Crit Care Resusc
-
Despite technological and medical advances for the treatment of SAH that have had a positive impact on outcomes over the last 20 years, but the all-cause mortality for this often-catastrophic condition remains high at 12 - 15%. Survival will ultimately depend on the severity of the haemorrhage, the subsequent loss of functional neurones and the extracranial reserve of the patient. ⋯ There is little or no evidence to justify the aggressive use of anti-vasospastic therapies as a preventative manner with exception of oral nimodipine in patients with low-grade aneurysmal subarachnoid haemorrhage. Concomitant use of induced hypertension/hypervolaemia/haemodilution cannot be recommended on current evidence, but if employed should be done on an individualised basis, considering the patients underlying neurological condition, cardiopulmonary reserve, adequacy of systemic and neurological monitoring and access to expert neuroradiological, neurosurgical and neurocritical care services.
-
Stroke is a medical emergency as it is the third commonest cause of death and the most important cause of acquired severe disability in adults. Stroke services, funding and research have lagged behind cardiac medicine but evidence is now available to support a much more interventional approach to the assessment and management of patients with ischaemic stroke. Randomised controlled trials and meta-analyses of the most important interventions are the main sources of evidence for this review. ⋯ Patients not eligible for thrombolysis should receive aspirin and specialised care in a stroke unit. Many other treatments have been evaluated for acute ischaemic stroke of which some have been shown to be ineffective such as haemodilution or anticoagulation, whilst other interventions have not been adequately investigated such as neuroprotection and blood pressure lowering strategies. There is now good evidence to support a much more active assessment and treatment of patients with stroke but it is recognised that stroke services still need substantial development to maximise the benefits from the current proven interventions.
-
Analysis of cerebrospinal fluid (CSF) obtained by lumbar puncture (LP) is fundamental to the management of inflammatory disease of the central nervous system (CNS), particularly that due to infection. This review summarises the role of lumbar puncture, anatomy and pathophysiology of CSF, techniques of obtaining CSF, indications, contraindications and complications of LP, methods of analysis and some of the implications of specific changes in CSF. The CNS is protected by unique immunological barriers, and has some unique responses to processes that breach these barriers. ⋯ Some CSF testing is sensitive, specific and timely, but other CNS disease processes will generate obscure and ambiguous results, and interpretation may benefit from liaison with experienced specialists in several fields. Polymerase chain reaction (PCR) testing has changed the practice of LP and is likely to generate further evolution. Some findings on CSF analysis may have implications beyond the individual patient - the consequences of the diagnosis of meningococcal meningitis, emerging pathogens such as West Nile virus or Nipah virus, and the identification of anthrax meningitis in the USA may be quite profound on both a local and global scale.