Neurocritical care
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Neuroimaging may prove useful in identifying cardiac arrest patients destined for a poor recovery, as certain patterns have been associated with a poor outcome. However, MRI changes evolve temporally and spatially, which may lead to misinterpretation and misclassification of patients. ⋯ MRI patterns after global hypoxic-ischemic injury follow a characteristic pattern with variable acute changes in the cortex, basal ganglia, and cerebellum, followed by predominantly cortical and white matter changes in the early and late subacute periods. Diffuse, persistent widespread changes on MRI may help to predict poor outcome.
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Medical management of cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) includes hypertensive, hypervolemic, and hemodilution ("triple-H") therapy. However, there is little information regarding the indications and guidance used to initiate and adjust triple-H therapy. ⋯ There are substantial differences in the administration of prophylactic triple-H, but there was high agreement on indication for therapeutic use. There was wide variability in the extent of ICU monitoring, diagnostic approach, physiologic parameters and values used as target of therapy. NICU availability was associated with more intensive monitoring. Lack of evidence and guidelines for triple-H therapy might largely explain these findings.
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Numerous scoring scales have been proposed and validated to evaluate coma for rapid pre-hospital assessment and triage, disease severity, and prognosis for morbidity and mortality. These scoring systems have been predicated on core features that serve as a basis for this review and include ease of use, inter-rater reliability, reproducibility, and predictive value. Here we review the benefits and limitations of the most popular coma scoring systems. ⋯ The best known and widely accepted scale is the Glasgow Coma Scale (GCS). The Reaction Level Scale (RLS85) has utility and proven benefit, but little acceptance outside of Scandinavia. The newer Full Outline of UnResponsiveness (FOUR) score provides an attractive replacement for all patients with fluctuating levels of consciousness and is gradually gaining wide acceptance.
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Clinical Trial
Lower head of the bed position does not change blood flow velocity in subarachnoid hemorrhage.
Transcranial Doppler (TCD) is commonly used to monitor for vasospasm in patients with aneurysmal subarachnoid hemorrhage (aSAH). Changes in head of the bed (HOB) positions alter blood flow velocities measured by TCD in patients with ischemic stroke. However, the effects of HOB position on the velocities of the cerebral blood flow have not been studied in aSAH patients. ⋯ HOB position did not significantly affect MFV in our patients with aSAH.
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Randomized Controlled Trial Comparative Study
Cerebral hemodynamic and metabolic effects of equi-osmolar doses mannitol and 23.4% saline in patients with edema following large ischemic stroke.
Cerebral edema after ischemic stroke is frequently treated with mannitol and hypertonic saline (HS); however, their relative cerebrovascular and metabolic effects are incompletely understood, and may operate independent of their ability to lower intracranial pressure. ⋯ We conclude that at higher perfusion pressures, osmotic agents may raise CBF in non-ischemic tissue. We conclude that at higher perfusion pressures, osmotic agents may raise CBF in non-ischemic tissue.