Neurocritical care
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Patient monitoring is routinely performed in all patients who receive neurocritical care. The combined use of monitors, including the neurologic examination, laboratory analysis, imaging studies, and physiological parameters, is common in a platform called multi-modality monitoring (MMM). ⋯ The use of MMM now is being facilitated by the evolution of bio-informatics in critical care including developing techniques to acquire, store, retrieve, and display integrated data and new analytic techniques for optimal clinical decision making. In this review, we will discuss the crucial initial steps toward data and information management, which in this emerging era of data-intensive science is already shifting concepts of care for acute brain injury and has the potential to both reshape how we do research and enhance cost-effective clinical care.
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Our goal was to perform a systematic review of the literature on the use of indomethacin and its effects on intracranial pressure (ICP) in patients with neurological illness. All articles from MEDLINE, BIOSIS, EMBASE, Global Health, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to July 2014), reference lists of relevant articles, and gray literature were searched. Two reviewers independently identified all manuscripts utilizing the following inclusion and exclusion criteria. ⋯ non-English, retrospective studies, no documentation of ICP response to indomethacin, and animal studies. A two-tier filter of references was conducted. First, we screened manuscripts by title and abstract. Second, those references passing the first filter were pulled, and the full manuscript was checked to see if it matched the criteria for inclusion. Two reviewers independently extracted data including population characteristics and treatment characteristics. The strength of evidence was adjudicated using both the Oxford and GRADE methodology. Our search strategy produced a total of 208 citations. Twelve original articles, 10 manuscripts, and 2 meeting proceeding, were considered for the review with all utilizing indomethacin, while documenting ICP in neurological patients. All studies were prospective. Across all studies, there were a total of 177 patients studied, with 152 receiving indomethacin and 25 serving as controls in a variety of heterogeneous studies. All but one study documented a decrease in ICP with indomethacin administration, with both bolus and continuous infusions. No significant complications were described. There currently exists Oxford level 2b, GRADE C evidence to support that indomethacin reduces ICP in the severe TBI population. Similar conclusions in other populations cannot be made at this time. Comments on its impact, on patient outcome, and side effects cannot be made given the available data. At this time, indomethacin for ICP control remains experimental and further prospective study is warranted.
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Review Case Reports
Dialysis-Induced Worsening of Cerebral Edema in Intracranial Hemorrhage: A Case Series and Clinical Perspective.
Intracranial hemorrhage (ICH) is not an uncommon complication of end-stage renal disease (ESRD), and may be complicated by cerebral edema. Hemodialysis (HD) may induce rapid osmolar and fluid shifts, increasing brain water content with the potential to worsen cerebral edema. The dangers of HD in patients with acute ICH have only been highlighted in isolated reports. ⋯ Hemodialysis may worsen cerebral edema in the setting of ICH sufficient to precipitate cerebral herniation. Caution should be exercised when dialysing a patient with an acute mass lesion and reduced intracranial compliance, especially those in whom HD is new or not routine. Delaying HD till risk of edema is attenuated, or ensuring gradual urea removal (such as with continuous hemofiltration) may be advisable.
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Review Case Reports
A Cause of Atypical Intracranial Subarachnoid Hemorrhage: Posterior Spinal Artery Aneurysms.
Approximately 1 % of cases of intracranial subarachnoid hemorrhage (SAH) are caused by spinal vascular pathologies. Among them, isolated spinal artery aneurysms are uncommon and a limited number of cases have been reported in the literature. ⋯ Isolated spinal artery aneurysms represent a rare cause of intracranial SAH. Symptoms such as back pain and lower-extremity weakness can be clues to the adequate diagnosis. Surgical or endovascular treatment should be pursued in all patients, as the risk of rebleeding is non-negligible.
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Review
The Role of Neuromuscular Blockade in Patients with Traumatic Brain Injury: A Systematic Review.
Management of Traumatic Brain Injury (TBI) focuses on controlling intracranial pressure (ICP), while other treatments, such as the use of neuromuscular blocking agents (NMBAs), need scientific evidence. We conducted a systematic review to investigate the usefulness of NMBAs in the context of TBI and/or increased ICP. We searched MEDLINE and EMBASE databases up to January 31st 2014, including both clinical and experimental findings. ⋯ However, retrospective evidence found potential harm by continuous NMBA infusion. In the context of TBI patients, we discuss the potentially positive effects of paralysis with its negative ones. Well-conducted randomized controlled trials and/or large pharmaco-epidemiologic studies are warranted.