Current neurology and neuroscience reports
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Brain injury is a dynamic process marked by an initial damaging insult followed by a cascade of physical, electrical, and metabolic changes capable of resulting in further patient disability. These subclinical changes should be detected at a time when therapeutic intervention is most efficacious and preemptive. ⋯ Intracranial pressure, continuous electroencephalography, brain tissue oxygen, cerebral microdialysis, cerebral blood flow, and jugular oximetry monitoring have been utilized to direct treatment of the critical ill neurologic and neurosurgical patient. Optimization of monitoring technique and protocol is an ongoing effort of intensivists in the field of neurocritical care.
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In the past 15 years, the increased availability and use of continuous electroencephalography (cEEG) in critically ill patients has substantially changed our understanding of the injured brain. We have become increasingly aware that electrographic seizures in this population may have only subtle or no clinical signs and that cEEG greatly increases the likelihood of detecting these seizures. This review highlights the rationale behind using cEEG rather than routine EEG for detection of nonconvulsive seizures and nonconvulsive status epilepticus in critically ill patients and defines which patients are at greatest risk. It also describes other applications of cEEG in the intensive care unit and how it may play an important role in monitoring brain function.
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Curr Neurol Neurosci Rep · Aug 2012
ReviewContinuous electroencephalography monitoring in neonates.
As more critically ill term and premature neonates are surviving their acute illness, their long-term neurodevelopmental morbidity is being recognized. Continuous monitoring of cerebral function, with electroencephalography or derived digital trends, can provide key information regarding seizures and background patterns, with direct treatment and prognostic implications. ⋯ Both conventional and amplitude-integrated electroencephalography can provide valuable data regarding the background trends. This review describes indications and methods for continuous electroencephalography monitoring in high-risk neonates.
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Sodium and fluid management in the brain injured patient directly impacts cerebral edema and cerebral perfusion pressure. Sodium is a major determinant of neuronal size and therefore hyponatremia is aggressively avoided, as hypoosmolar states result in cerebral edema. ⋯ Knowledge of normal homeostatic and brain regulatory volume mechanisms is necessary to avoid inducing further neuronal or systemic injury while trying to correct sodium and fluid disorders in brain injured patients. Osmotherapy is a common part of managing cerebral edema in neurocritical care units, but more studies are needed to establish practice guidelines.
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Curr Neurol Neurosci Rep · Aug 2012
ReviewRecent developments in our understanding of the semiology and treatment of psychogenic nonepileptic seizures.
Psychogenic nonepileptic seizures (PNES) pose clinical challenges in terms of diagnosis and management. Recent studies have thrown further light on the extent to which features of PNES semiology may distinguish PNES patients from those with epilepsy. Management of this patient group will include discussion of the diagnosis, withdrawal of antiepileptic drugs, and psychological intervention when PNES persist. However, the evidence base for these different stages remains limited, although recent studies are beginning to provide guidance for clinicians and future research.