Neurocritical care
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Case Reports
Decompressive laparotomy for refractory intracranial hypertension after traumatic brain injury.
Intracranial hypertension is a crucial modifiable risk factor for poor outcome after traumatic brain injury (TBI). Limited evidence suggests that decompressive laparotomy may be an effective treatment for refractory ICH in patients who have elevated intra-abdominal pressure. ⋯ Elevated intra-abdominal pressure can exacerbate intracranial hypertension in patients with TBI. Recognition of this condition and treatment with decompressive laparotomy may be useful in patients with intracranial hypertension refractory to optimal medical therapy.
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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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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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Rebleeding after initial aneurysmal subarachnoid hemorrhage (SAH) can have substantial impact on overall patient outcome. While older studies have suggested rebleeding occurs in about 4% of patients during the first day after initial aneurysmal bleed, these studies may have failed to capture very early rebleeds and, consequently, underestimated the impact of rebleeding. An electronic literature search was performed to identify English-language articles published or available for review from February 1975 through October 2010. ⋯ Although most studies supported an incidence of rebleeding ≤4%, studies investigating ultra-early rebleeding reported bleeding within the first 24 h following aneurysmal SAH in as many as 9-17% of patients, with most cases occurring within 6 h of initial hemorrhage. Overall, studies investigating antifibrinolytic therapy to reduce rebleeding have failed to clearly demonstrate overall therapeutic benefit. Short-course antifibrinolytic therapy may have a role prior to initial aneurysm repair, although insufficient data are currently available.