Neurocritical care
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Independent predictors of outcome for ischemic stroke include age and initial stroke severity. Intracranial large-vessel occlusion would be expected to predict poor outcome. Because large-vessel occlusion and stroke severity are likely correlated, it is unclear if largevessel occlusion independently predicts outcome or is simply a marker for stroke severity. ⋯ In patients presenting with acute brain ischemia, intracranial large-vessel occlusion independently predicts poor neurological outcome at hospital discharge, as does the presence of a high NIHSS score. Performing routine intracranial vascular imaging on acute stroke patients may allow for more accurate determination of prognosis and may also guide therapy.
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Status epilepticus is a life-threatening medical condition. In its most severe form, refractory status epilepticus (RSE) seizures may not respond to first and second-line anti-epileptic drugs. RSE is associated with a high mortality and significant medical complications in survivors with prolonged hospitalizations. ⋯ Few evidence-based data exist to guide management of RSE. Our case emphasizes the need for continuous aggressive therapy when neuroimaging remains normal.
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Recent advances in continuous electroencephalogram (EEG) monitoring with digital EEG acquisition, storage, and quantitative analysis allow uninterrupted assessment of cerebral cortical activity in critically ill neurological-neurosurgical patients. Early recognition of worsening brain function can prove of vital importance as one can initiate measures aimed to prevent further brain damage. Although continuous EEG monitoring provides adequate spatial and temporal resolution and is able to continuously assess brain function in these critically ill patients, it requires a trained electroencephalographer to interpret the massive amounts of data generated. ⋯ This permits real-time viewing of several hours of EEG on a single page. Examples are presented from three patients, two with recurrent seizures and one with diagnosis of subarachnoid hemorrhage. These patients illustrate the ability of this novel method to detect important real-time physiological changes in brain function that could enable early interventions aimed to prevent irreversible brain damage.
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Editorial Comment
The life-saving properties of blood: mitigating cerebral insult after traumatic brain injury.
Transfusion of packed red blood cells in critically injured patients has been a lifesaving (although not completely benign) intervention for decades. The traumatically injured brain has been thought to be particularly susceptible to injury from anemia, due to the well-documented association of worsening mortality and functional outcome in the presence of hypotension and hypoxia, as well as the known vulnerability of many neuronal populations to ischemia. ⋯ Although many practitioners have commonly utilized hemoglobin (Hgb) or hematocrit thresholds for transfusion in these patients, the rationale for this practice has largely been centered on older studies in general critical care populations and animal evidence. Furthermore, in addition to an ideal " target " Hgb, many other questions remain about this clinical practice, such as the optimal duration of maintaining a specific Hgb level, and the ultimate effects of transfusion on neurological and functional outcome.
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Cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH) is a devastating complication, yet despite multiple lines of investigation an effective treatment remains lacking. Cytokine-mediated inflammation has been implicated as a causative factor in the development of posthemorrhagic vasospasm. In previous experiments using the rat femoral artery model of vasospasm, we demonstrated that elevated levels of the proinflammatory cytokine interleukin (IL)-6 are present after hemorrhage and that a polyclonal antibody against IL-6 is capable of attenuating experimental vasospasm. ⋯ These findings support the conclusion that inflammatory cytokines, in particular IL-6, play an important role in development of vasospasm in the rat femoral artery model. Furthermore, these results suggest that the inhibition of inflammatory cytokines may be an appropriate strategy for the treatment of vasospasm after SAH.