Neurocritical care
-
Multicenter Study
Acute coagulopathy in isolated blunt traumatic brain injury.
The role of acute coagulopathy after traumatic brain injury (TBI) on outcome has gained increasing appreciation over the recent years. This study was conducted to assess the frequency, outcome, and risk factors associated with this complication. ⋯ Coagulopathy upon ER admission is frequent after isolated blunt TBI and represents a powerful, independent predictor related to prognosis. Future research should aim to determine the beneficial effects of early treatment of TBI-associated coagulopathy.
-
Venous thrombo-embolism (VTE) is frequently encountered in critically ill neurological and neurosurgical patients admitted to intensive care units. This patient population includes those with brain neoplasm, intracranial hemorrhage, ischemic stroke, subarachnoid hemorrhage, pre- and post-operative patients undergoing neurosurgical procedures and those with traumatic brain injury, and acute spinal cord injury (SCI). There is a wide variability in clinical practice for thromboprophylaxis in these patients, in part due to paucity of data based on randomized clinical trials. ⋯ Inferior vena cava filters may play a role in thromboprophylaxis in selected cases. Without clear guidelines that can be universally applied to this diverse group of patients, prophylaxis for VTE should be tailored to the individual patient with cautious assessment of benefits versus risks. There is a need for higher level evidence to guide VTE prophylaxis in certain subgroups of this patient population.
-
Randomized Controlled Trial
Prospective, randomized, single-blinded comparative trial of intravenous levetiracetam versus phenytoin for seizure prophylaxis.
Anti-epileptic drugs are commonly used for seizure prophylaxis after neurological injury. We performed a study comparing intravenous (IV) levetiracetam (LEV) to IV phenytoin (PHT) for seizure prophylaxis after neurological injury. ⋯ This study of LEV versus PHT for seizure prevention in the NSICU showed improved long-term outcomes of LEV-treated patients vis-à-vis PHT-treated patients. LEV appears to be an alternative to PHT for seizure prophylaxis in this setting.
-
Impaired cerebrovascular reactivity (CR) has been reported to be associated with adverse outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). However, CR may be determined using different paradigms and it is unclear, which measurement method most suitable reflects the clinical course or is able to predict clinical deterioration. ⋯ Due to the low number of included subjects, the obtained results are preliminary. However, they indicate that either the present technique of index-determination is not sensitive enough or that there is no strong relation between the measured indices and clinical outcome. Future verification is required of continuous against already established non-continuous monitoring techniques of CR in order to relate both to clinical outcome.
-
Many ICUs have implemented protocols for tight glucose control, but there are few data on hypoglycemia and neurologic outcomes in patients with subarachnoid hemorrhage (SAH). ⋯ In patients with SAH, nadir glucose < 80 mg/dl is associated with cerebral infarction, vasospasm, and worse functional outcomes in multivariate models. Protocols for target glucose 80-110 mg/dl effectively control hyperglycemia, but may place patients with SAH at risk for vasospasm, cerebral infarction, and poor outcome even when severe hypoglycemia does not occur.