Neurocritical care
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Paroxysmal sympathetic hyperactivity (PSH) is a complication of acquired brain injury manifesting with episodic tachycardia, tachypnea, hypertension, diaphoresis, hypertonia, and posturing. No universally accepted diagnostic criteria exist and diagnosis is often delayed until the rehabilitation phase. ⋯ Paroxysmal sympathetic hyperactivity can be diagnosed early in the ICU. Strict diagnostic criteria supported the clinician's diagnosis in the majority of cases. Diagnosis should not be rejected because of any particular sign's absence, especially dystonia and posturing.
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Intracerebral hemorrhage (ICH) with intraventricular extension (IVH) is a devastating disease with a particular high mortality. In some aspects, IVH may resemble subarachnoid hemorrhage. The incidence and role of cerebral vasospasm in ICH with IVH are poorly understood. Here, we aimed to analyze the incidence and relationship of cerebral vasospasm to clinical characteristics, in-hospital mortality, and functional outcome at 3 months in patients suffering ICH with IVH. ⋯ Cerebral vasospasm seems to be a frequent complication after ICH with IVH and might be associated with DCI. Larger studies are warranted to confirm this hypothesis.
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Brain edema is a serious complication of ischemic stroke that can lead to secondary neurological deterioration and death. Glyburide is reported to prevent brain swelling in preclinical rodent models of ischemic stroke through inhibition of a non-selective channel composed of sulfonylurea receptor 1 and transient receptor potential cation channel subfamily M member 4. However, the relevance of this pathway to the development of cerebral edema in stroke patients is not known. ⋯ Several surrogate markers of vasogenic edema appear to be reduced in the setting of IV glyburide treatment in human stroke. Verification of these potential imaging and blood biomarkers is warranted in the context of a randomized, placebo-controlled trial.
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While the bioethical principle of beneficence originated in antiquity, the ascension of autonomy, or "self-rule," has redefined the physician-patient relationship to the extent that autonomy often dominates medical decision-making. Philosophical and social movements, medical research atrocities, consumerism, and case law have all had their influence on this paradigm shift. Consequently, the contemporary physician encounters an uncertainty in medical practice on how to resolve conflicts that arise in the pursuit of valuing both autonomy and beneficence. ⋯ This conundrum has been an important subject of the bioethics and social science literature but often this discourse is not disseminated to the clinicians confronting these issues. The purpose of this essay is to present a history of the principles of autonomy and beneficence and then present a shared medical decision-making model, collaborative autonomy, to provide guidance to neurologic critical care providers in how to resolve such dilemmas. Clinical vignettes will help illustrate the model.
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Observational Study
Subarachnoid Extension of Primary Intracerebral Hemorrhage is Associated with Fevers.
Extension of hemorrhage into the subarachnoid space in primary intracerebral hemorrhage (ICH) has recently been associated with poor outcomes, although the mechanisms underlying that association are uncertain. The objectives of this study are to confirm the association between fever and poor outcomes after ICH, and to determine whether subarachnoid hemorrhage extension (SAHE) is associated with fevers. ⋯ Our data confirm the deleterious effect of fever on the outcome of patients with ICH and show that SAHE is an independent predictor of fever after ICH. SAHE may provoke dysfunctional thermoregulation similar to what is observed after aneurysmal subarachnoid hemorrhage, creating mechanistic pathway between SAHE and poor functional outcomes.