Neurocritical care
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Osmotic agents such as mannitol remain a mainstay in the management of cerebral edema and raised intracranial pressure. Some patients do not respond to sustained mannitol administration with the expected rise in serum osmolality, and this may correlate with lack of therapeutic efficacy. ⋯ A substantial proportion of patients receiving sustained mannitol do not manifest the expected osmotic response. This lack of response may correlate with the failure of clinical efficacy seen in a subgroup of patients, who then require alternate agents such as hypertonic saline. This association merits further exploration.
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Cerebral vasospasm (CV) with infarction causes a significant degree of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). We sought to determine if reduced cerebral blood flow (CBF) on Xenon CT within 48 h of the ictus was predictive of developing CV with infarction. ⋯ Lower initial CBF at presentation is a risk factor for developing CV with infarction. These findings may help in early prediction of this entity and may have therapeutic implications in the future.
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Transcranial Doppler sonography (TCD) is a noninvasive method for detecting arterial cerebral vasospasm (CVS) in aneurysmal subarachnoid hemorrhage (SAH). Computed tomographic angiography (CTA) has been increasingly used for CVS diagnosis. The purpose of this study was to evaluate the degree of agreement between TCD and CTA in diagnosing clinical CVS following SAH, and to define the role of CTA in triaging patients prior to digital subtraction angiography (DSA) and endovascular intervention. ⋯ Clinical evaluation and TCD can reliably diagnose CVS in symptomatic patients and PMV >180 cm/s, or can rule out CVS in asymptomatic patients with PMV <140 cm/s. In this category of patients, adding a CTA to clinical evaluation and TCD may not be warranted.
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Review Case Reports
Spontaneous spinal epidural hematoma of unknown etiology: case report and literature review.
Our objective is to emphasize the importance of recognizing and rapidly treating spontaneous spinal epidural hematoma (SSEH). SSEH is a pathologic entity traditionally thought to be exceptionally rare but which, in the era of MR imaging, is becoming increasingly prevalent, and which if treated with sufficient rapidity can be completely curable. ⋯ As evidenced in the literature, outcome depends on time to operation and prognosis is impacted by age and preoperative deficit. Because of the high risk of poor outcome without treatment, SSEH should always be a diagnostic consideration in patients whose presentation is even slightly suggestive. Rapid, appropriate treatment of these patients can often lead to complete recovery of function, whereas any delay in appropriate treatment can be catastrophic.
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Controlled Clinical Trial
Monitoring with the Somanetics INVOS 5100C after aneurysmal subarachnoid hemorrhage.
Vasospasm is a major cause of morbidity after subarachnoid hemorrhage (SAH), and current screening techniques (angiography, transcranial Doppler [TCD], and clinical examination) have serious limitations. Brain oximetry is a promising noninvasive tool to detect reduced brain oxygenation from vasospasm. ⋯ INVOS rO2 readings are associated with other factors that relate to cerebral oxygen delivery but seem to be of limited use as a screening tool for vasospasm or cerebral infarction after SAH.