Neurocritical care
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Poor clinical condition is the most important predictor of neurological outcome and mortality after subarachnoid hemorrhage (SAH). Rupture of an intracranial aneurysm was shown to be associated with acute ischemic brain injury in poor grade patients in autopsy studies and small magnetic resonance imaging series. ⋯ Admission DWI demonstrates multifocal areas of acute ischemic injury in poor grade SAH patients. These ischemic lesions may be related to transient intracranial circulatory arrest, acute vasoconstriction, microcirculatory disturbances, or decreased cerebral perfusion from neurogenic cardiac dysfunction. Ischemic brain injury in poor grade SAH may be a feasible target for acute resuscitation strategies.
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Case Reports
Multimodal neuromonitoring in a patient with aneurysmal subarachnoid hemorrhage associated with aortic coarctation.
Aortic coarctation (AC) rarely remains undiagnosed until adulthood. Intracranial aneurysms and spontaneous subarachnoid hemorrhage (SAH) are more frequent in patients with AC than in the general population. ⋯ Cerebral aneurysm rupture associated with coarctation of the aorta is rare. The aim of this report is to call attention to AC in, particularly, young patients presenting with SAH and to discuss advanced multimodal neuromonitoring techniques used to optimize intensive care management.
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As the practice of aggressive temperature control has become more commonplace, new clinical problems are arising, of which shivering is the most common. Treatment for shivering while avoiding the negative consequences of many anti-shivering therapies is often difficult. We have developed a stepwise protocol that emphasizes use of the least sedating regimen to achieve adequate shiver control. ⋯ A significant proportion of patients undergoing temperature modulation can be effectively treated for shivering without over-sedation and paralysis. Patients at higher risk for needing more interventions are younger men with decreased BSA.
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Case Reports
The challenges with brain death determination in adult patients on extracorporeal membrane oxygenation.
To identify a reliable method of performing apnea testing as part of brain death determination in adult patients who develop loss of brainstem reflexes while receiving extracorporeal membrane oxygenation (ECMO). ECMO provides extracirculatory support to patients in cardiorespiratory failure who would otherwise be expected to die. Many studies have reported brain death as a potential complication of adult ECMO, but none have cited how apnea testing was performed in these patients. ⋯ Apnea testing is essential in the determination of brain death, but may not be employed in ECMO-treated adult patients. Apnea testing using the above protocol may assist in better decision making for adult ECMO patients at risk of brain death.
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Case Reports
Emergent, controlled lumbar drainage for intracranial pressure monitoring during orthotopic liver transplantation.
Measurement of intracranial pressure (ICP) is recommended in comatose acute liver failure (ALF) patients due to risk of rapid global cerebral edema. External ventricular drains (EVD) can be placed to drain cerebrospinal fluid and monitor ICP simultaneously although this remains controversial in the neurosurgical community given the risk of hemorrhagic complications. We describe a patient with ALF and global cerebral edema whose EVD failed immediately before orthotopic liver transplantation (OLT) in which a lumbar drain (LD) was used temporarily to monitor ICP. ⋯ Controlled CSF drainage using a lumbar drain can be used to monitor ICP when leveled at the foramen of Monro if EVD failure occurs perioperatively. The LD can temporarily guide ICP management until the EVD flow can be re-established after OLT.