Neurosurgery clinics of North America
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Neurosurg. Clin. N. Am. · Oct 1994
Review Case ReportsStatus epilepticus. A perspective from the neuroscience intensive care unit.
Patients with GCSE and NCSE are common and may present to the emergency department or the NICU. In the NICU, NCSE is a more common presentation than GCSE. In the emergency department, GCSE commonly evolves to NCSE, either as a late sequela of prolonged SE or due to partial treatment with antiepileptic medication or neuromuscular blocking agents. ⋯ The knowledgeable and prompt use of intravenous lorazepam, a diazepam-phenytoin combination, or phenobarbital is acceptable as first-line treatment and as part of a systematic treatment algorithm. Refractory SE has been treated conventionally with high-dose intravenous barbiturate coma. Recent evidence suggests that high-dose intravenous midazolam may provide a useful alternative.
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Transcranial Doppler ultrasonography is an extremely useful adjunct in neurosurgical intensive care. Continuous improvements in TCD equipment as well as computer software have improved examination success and also vessel identification. ⋯ In the future, TCD may offer the ability to estimate the ICP using noninvasive means by evaluating velocity in the middle cerebral artery and arterial blood pressure tracings. The noninvasive determination of cerebral autoregulation may be useful in evaluating strategies to improve cerebral autoregulation as well as aid in the optimal management of ICP control and preservation of optimal cerebral circulation.
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Critical care of a patient with SAH should focus on the prevention or immediate treatment of the common sequelae of this disorder that adversely affect outcome: vasospasm, rebleeding, hydrocephalus, seizures, and associated medical problems. The frequency of rebleeding can be lessened by early surgical or endovascular intervention. The extent of SAH on the CT scan can identify those patients at highest risk for vasospasm, and all patients must be closely monitored in the ICU with serial neurological examinations and transcranial Doppler studies. ⋯ Seizures, which can cause intracranial and systemic hypertension, high cerebral metabolic demand, and delayed neurological injury, should be prevented with prophylactic use of anticonvulsants. In addition, early recognition and treatment of associated medical complications are critical. Novel endovascular approaches, meticulous surgical technique, and aggressive ICU care will undoubtedly lead to improved outcome following aneurysmal SAH.
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Neurosurg. Clin. N. Am. · Oct 1994
ReviewFluid and electrolyte disorders in neurosurgical intensive care.
The management of fluid and electrolytes is an important aspect of the intensive care of patients with intracranial disease and injury because the central nervous system has a critical role in fluid and electrolyte and acid-base homeostasis. This article reviews fluids and electrolytes and acid-base balance, their common disturbances in neurosurgical disorders, and their practical management.
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The subject of spinal cord pathology can be addressed in several ways. This article tackles spinal cord pathology by examining the topic according to purely nosologic criteria. Topics discussed include malformations, traumatic injuries, vascular and circulatory diseases, tumors, infections and inflammatory diseases, demyelinating diseases, toxic-metabolic and nutritional diseases, degenerative diseases, and miscellaneous other disorders.