Neurocritical care
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Delayed ischemic deficit from vasospasm is a leading cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage. Although several treatment modalities have been used to reverse the deleterious effects of vasospasm, alternative therapies are needed, as conventional therapies are often ineffective or contraindicated. Intrathecal nicardipine has been suggested for the prevention of vasospasm. We report our clinical experience with intraventricular nicardipine for refractory vasospasm in eight patients in whom conventional therapies were ineffective, contraindicated, or technically not feasible. ⋯ Our preliminary observations suggest that intraventricular nicardipine could be considered as a safe and effective treatment modality to treat vasospasm refractory to conventional management. A randomized, controlled trial to verify the efficacy and safety of intrathecal nicardipine in the prevention and treatment of cerebral vasospasm is warranted.
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Hypothermic brain protection has been linked to how rapidly cooling is initiated and how quickly and uniformly the therapeutic hypothermic zone (THZ) is reached. The nasopharyngeal (NP) approach is uniquely suited for preferential brain cooling due to anatomic proximity to the cerebral circulation, cavernous sinus, and carotid arteries. This study explores a novel NP cooling approach employing evaporative characteristics of aerosolized perfluorochemical (PFC). ⋯ The NP-PFC procedure more rapidly induced preferential brain cooling as compared to WBC without adverse effects.
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In patients with severe head trauma, endotracheal suctioning can result in adverse reactions including cough, systemic hypertension, increased intracranial pressure, and reduced cerebral perfusion pressure. The aim of this prospective, blinded clinical trial in mechanically ventilated patients with severe head trauma whose cough reflexes were still intact was to assess the effectiveness of endotracheally instilled lidocaine in preventing endotracheal suctioning-induced changes in cerebral hemodynamics (increase in intracranial pressure and reduced cerebral perfusion pressure) after a single endotracheal suctioning. ⋯ In mechanically ventilated patients with severe head trauma endotracheal lidocaine instillation effectively and dose-dependently prevents the endotracheal suctioning-induced intracranial pressure increase and cerebral perfusion pressure reduction.
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Release of cardiac biomarkers is reported in patients with subarachnoid hemorrhage (SAH). Data addressing the impact of cardiac injury on outcome in these patients is sparse. This study was conducted to ascertain the association of elevation of serum cardiac Troponin-I (cTnI) with mortality and neurological outcome in patients with SAH. ⋯ Patients with subarachnoid hemorrhage and elevated cTnI are found to have worse neurological status at admission. These patients have a worse neurological outcome and in-hospital mortality.
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Comparative Study
One-minute dynamic cerebral autoregulation in severe head injury patients and its comparison with static autoregulation. A transcranial Doppler study.
To compare dynamic and static responses of cerebral blood flow to sudden or slow changes in arterial pressure in severe traumatic brain injury (TBI) patients. ⋯ A sharp dynamic vasodilator response could not be sustained, and a slow or absent reaction to a sudden hypotensive challenge could show an acceptable cerebral autoregulation in the steady state. We found that patients with impaired static cerebral autoregulation had a poor outcome, whereas those with preserved static cerebral autoregulation experience favorable outcomes.