Neurocritical care
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Mortality and morbidity have remained high in bacterial meningitis. Impairment of cerebral energy metabolism probably contributes to unfavorable outcome. Intracerebral microdialysis is routinely used to monitor cerebral energy metabolism, and recent experimental studies indicate that this technique may separate ischemia and non-ischemic mitochondrial dysfunction. The present study is a retrospective interpretation of biochemical data obtained in a series of patients with severe community-acquired meningitis. ⋯ In patients with severe community-acquired meningitis, compromised cerebral energy metabolism occurs frequently and was diagnosed in 7 out of 15 cases. A biochemical pattern of non-ischemic mitochondrial dysfunction appears to be a more common underlying condition than cerebral ischemia.
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Hepatic encephalopathy (HE) is a frequent complication of cirrhosis and a major public health problem. The incidence is increasing because of improved cirrhosis prognosis. The most widely used scale used to evaluate HE is the West-Haven (WH) scale, with scores ranging from 0 to 4. This scale is easy to use but not suitable for patients with altered consciousness and is not well known by physicians other than hepatologists who manage these conditions. For deep coma, the validated Glasgow Coma Scale (GCS) has been proposed. A new scale for comatose patients, the Full Outline of UnResponsiveness (FOUR) score, has recently been proposed and widely validated. The scale covers eye and motor responses, brainstem reflexes and breathing patterns and is the most validated coma scale. ⋯ The FOUR score can be used to detect and quantify HE in cirrhotic patients, especially by non-hepatologists who are not familiar with the WH scale.
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Patients recovering from aneurysmal subarachnoid hemorrhage (SAH) are at risk for developing delayed cerebral ischemia (DCI). Experimental and human studies implicate the vasoconstrictor P450 eicosanoid 20-hydroxyeicosatetraenoic acid (20-HETE) in the pathogenesis of DCI. To date, no studies have evaluated the role of vasodilator epoxyeicosatrienoic acids (EETs) in DCI. ⋯ Our findings suggest that P450 eicosanoids play an important role in the pathogenesis of DCI. While 20-HETE may contribute to the development of DCI, 14,15-EET may afford protection against DCI. Strategies to enhance 14,15-EET, including sEH inhibition, should be considered as part of a comprehensive approach to prevent DCI.
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Therapeutic strategies that cause an alteration in patient temperature, such as controlled normothermia (CN), therapeutic hypothermia (TH), and pentobarbital infusion (PI), are often used to manage complications caused by acute brain injury. The purpose of this study was to evaluate pharmacokinetic (PK) parameters of vancomycin in patients with acute brain injury undergoing temperature modulation. ⋯ Patients who underwent TH/PI did not exhibit PK alterations when compared to predicted PK parameters based on population data, while patients who underwent CN experienced PK alterations favoring an increased elimination of vancomycin.
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Review Case Reports
Dialysis-Induced Worsening of Cerebral Edema in Intracranial Hemorrhage: A Case Series and Clinical Perspective.
Intracranial hemorrhage (ICH) is not an uncommon complication of end-stage renal disease (ESRD), and may be complicated by cerebral edema. Hemodialysis (HD) may induce rapid osmolar and fluid shifts, increasing brain water content with the potential to worsen cerebral edema. The dangers of HD in patients with acute ICH have only been highlighted in isolated reports. ⋯ Hemodialysis may worsen cerebral edema in the setting of ICH sufficient to precipitate cerebral herniation. Caution should be exercised when dialysing a patient with an acute mass lesion and reduced intracranial compliance, especially those in whom HD is new or not routine. Delaying HD till risk of edema is attenuated, or ensuring gradual urea removal (such as with continuous hemofiltration) may be advisable.