Neurocritical care
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Intraventricular fibrinolysis (IVF) in subarachnoid hemorrhage (SAH) is an emerging strategy aiming to hasten clot lysis, treat hydrocephalus, and reduce permanent shunt rates. Because of clinical heterogeneity of investigated patient effects of IVF on permanent shunt incidence and functional outcome are widely debated. The present study is the first to investigate solely endovascular-treated SAH patients. ⋯ In endovascular-treated SAH patients IVF neither reduced permanent shunt dependency nor influenced functional outcome. Despite established effects on intraventricular clot resolution IVF appears less powerful in SAH as compared to ICH. Given the reported positive effects of lumbar drainage (LD) in SAH, a prospective analysis of a combined treatment approach of IVF and subsequent lumbar drain sOeems warranted aiming to reduce permanent shunting and improve functional outcome.
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Despite straightforward guidelines on brain death determination by the American Academy of Neurology (AAN), substantial practice variability exists internationally, between states, and among institutions. We created a simulation-based training course on proper determination based on the AAN practice parameters to address and assess knowledge and practice gaps at our institution. ⋯ Baseline knowledge of brain death determination among providers was low but improved greatly after the course. Our intervention represents an effective model that can be replicated at other institutions to train clinicians in the determination of brain death according to evidence-based guidelines.
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Delayed ischemic neurological deficit (DIND) due to symptomatic vasospasm is a major cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). The aim of this study was to elucidate the safety and feasibility of intrathecal milrinone infusion via lumber subarachnoid catheter for prevention of DIND after aSAH. ⋯ Intrathecal milrinone injection via lumbar catheter was safe and feasible, and further randomized prospective studies are needed to confirm the effectiveness of this regimen in the patients with SAH.
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Comparative Study
The FOUR Score Predicts Mortality, Endotracheal Intubation and ICU Length of Stay After Traumatic Brain Injury.
The Glasgow Coma Scale (GCS) is the most widely accepted scale for assessing levels of consciousness, clinical status, as well as prognosis of traumatic brain injury (TBI) patients. The Full Outline of UnResponsiveness (FOUR) score is a new coma scale developed addressing the limitations of the GCS. The aim of this prospective cohort study was to compare the performance of the FOUR score vs. the GCS in predicting TBI outcomes. ⋯ The FOUR score was superior to the GCS in predicting in-hospital mortality in TBI patients. There was no difference between both scores in predicting unfavorable outcome, endotracheal intubation, and ICU LOS.
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The apnea test is a crucial component of the clinical diagnosis of brain death. Apprehension about hypoxemia, hypotension, and/or cardiac arrhythmias may sometimes lead clinicians to avoid performing or prematurely terminate the apnea test. The purpose of this study was to perform a contemporary re-evaluation of the safety of the apnea test. ⋯ Apnea determined using the oxygenation diffusion method during brain death testing is very safe, provided appropriate prerequisites are met. We found a major decrease in the number of aborted or not attempted apnea tests compared to previous studies.