Neurocritical care
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Propofol infusion syndrome (PRIS) is well known, often associated with, lethal complication of sedation with propofol. PRIS seems to be associated with young age, traumatic brain injury (TBI), higher cumulative doses of propofol, and the concomitant use of catecholamines. Known manifestations of PRIS are metabolic acidosis, rhabdomyolysis, and cardiac failure. While fatal PRIS can occur suddenly and rapidly, there is no sensitive test or early warning sign, and the only preventive measure is to limit propofol dosage and its duration. ⋯ From the findings of this study, we conclude that meticulous observation and analysis of the ECG during propofol sedation might result in earlier recognition of developing PRIS.
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The treatment and outcomes of heparin-induced thrombocytopenia (HIT) are not well described in neurosurgery patients. This study reviewed the treatment for HIT in subarachnoid hemorrhage (SAH) patients, and compared outcomes in patients with isolated HIT (iHIT) and HIT with thrombotic syndrome (HITTS). ⋯ SAH patients with iHIT and HITTS did not differ in the incidence of new thromboses, incidence of hemorrhage, or hospice/death. Patients with iHIT had fewer "poor treatment-related effects" than HITTS patients.
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Case Reports
Intra-arterial dantrolene for refractory cerebral vasospasm after aneurysmal subarachnoid hemorrhage.
Intravenous dantrolene has been used to prevent and treat cerebral vasospasm. We report a case of refractory cerebral vasospasm treated with intra-arterial dantrolene after aneurysmal subarachnoid hemorrhage. ⋯ Intra-arterial dantrolene induced a sustained improvement in cerebral vasospasm secondary to ruptured aneurysm. No significant side effects were observed during or after the infusion of the drug.
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Spinal reflexes can be seen in the setting of brain death. We present a new spinal reflex. We also review spinal movements in pediatric brain death and provide suggestions to distinguish them from movements generated by the brain. ⋯ "Thumbs up sign" should be added to the list of spinal reflexes seen with brain death. Spinal reflexes in brain death can be clinically recognized and should explained to all involved parties to avoid unnecessary testing, confusion for family members, and delay or refusal of organ donation.
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Case Reports
Strategic placement of bedside ventriculostomies using ultrasound image guidance: report of three cases.
The blind free-hand technique for external ventricular drain (EVD) placement sometimes requires multiple attempts, and catheter location is often less than ideal. Our institution has adapted an intraoperative ultrasound-guided ventriculostomy technique for the placement of EVDs at the bedside. Our experience with ultrasound at the bedside has proven to be invaluable in certain circumstances. We present three cases of strategic EVD catheter trajectories that were made possible at the bedside with the use of ultrasound. ⋯ Ultrasound-guided bedside EVD placement allows EVD trajectories to be customized based on real-time information to accommodate for distorted and dynamic anatomy of the brain and its ventricles.