Neurocritical care
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Comparative Study Clinical Trial
Computer-assisted volumetric analysis compared with ABC/2 method for assessing warfarin-related intracranial hemorrhage volumes.
Intraparenchymal hemorrhage (IPH) volume is a powerful predictor of 30-day mortality. Warfarin-related intracranial hemorrhage (ICH) has a higher mortality than ICH without anticoagulation, possibly due to continued growth after 24 h, larger average size, and extension to extraparenchymal compartments. We compared 2 methods of measuring ICH volume in patients with warfarin-related ICH. ⋯ The ABC/2 method accurately and quickly estimates smaller, ellipsoid intraparenchymal hematomas but is inaccurate for larger, complex-shaped warfarin-related intraparenchymal, intraventricular, and subdural hematomas. Warfarin-related ICH mortality may be underestimated by the ABC/2 method because of larger, complex-shaped, and multicompartmental hematomas.
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In the current era of early surgery, there has been little interest in the use of antifibrinolytic therapy to prevent rebleeding after aneurysmal subarachnoid hemorrhage (aSAH). Older studies demonstrated that antifibrinolytics can reduce rebleeding, but long-term therapy results in increased cerebral ischemia from vasospasm, leading to no appreciable effect on mortality. While early surgery would seem to obviate the need for long-term antifibrinolytic use, a subgroup of patients may benefit from early therapy. ⋯ In this review, we examine the clinical pharmacology, dosing, monitoring, complications, and side effects of antifibrinolytic treatment. We conclude that early short-term antifibrinolytic therapy might be a reasonable strategy to prevent acute rebleeding and improve long-term outcome in aSAH patients. Additional randomized clinical trials are necessary to determine whether this management strategy is effective.
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Randomized Controlled Trial Multicenter Study
Association between disability measures and short-term health care costs following intracerebral hemorrhage.
Small improvements in clinical outcomes after intracerebral hemorrhage (ICH) can have a substantial impact on overall health care costs, yet little data exists on the costs associated with the most commonly studied clinical outcomes in this type of stroke. ⋯ Health care costs vary significantly by levels of disability as measured by the mRS, but costs do not vary across the full range of mRS outcomes. The mRS is more informative than the Barthel index and NIHSS for discriminating the resource use and costs associated with different levels of disability after ICH.
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In various surgical procedures, evidence for racial/ethnic disparities has continued to grow in recent years. Our purpose was to review the current literature regarding racial/ethnic disparities in the United States in the surgical treatment and outcome of three different cerebrovascular disease entities: carotid stenosis, intracranial aneurysm, and cerebral arteriovenous malformation (AVM). ⋯ Results of this comprehensive literature review suggest that racial disparities in cerebrovascular disease are understudied. Race-associated differences in neurosurgical outcomes must be documented and vigorously investigated to determine the basis of any observed differences and ensure that we are providing the best care possible to all of our patients.
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Randomized Controlled Trial
Intensive insulin therapy after severe traumatic brain injury: a randomized clinical trial.
To investigate the risks and possible benefits of routine versus intensive insulin therapy, assessed by the frequency of hypoglycemic events defined as a glucose concentration less than 80 mg/dl (<4.44 mmol/l) in patients admitted to the intensive care unit (ICU) after severe traumatic brain injury (TBI). ⋯ Intensive insulin therapy significantly increases the risk of hypoglycemic episodes. Even though patients receiving intensive insulin therapy have shorter ICU stays and infection rates similar to those receiving conventional insulin therapy, both groups have similar follow-up mortality and neurologic outcome. Hence if intensive insulin therapy is to be used, great effort must be taken to avoid hypoglycemia.