Neurocritical care
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Cerebral vasospasm and delayed cerebral ischemia account for significant morbidity and mortality after aneurysmal subarachnoid hemorrhage. While most patients are managed with triple-H therapy, endovascular treatments have been used when triple-H treatment cannot be used or is ineffective. An electronic literature search was conducted to identify English language articles published through October 2010 that addressed endovascular management of vasospasm. ⋯ Both have generally been shown to successfully treat vasospasm and improve neurological condition, with no clear benefit from one treatment compared with another. There are reports of complications with both therapies including vessel rupture during angioplasty, intracranial hypertension, and possible neurotoxicity associated with papaverine. Limited data are available evaluating nicardipine or verapamil, with positive benefits reported with nicardipine and inconsistent benefits with verapamil.
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Several non-invasive and invasive modalities have been used to monitor patients for cerebral ischemia after subarachnoid hemorrhage. A literature search was performed to identify original research studies testing monitors that may be used in addition to the standard measures of brain function and cerebral blood flow. Fifty observational studies were identified that evaluated the role of electroencephalography, brain tissue oxygenation monitoring, cerebral microdialysis, thermal diffusion flowmetry, or near-infrared spectroscopy in patients after subarachnoid hemorrhage.
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Outcome from trauma, surgery, and a variety of other medical conditions has been shown to be positively affected by providing treatment at facilities experiencing a high volume of patients with those conditions. An electronic literature search was made to identify English-language articles available through March 2011, addressing the effect of patient treatment volume on outcome for patients with subarachnoid hemorrhage. Limited data were identified, with 16 citations included in the current review. ⋯ Patients treated at low-volume hospitals are less likely to experience definitive treatment. Furthermore, transfer to high-volume centers may be inadequately arranged. Several factors may influence the better outcome at high-volume centers, including the availability of neurointensivists and interventional neuroradiologists.
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Hypovolemia is common after subarachnoid hemorrhage, and fluid imbalance negatively affects clinical outcome. Standard bedside volume measures fail to adequately assess fluid status after subarachnoid hemorrhage. ⋯ These studies highlight that fluid status is often affected and difficult to assess after subarachnoid hemorrhage. Both non-invasive and invasive monitors may be used to more accurately define volume status.
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Review Practice Guideline
Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society's Multidisciplinary Consensus Conference.
Subarachnoid hemorrhage (SAH) is an acute cerebrovascular event which can have devastating effects on the central nervous system as well as a profound impact on several other organs. SAH patients are routinely admitted to an intensive care unit and are cared for by a multidisciplinary team. A lack of high quality data has led to numerous approaches to management and limited guidance on choosing among them. ⋯ Recommendations were developed using the GRADE system. Emphasis was placed on the principle that recommendations should be based not only on the quality of the data but also tradeoffs and translation into practice. Strong consideration was given to providing guidance and recommendations for all issues faced in the daily management of SAH patients, even in the absence of high quality data.