Articles: subarachnoid-hemorrhage.
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One of the most serious complications after subarachnoid hemorrhage (SAH) is delayed cerebral ischemia, the cause of which is multifactorial. Delayed cerebral ischemia considerably worsens neurological outcome and increases the risk of death. The targets of hemodynamic management of SAH have widely changed over the past 30 years. ⋯ More recently, the concept of goal-directed therapy targeting euvolemia, with or without hypertension, is gaining preference. Despite the evolving concepts and the vast literature, fundamental questions related to hemodynamic optimization and its effects on cerebral perfusion and patient outcomes remain unanswered. In this review, we explain the rationale underlying the approaches to hemodynamic management and provide guidance on contemporary strategies related to fluid administration and blood pressure and cardiac output manipulation in the management of SAH.
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Aneurysmal subarachnoid hemorrhage is a medical condition that can lead to intracranial hypertension, negatively impacting patients' outcomes. This review article explores the underlying pathophysiology that causes increased intracranial pressure (ICP) during hospitalization. Hydrocephalus, brain swelling, and intracranial hematoma could produce an ICP rise. ⋯ Indications for ICP monitoring include neurological deterioration, hydrocephalus, brain swelling, intracranial masses, and the need for cerebrospinal fluid drainage. This review emphasizes the importance of ICP monitoring and presents findings from the Synapse-ICU study, which supports a correlation between ICP monitoring and treatment with better patient outcomes. The review also discusses various therapeutic strategies for managing increased ICP and identifies potential areas for future research.
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Observational Study
Effects of Tranexamic Acid in Patients with Subarachnoid Hemorrhage in Brazil: A Prospective Observational Study with Propensity Score Analysis.
Rebleeding from a ruptured aneurysm increases the risk of unfavorable outcomes after subarachnoid hemorrhage (SAH) and is prevented by early aneurysm occlusion. The role of antifibrinolytics before aneurysm obliteration remains controversial. We investigated the effects of tranexamic acid on long-term functional outcomes of patients with aneurysmal SAH (aSAH). ⋯ Our findings in a cohort with delayed aneurysm treatment reinforce previous data that TXA use before aneurysm occlusion does not improve functional outcomes in aSAH.
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A 72-year-old female with a history of hypertension and hyperlipidemia presented to the emergency department from an outside hospital with acute confusion and global amnesia immediately following cervical epidural steroid injection with fluoroscopic guidance for radiculopathy relief. On exam, she was oriented to self, but disoriented to place and situation. Otherwise, she was neurologically intact with no deficits. ⋯ The 80 kV sequence revealed prominent diffuse hyperdensity throughout the cerebrospinal fluid spaces in bilateral cerebral hemispheres, basal cisterns, and posterior fossa consistent with the initial CT, but these corresponding regions were relatively less dense on the 150 kV sequence. These findings were consistent with contrast material in the cerebrospinal fluid spaces without evidence of intracranial hemorrhage or transcortical infarct. Three hours later, the patient's transient confusion resolved, and she was discharged home the next morning without any neurological deficit.
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Blood blister-like aneurysms (BBAs) are infrequent but challenging small aneurysms with fragile domes consisting of a thin adventitia layer.1 Flow diversion and microsurgical trapping are acceptable treatment options. While endovascular treatment is becoming the first choice in developed countries, it is prohibitive in most developing countries, where microsurgical treatment is the only feasible option. Microsurgical treatment offers superior obliteration rates at similar neurologic outcomes than endovascular treatment.1-3 Mastering high-flow revascularization and pressure monitoring is necessary to improve outcomes of BBA, especially in the developing world. ⋯ A right superficial temporal artery to M4 middle cerebral artery (MCA) bypass was used to both maintain perfusion during a high-flow bypass and to measure cerebral blood pressure. An external carotid artery to MCA bypass using a saphenous vein graft provided >80% of baseline MCA arterial pressure, which prevents delayed ischemic strokes.4 The patient tolerated the procedure well and was discharged home without deficits on postoperative day 15 after vasospasm watch. The patient consented to the procedure and provided consent to the publication of her images.