports, and a few prospective case-control studies, which are the subject of the present review article. All these studies, when considered in their entirety, suggest that IVF has a positive impact on mortality and functional outcome, and could be considered as a treatment option for selected patients.