Neurocritical care
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Review
Cerebral blood flow, brain tissue oxygen, and metabolic effects of decompressive craniectomy.
Decompressive craniectomy (DC) is used for patients with traumatic brain injury (TBI), malignant edema from middle cerebral artery infarction, aneurysmal subarachnoid hemorrhage, and non-traumatic intracerebral or cerebellar hemorrhage. The objective of the procedure is to relieve intractable intracranial hypertension and/or to prevent or reverse cerebral herniation. Decompressive craniectomy has been shown to decrease mortality in selected patients with large hemispheric infarction and to control intracranial pressure in addition to improving pressure-volume compensatory reserve after TBI. ⋯ There are several unresolved controversies regarding optimal candidate selection, timing, technique, and post-operative management and complications. The nature and temporal progression of alterations in cerebral blood flow, brain tissue oxygen, and microdialysis markers have only recently been researched. Elucidating the pathophysiology of pressure-flow and cerebral hemodynamic consequences of DC could assist in optimizing clinical decision making and further defining the role of decompressive craniectomy.
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Little is known about the efficacy of single versus dual extraventricular drain (EVD) use in intraventricular hemorrhage (IVH), with and without thrombolytic therapy. ⋯ The decision to place dual EVDs is generally reserved for large IVH (>40 ml) with casting and mass effect. The use of dual simultaneous catheters may increase clot resolution with or without adjunctive thrombolytic therapy.
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To evaluate clinical features and prognostic factors of cerebral infarctions in adults with community-acquired bacterial meningitis. ⋯ Cerebral infarction is a common and severe complication in adults with community-acquired bacterial meningitis. Preventing cerebral infarctions will be important in reducing the high morbidity and mortality rate in adults with community-acquired bacterial meningitis.
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Delayed cerebral arterial vasospasm is one of the leading causes of death and disability after aneurysmal subarachnoid hemorrhage (aSAH). We evaluated the safety of intraventricular nicardipine (IVN) for vasospasm (VSP) in aSAH patients, and outcomes compared with a control population. ⋯ IVN appears relatively safe and effective in treating VSP by TCD, but there was no difference in clinical outcomes between nicardipine and control patients at 30 and 90 days. In the future, larger studies are needed to evaluate the clinical outcome with IVN.
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Case Reports
Lack of increase in intracranial pressure after epidural blood patch in spinal cerebrospinal fluid leak.
Epidural blood patch (EBP) is one therapeutic measure for patients suffering from spontaneous intracranial hypotension (SIH) or post-lumbar puncture headaches. It has been proposed that an EBP may directly seal a spinal cerebrospinal fluid (CSF) fistula or result in an increase in intracranial pressure (ICP) by a shift of CSF from the spinal to the intracranial compartment. To the best of our knowledge this is the first case of a patient with SIH and neurological deterioration in whom ICP was measured before, during, and after spinal EBP. ⋯ A shift of CSF from the spinal to the cranial compartment with a subsequent rise in ICP might not be a beneficial therapeutic mechanism of spinal epidural blood patching.