Neurocritical care
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Cost-effectiveness analysis relies on preference-weighted health outcome measures as they form the basis for quality adjusted life years. Studies of preference-weighted outcomes for children following traumatic brain injury are lacking. ⋯ The findings support the use of the QWB score with parental report to measure preference-weighted health outcomes of children following a traumatic brain injury. Information from the study can be used in economic evaluations of interventions to prevent or treat traumatic brain injuries in children.
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Clinical Trial
Critically ill cancer patients are not consistently hypercoagulable after craniotomy.
Recent reports using thrombelastography have suggested that neurosurgical patients develop a hypercoagulable state in the postoperative period. Since venous thromboembolism is a potentially life threatening complication in these patients, we studied a similar population in our institution. ⋯ Hypercoagulability as defined by the CI was not a common finding in this study. Although the TPI indicated hypercoagulability in a large number of patients, we do not believe it is a good tool to assess the patient's clotting status or predictor of thrombosis because in contrast to the CI, it does not take into account the enzymatic portions of the clotting cascade. A larger TEG study is warranted to determine the clinical significance of these changes in this and other populations.
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Recombinant activated Factor VII (rFVIIa) has recently gained popularity for rapid reversal of coagulopathy during operative neurosurgery. Patients undergoing chronic subdural hematoma (CSDH) or epidural hematoma (EDH) evacuation often have their coagulation status judged by preoperative international normalized ratio (INR). We present our experience in two patients with significant clinical coagulopathy who were successfully reversed with rFVIIa in the setting of normal INR. ⋯ These two patients are the first to be examined for the use of rFVIIa for reversal of clinical coagulopathy in the setting of normal INR. Our experience suggests that normal INR should not be a deterrent for patients to receive rFVIIa in the setting of strong neurosurgical suspicion for underlying clinical coagulopathy.
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Case Reports
Symptomatic cerebral air embolism during neuro-angiographic procedures: incidence and problem avoidance.
While clinically symptomatic cerebral air embolism secondary to neuro-angiographic procedures is rare, the incidence in a large series of procedures is unknown. Understanding this complication's frequency and etiology is critical if systems are to be instituted to reduce its incidence. ⋯ Symptomatic cerebral air embolism is a rare event during neuro-angiographic procedures. Analysis of the etiologies of this infrequent event may permit us to further reduce its incidence.
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A 38-year-old man with severe head trauma complicated by paroxysmal severe intracranial pressure elevation associated with tachypnea, tachycardia, diaphoresis, and extensor posturing was diagnosed as suffering from paroxysmal autonomic instability with dystonia (PAID). These events were unresponsive to standard medical therapy, which included morphine, fentanyl, labetalol, lorazepam, metoprolol, and clonidine. ⋯ Dexmedetomidine may be a novel pharmacologic agent to aid in abrogating PAID.