Neurocritical care
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Cerebral infarction is a common complication of aneurysmal subarachnoid hemorrhage (SAH), but usually occurs several days after onset as a complication of vasospasm or aneurysm repair. The frequency, causes, and clinical impact of acute infarction associated with the primary hemorrhage are poorly understood. ⋯ Early cerebral infarction on CT is a rare but devastating complication of acute SAH. The observed associations with coma, global cerebral edema, intraventricular hemorrhage, and loss of consciousness at onset suggest that intracranial circulatory arrest may play a role in the pathogenesis of this disorder.
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Management of intracranial hypertension is pivotal in the care of brain-injured patients. ⋯ Further, the evidence is compelling that a randomized-controlled trial is indicated to test the hypothesis that chest physiotherapy may actually result in short-term resolution of high intracranial pressure, and thus provide one more clinical tool in the management of elevated intracranial pressure.
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Clinical Trial
Critically ill cancer patients are not consistently hypercoagulable after craniotomy.
Recent reports using thrombelastography have suggested that neurosurgical patients develop a hypercoagulable state in the postoperative period. Since venous thromboembolism is a potentially life threatening complication in these patients, we studied a similar population in our institution. ⋯ Hypercoagulability as defined by the CI was not a common finding in this study. Although the TPI indicated hypercoagulability in a large number of patients, we do not believe it is a good tool to assess the patient's clotting status or predictor of thrombosis because in contrast to the CI, it does not take into account the enzymatic portions of the clotting cascade. A larger TEG study is warranted to determine the clinical significance of these changes in this and other populations.
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Cost-effectiveness analysis relies on preference-weighted health outcome measures as they form the basis for quality adjusted life years. Studies of preference-weighted outcomes for children following traumatic brain injury are lacking. ⋯ The findings support the use of the QWB score with parental report to measure preference-weighted health outcomes of children following a traumatic brain injury. Information from the study can be used in economic evaluations of interventions to prevent or treat traumatic brain injuries in children.
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Recombinant activated Factor VII (rFVIIa) has recently gained popularity for rapid reversal of coagulopathy during operative neurosurgery. Patients undergoing chronic subdural hematoma (CSDH) or epidural hematoma (EDH) evacuation often have their coagulation status judged by preoperative international normalized ratio (INR). We present our experience in two patients with significant clinical coagulopathy who were successfully reversed with rFVIIa in the setting of normal INR. ⋯ These two patients are the first to be examined for the use of rFVIIa for reversal of clinical coagulopathy in the setting of normal INR. Our experience suggests that normal INR should not be a deterrent for patients to receive rFVIIa in the setting of strong neurosurgical suspicion for underlying clinical coagulopathy.