Neurocritical care
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The ideal therapy and neurocritical care for patients with aneurysmal subarachnoid hemorrhage (SAH) follows from an early and accurate diagnosis. However, approximately 30% of patients with SAH are misdiagnosed at their initial visit to a physician. ⋯ I suggest a strategy for selecting which patients with headache require evaluation beyond history and physical examination and how that evaluation should proceed. Other diagnostic issues are also discussed, such as use of magnetic resonance scanning and angiography for diagnosis, distinguishing the traumatic LP from true SAH, the concept of warning bleeds, and the LP-first diagnostic strategy.
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Until now, there has been no gold standard for monitoring delirium in intensive care unit (ICU) patients. In this prospective cohort study, a new score, the Delirium Detection Score (DDS), for severity of delirium in the ICU was evaluated. ⋯ The DDS demonstrated good validity with excellent sensitivity and specificity for delirium. The severity of delirium can be more accurately estimated by the DDS. By its composition of several items, the DDS might help to start a symptom-guided therapy immediately.
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Cerebral vasospasm remains a major complication associated with aneurysmal subarachnoid hemorrhage. Although several case reports have demonstrated that intraventricular hemorrhage (IVH) related to a ruptured arteriovenous malformation can result in vasospasm in the absence of subarachnoid hemorrhage, to our knowledge, this is the first case report of cerebral vasospasm associated with primary IVH. ⋯ Cerebral vasospasm may contribute to the comorbidities of IVH. Routine transcranial Doppler may be warranted for screening of cerebral vasospasm in IVH patients.
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The value of brain tissue oxygenation (PbtO2) measurements in determining brain death is unknown. ⋯ PbtO2 can be successfully and accurately used as a bedside adjunctive test for brain death. The use of PbtO2 as a sole confirmatory test for brain death in the setting of an appropriate clinical examination will require the evaluation of a larger number of patients to assess its sensitivity and specificity.
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Prognostic determination of patients in coma after resuscitation from cardiac arrest is both common and difficult. We explored clinical and electrophysiological testing to determine their associations with favorable and poor outcomes. ⋯ It seems unlikely that any single test will prove to have 100% predictive value for outcome; further studies combining clinical, EEG, and SSEP testing are warranted.