Neurocritical care
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Although neurogenic stunned myocardium (NSM) after aneurysmal subarachnoid hemorrhage (SAH) is well described, its clinical significance remains poorly defined. We investigated the influence of left ventricular (LV) dysfunction and cerebral vasospasm on cerebral infarction, serious cardiovascular events, and functional outcome after SAH. ⋯ LV dysfunction after SAH increases the risk of cerebral infarction from vasospasm, hypotension, and pulmonary edema, but with aggressive ICU support does not affect short-term survival or functional outcome. Antihypertensive medication may confer cardioprotection and reduce the risk of catecholamine-mediated injury after SAH.
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Cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH) is a frequent but unpredictable complication associated with poor outcome. Current vasospasm therapies are suboptimal; new therapies are needed. Clazosentan, an endothelin receptor antagonist, has shown promise in phase 2 studies, and two randomized, double-blind, placebo-controlled phase 3 trials (CONSCIOUS-2 and CONSCIOUS-3) are underway to further investigate its impact on vasospasm-related outcome after aSAH. ⋯ Main secondary endpoint is extended Glasgow Outcome Scale at week 12. A critical events committee assesses all data centrally to ensure consistency in interpretation, and patient management guidelines are used to standardize care. Results are expected at the end of 2010 and 2011 for CONSCIOUS-2 and CONSCIOUS-3, respectively.
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Hemodynamic augmentation by increasing cardiac output with dobutamine (DOB) is believed to be a useful method of elevating decreased cerebral blood flow in the territory affected by vasospasm following aneurysmal subarachnoid hemorrhage (SAH). We described the clinical utility of uncalibrated radial artery-based pulse contour cardiac output (APCO) and near-infrared spectroscopy regional cerebral oxygen saturation (rSO(2)) monitoring for reversing vasospasm symptoms with DOB-induced hyperdynamic therapy. ⋯ Our clinical experience indicates that integrative monitoring with APCO and rSO(2) may provide continuous, real-time, and clinically relevant information on the effectiveness of medical treatment of distal vessel vasospasm.
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Myocardial injury after aneurysmal subarachnoid hemorrhage (aSAH) is associated with poor outcomes. Delayed cerebral ischemia (DCI) is also a complication of aSAH. We sought to determine whether (1) DCI could be predicted by demographics, aSAH severity/aneurysm location, or aSAH-associated myocardial injury (SAHMI), and (2) DCI is associated with increased mortality after aSAH. ⋯ Elevated CO and Fisher grade are predictors of DCI after aSAH. However, prevention of DCI may not decrease mortality.
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Decompressive surgery for malignant middle cerebral artery infarction increases the number of surviving patients; this, however, leaves some patients severely disabled. This study analyzed the patients' retrospective consent to hemicraniectomy in light of the experienced functional outcome 12 months after hospital stay. ⋯ Retrospective consent to hemicraniectomy for treatment of malignant MCA infarction depends on functional long-term outcome. We need to identify those patients who would survive the malignant MCA infarction due to decompressive surgery but only reach a severely reduced functional status.