Neurocritical care
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To report experience with intra-arterial (IA) calcium channel blocker (nicardipine) in patients with acute ischemic stroke with and without reteplase, mechanical thrombectomy (snare), and primary angioplasty to achieve maximal recanalization. Selective delivery of calcium channel blocker may improve perfusion and possibly provide neuroprotection in cerebral ischemia. ⋯ Intra-arterial delivery of nicardipine in doses up to 5 mg is well tolerated among patients with acute ischemic stroke. Further studies are required to determine the potential efficacy of this approach with or without thrombolytics.
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A fundamental purpose of neurocritical care is the management of secondary brain injury. This is often accomplished by monitoring and managing individual patient parameters including physiological vital signs. Yet, the ability to record physiological data exceeds our ability to fully integrate it into patient care. We propose that advances in monitoring must be accompanied by advances in methods of high-frequency, multivariate data analysis that integrate the multiple processes occurring in critically ill patients. ⋯ Recording of many physiological variables across multiple patients is feasible and can lead to new clinical insights. Computational and analytical methods previously used primarily for basic science may have clinical relevance and can potentially be adapted to provide physicians with improved ability to integrate complex information for decision making in neurocritical care.
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Hypertensive, hypervolemic, and hemodilutional (HHH) therapy for vasospasm in subarachnoid hemorrhage (SAH) refractory to phenylephrine requires high doses of catecholamines, leading to adverse adrenergic effects. Arginine vasopressin (AVP) has been shown to stabilize advanced shock states while facilitating reduction of catecholamine doses, but its use has never been reported in SAH. In this retrospective study, we investigated the hemodynamic effects and feasibility of supplementary AVP in refractory HHH therapy in SAH. ⋯ AVP may be considered as an alternative supplementary vasopressor in refractory HHH therapy with phenylephrine in SAH. Although we did not observe any deleterious effect of AVP on cerebral circulation, close observation for development of cerebral vasospasm should be undertaken, until it is clearly demonstrated that AVP has no adverse effects on regional cerebral blood flow and symptomatic cerebral vasospasm. Our limited data suggest that low-dose AVP does not cause brain edema, but further study is merited.
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Levetiracetam (LEV) is used in the setting of acute brain injury for seizure treatment or prophylaxis but its safety and efficacy in this setting is unknown. ⋯ The results of this study suggest that LEV is a frequently used AED in the setting of acute brain injury and that it may be a desirable alternative to phenytoin. Prospective studies evaluating the long-term safety, efficacy and outcomes of LEV in this setting are indicated.
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The importance of preoperative response to external ventricular drainage (EVD) for treatment of acute hydrocephalus (HCP) following poor grade (Hunt & Hess grade IV or V) aneurysmal subarachnoid hemorrhage (aSAH) has not been clearly defined. The effect of EVD response on preoperative grade and prognosis is described. ⋯ Long-term outcomes in poor grade patients who improve after EVD placement are similar to patients with lower grade hemorrhages. When an EVD is placed preoperatively in a poor grade aSAH patient, the neurological status after EVD determines the clinical grade.