Neurocritical care
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Clinical Trial
Continuous cerebral blood flow autoregulation monitoring in patients undergoing liver transplantation.
Clinical monitoring of cerebral blood flow (CBF) autoregulation in patients undergoing liver transplantation may provide a means for optimizing blood pressure to reduce the risk of brain injury. The purpose of this pilot project is to test the feasibility of autoregulation monitoring with transcranial Doppler (TCD) and near-infrared spectroscopy (NIRS) in patients undergoing liver transplantation and to assess changes that may occur perioperatively. ⋯ These results suggest that autoregulation is impaired in patients undergoing liver transplantation, even in the absence of acute, fulminant liver failure. Identification of patients at risk for neurologic complications after surgery may allow for prompt neuroprotective interventions, including directed pressure management.
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Practice Guideline
Guidelines for the evaluation and management of status epilepticus.
Status epilepticus (SE) treatment strategies vary substantially from one institution to another due to the lack of data to support one treatment over another. To provide guidance for the acute treatment of SE in critically ill patients, the Neurocritical Care Society organized a writing committee to evaluate the literature and develop an evidence-based and expert consensus practice guideline. Literature searches were conducted using PubMed and studies meeting the criteria established by the writing committee were evaluated. Recommendations were developed based on the literature using standardized assessment methods from the American Heart Association and Grading of Recommendations Assessment, Development, and Evaluation systems, as well as expert opinion when sufficient data were lacking.
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Case Reports
Treatment of intracerebral hemorrhage with tranexamic acid after thrombolysis with tissue plasminogen activator.
Thrombolytic treatment with intravenous tissue plasminogen activator (i.v. tPA) is the only FDA-approved therapy for acute ischemic stroke. There are risks associated with thrombolytics, including intracranial and extracranial hemorrhage and hypersensitivity reactions. Established treatment for post-tPA hemorrhage includes administration of blood products including cryoprecipitate, fresh frozen plasma, and platelets which have poorly established efficacy. Tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA) have been studied as hemostatic therapies in post-operative hemorrhage, menorrhagia, intracranial hemorrhage (ICH), subarachnoid hemorrhage, and trauma patients. There is no reported literature on the use of TXA to reverse thrombolytic therapy with tPA. ⋯ TXA is an inexpensive medication which competitively inhibits the activation of plasminogen and can be given to reverse thrombolysis in the setting of hemorrhage after i.v. thrombolytic therapy.
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Transcranial Doppler (TCD) pulsatility index (PI) has traditionally been interpreted as a descriptor of distal cerebrovascular resistance (CVR). We sought to evaluate the relationship between PI and CVR in situations, where CVR increases (mild hypocapnia) and decreases (plateau waves of intracranial pressure-ICP). ⋯ TCD pulsatility index can be easily and quickly assessed but is usually misinterpreted as a descriptor of CVR. The mathematical model presents a complex relationship between PI and multiple haemodynamic variables.
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Optimal resuscitation after traumatic brain injury (TBI) remains uncertain. We hypothesize that cerebral metabolic crisis is frequent despite adequate resuscitation of the TBI patient and that metabolic crisis negatively influences outcome. ⋯ Metabolic crisis occurs frequently after TBI despite adequate resuscitation and controlled ICP, and is a strong independent predictor of poor outcome at 6 months.