Neurocritical care
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Clinical applications of dexmedetomidine (DEX) for neurosurgical procedures have not been adequately investigated. This study aimed to test the use of DEX infusion, alone or as an adjunct to propofol infusion, as compared to propofol infusion in patients with an unruptured cerebral aneurysm after uneventful intracranial procedures. ⋯ DEX could be used safely for both intubated and extubated patients following uneventful intracranial procedures for an unruptured cerebral aneurysm, though it significantly reduced HR. Our findings also indicate that it is preferable to add low-dose propofol to DEX for management of intubated patients.
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Cerebral edema and raised intracranial pressure are common problems in neurological intensive care. Osmotherapy, typically using mannitol or hypertonic saline (HTS), has become one of the first-line interventions. However, the literature on the use of these agents is heterogeneous and lacking in class I studies. The authors hypothesized that clinical practice would reflect this heterogeneity with respect to choice of agent, dosing strategy, and methods for monitoring therapy. ⋯ Treatment of cerebral edema using osmotically active substances varies considerably between practitioners. This variation could hamper efforts to design and implement multicenter trials in neurocritical care.
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Medical management of cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) includes hypertensive, hypervolemic, and hemodilution ("triple-H") therapy. However, there is little information regarding the indications and guidance used to initiate and adjust triple-H therapy. ⋯ There are substantial differences in the administration of prophylactic triple-H, but there was high agreement on indication for therapeutic use. There was wide variability in the extent of ICU monitoring, diagnostic approach, physiologic parameters and values used as target of therapy. NICU availability was associated with more intensive monitoring. Lack of evidence and guidelines for triple-H therapy might largely explain these findings.
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Neuroimaging may prove useful in identifying cardiac arrest patients destined for a poor recovery, as certain patterns have been associated with a poor outcome. However, MRI changes evolve temporally and spatially, which may lead to misinterpretation and misclassification of patients. ⋯ MRI patterns after global hypoxic-ischemic injury follow a characteristic pattern with variable acute changes in the cortex, basal ganglia, and cerebellum, followed by predominantly cortical and white matter changes in the early and late subacute periods. Diffuse, persistent widespread changes on MRI may help to predict poor outcome.
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Randomized Controlled Trial Comparative Study
Cerebral hemodynamic and metabolic effects of equi-osmolar doses mannitol and 23.4% saline in patients with edema following large ischemic stroke.
Cerebral edema after ischemic stroke is frequently treated with mannitol and hypertonic saline (HS); however, their relative cerebrovascular and metabolic effects are incompletely understood, and may operate independent of their ability to lower intracranial pressure. ⋯ We conclude that at higher perfusion pressures, osmotic agents may raise CBF in non-ischemic tissue. We conclude that at higher perfusion pressures, osmotic agents may raise CBF in non-ischemic tissue.