Neurocritical care
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The initial noncontrast computed tomography (CT) study of the head after an aneurysmal subarachnoid hemorrhage (SAH) is used to predict the risk of developing vasospasm. Changes in the extent of subarachnoid blood seen on CT images occur as a function of time after SAH, but there is no consensus on the time interval during which this study needs to be completed. ⋯ We propose that only CT scans obtained within 24 h of a subarachnoid bleeding event should be used to estimate the risk of vasospasm.
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To evaluate the effects of the neurological "wake-up test" (NWT), defined as interruption of continuous propofol sedation and evaluation of the patient's level of consciousness, on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in patients with severe subarachnoid hemorrhage (SAH) or traumatic brain injury (TBI). ⋯ When continuous propofol sedation was interrupted and NWT was performed in severely brain-injured patients, the mean ICP and CPP levels were modestly increased. A subset of patients showed more pronounced changes. To date, the role of the NWT in the neurointensive care of TBI and SAH patients is unclear. Although the NWT is safe in the majority of patients and may provide useful clinical information about the patient's level of consciousness, alternate monitoring methods are suggested in patients showing marked ICP and/or CPP changes during NWT.
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Several studies have been performed to assess the prognostic value of early neurological and neurophysiological findings in patients with postanoxic coma, but they have not led to precise, generally accepted, prognostic rules. This study was performed to assess whether it is possible to create a prognostic outcome table, using a combination of clinical variables and the electroencephalogram (EEG). ⋯ Age is an important variable determining the prognostic value of the EEG and should always be taken into consideration. The prognostic categories, especially when derived from the Young-classification, showed a good prognostic value. Although this is a pilot study, we believe that the revised prognostic categories have a good prognostic value in predicting outcome and are worth further investigation and validation.
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To determine the safety and tolerability of super-selective intra-arterial magnesium sulfate in combination with intra-arterial nicardipine in patients with cerebral vasospasm after subarachnoid hemorrhage. ⋯ Administration of intra-arterial magnesium sulfate in combination with nicardipine was well tolerated in patients with subarachnoid hemorrhage and cerebral vasospasm without a significant change in MAP and ICP. The efficacy of this combination therapy should be evaluated in a larger, controlled setting.
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Comparative Study
Placement of external ventricular drains and intracranial pressure monitors by neurointensivists.
External ventricular drains (EVDs) and intracranial pressure (ICP) monitors are widely used in the Neurological Critical Care Unit (NCCU) to measure ICP and divert cerebrospinal fluid (CSF). EVDs and ICP monitors have historically been placed by neurosurgeons; however, with recent staffing of NCCUs by neurointensivists, a growing number of EVDs and ICP monitors are being placed by these specialists. ⋯ Patients receiving ICP monitors had no complications. These complication rates are comparable to published rates, which suggest that placement of EVDs and ICP monitors by neurointensivists may be safe and effective. However, small sample size (n = 36) prohibits definitive safety and efficacy conclusions. For this reason, further research analyzing a larger patient sample is warranted.