Neurocritical care
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Although there are extensive data on long-term disability after subarachnoid hemorrhage (SAH), there are few data on the trajectory of functional recovery after hospital discharge. ⋯ Although our sample size is small, our findings suggest that a substantial proportion of patients with SAH who are disabled at discharge go on to regain functional independence within 6 months.
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To evaluate the use of hyperosmolar therapy in the management of elevated intracranial pressure (ICP) and transtentorial herniation (TTH) in patients with renal failure and supratentorial lesions. ⋯ Treatment with hyperosmolar therapy, primarily 23.4% saline solution, was associated with clinical reversal of TTH and reduction in ICP and had few adverse effects in this cohort. Hyperosmolar therapy may be safe and effective in patients with renal failure and these initial findings should be validated in a prospective study.
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Prompt management of aneurysmal subarachnoid hemorrhage (SAH) is critical. Literature is inconclusive regarding outcomes for patients directly admitted to specialized centers versus transferred from lower-volume hospitals. Providers are often unclear about the safety of transferring critical patients. This study evaluated the "transfer effect" in a large sample of aneurysmal SAH patients undergoing treatment. ⋯ Patients treated in the lowest volume hospitals were 1.6 times more likely to die than those treated at the highest quintile hospitals. Among the critically ill grade V patients, transfer to higher-volume specialized centers did not increase the likelihood of a poor prognosis.
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Interhospital transfer of patients with intracranial hemorrhage can offer improved care, but may be associated with complications. ⋯ Transferred patients had similar rates of death, disability and LOS as directly admitted patients, though worse 3-month cognitive outcomes. Prolonged time to interhospital transfer was associated with an increased risk of aneurysm rerupture and tracheostomy.
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In the postpartum patient, sudden depression of consciousness may be caused by a number of etiologies and can result in serious consequences. Rapid, accurate diagnosis allows for specific treatments that optimize outcome, but diagnosis can be challenging in this population. We present a case of postpartum herniation due to intracranial hypotension in a patient with eclampsia, posterior reversible encephalopathy syndrome (PRES), and intracerebral hemorrhage (ICH). ⋯ Intracranial hypotension may coexist with other potential causes of cerebral herniation in the postpartum period. Establishing this diagnosis is crucial because its treatment is opposite that of other causes of herniation.