Neurocritical care
-
Review Case Reports
The Frozen Brain State of Cryptococcus gattii: A Globe-Trotting, Tropical, Neurotropic Fungus.
Initially reported in tropical regions, Cryptococcus gattii infection is now diagnosed globally. Methods: case report; Literature review. Although initial reports described outbreaks of pulmonary and central nervous system (CNS) disease in tropical regions such as Australia and New Guinea, it is now clear that Cryptococcus gattii is a global, neurotropic pathogen. ⋯ Following institution of antifungal therapy, about 10% of patients can worsen due to immune reconstitution inflammatory syndrome which responds to steroids. We recommend neurocritical and neurosurgical management of C. gattii patients with CNS involvement and elevated ICP. There is often poor correlation between elevated ICP and neuroimaging due to the frozen brain state.
-
Neurosurgical involvement in the care of major stroke complications has yielded striking results in the subtentorial region but equivocal outcomes in the supratentorial compartment. Most neurosurgeons want to see some degree of deterioration before proceeding; thus, timing will be debated. Viewpoints have changed over the years regarding surgical or medical intervention, but in many patients the procedure has not produced a definitive change in outcome other than preventing death from terminal brainstem shift. The introduction of craniectomy (and craniotomy) to treat swollen ischemic brain or intracranial hemorrhage has historical interest.
-
Patient-specific factors can alter the pharmacokinetic disposition of valproic acid. Specifically, the free fraction of valproic acid can increase substantially in patients with hypoalbuminemia or as serum drug concentrations rise due to saturable protein binding. Direct measurement of free serum drug concentrations allows for accurate assessment of drug levels, but the assay may not be readily available in all institutions. The effect of hypoalbuminemia on free fraction has been quantified and serves as the basis of an equation used to "correct" measured total valproic acid concentrations. The aim of this study was to evaluate the accuracy of the equation. ⋯ There is discordance between predicted and measured free serum valproic acid concentrations when using the proposed equation. Because of the potential impact of underestimation and variability of free valproic acid concentrations, a measured free level is the ideal option for therapeutic drug monitoring of valproic acid.
-
Observational Study
Diagnostic Accuracy of Procalcitonin for Early Aspiration Pneumonia in Critically Ill Patients with Coma: A Prospective Study.
Early diagnostic orientation for differentiating pneumonia from pneumonitis at the early stage after aspiration would be valuable to avoid unnecessary antibiotic therapy. We assessed the accuracy of procalcitonin (PCT) in diagnosing aspiration pneumonia (AP) in intensive care unit (ICU) patients requiring mechanical ventilation after out-of-hospital coma. ⋯ Early and repeated assays of PCT, CRP, and WBC demonstrated significant increases in all three biomarkers in patients with versus without AP. All three biomarkers had poor diagnostic performance for ruling out AP. Whereas PCT had the fastest kinetics, PCT assays within 48 h after ICU admission do not help to diagnose AP in ICU patients with coma.
-
Studies suggested that the neutrophil-to-lymphocyte ratio (NLR) was associated with unfavorable outcomes in different diseases such as intracerebral hemorrhage, cardiovascular problem, cancer, and severe traumatic brain injury (sTBI). We aimed to evaluate the relationship between peak NLR and 1-year outcomes in patients with sTBI. ⋯ Peak NLR was associated with the clinical prognosis after sTBI and was a promising predictor for 1-year outcomes.