Neurocritical care
-
Case Reports
Treatment of intracerebral hemorrhage with tranexamic acid after thrombolysis with tissue plasminogen activator.
Thrombolytic treatment with intravenous tissue plasminogen activator (i.v. tPA) is the only FDA-approved therapy for acute ischemic stroke. There are risks associated with thrombolytics, including intracranial and extracranial hemorrhage and hypersensitivity reactions. Established treatment for post-tPA hemorrhage includes administration of blood products including cryoprecipitate, fresh frozen plasma, and platelets which have poorly established efficacy. Tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA) have been studied as hemostatic therapies in post-operative hemorrhage, menorrhagia, intracranial hemorrhage (ICH), subarachnoid hemorrhage, and trauma patients. There is no reported literature on the use of TXA to reverse thrombolytic therapy with tPA. ⋯ TXA is an inexpensive medication which competitively inhibits the activation of plasminogen and can be given to reverse thrombolysis in the setting of hemorrhage after i.v. thrombolytic therapy.
-
Periodic epileptiform discharges (PEDs) are a frequent finding in comatose patients undergoing continuous EEG (cEEG) monitoring, but their clinical significance is unclear. PET and SPECT studies indicate that PEDs can be associated with focal hypermetabolism and hyperemia, suggesting that in some cases this pattern may be ictal and potentially harmful. We hypothesized that frequent PED activity in comatose patients is associated with reduced likelihood of recovery of consciousness. ⋯ Persistent spontaneous PED activity in comatose patients is associated with SIRPIDs and electrographic seizures, but has no impact on the likelihood of survival or recovery of consciousness.
-
Observational clinical studies demonstrate that brain hypoxia is associated with poor outcome after severe traumatic brain injury (TBI). In this study, available medical literature was reviewed to examine whether brain tissue oxygen (PbtO2)-based therapy is associated with improved patient outcome after severe TBI. Clinical studies published between 1993 and 2010 that compared PbtO2-based therapy combined with intracranial and cerebral perfusion pressure (ICP/CPP)-based therapy to ICP/CPP-based therapy alone were identified from electronic databases, Index Medicus, bibliographies of pertinent articles, and expert consultation. ⋯ Summary results suggest that combined ICP/CPP- and PbtO2-based therapy is associated with better outcome after severe TBI than ICP/CPP-based therapy alone. Cross-organizational practice variances cannot be controlled for in this type of review and so we cannot answer whether PbtO2-based therapy improves outcome. However, the potentially large incremental value of PbtO2-based therapy provides justification for a randomized clinical trial.
-
Review Case Reports
Bickerstaff's brainstem encephalitis presenting to the ICU.
Bickerstaff's brainstem encephalitis continues to pose a diagnostic and treatment challenge since the original descriptions by Bickerstaff and Miller-Fisher. The clinical syndrome overlaps with AIDP and MFS, but is accompanied by decreased level of consciousness not attributable to other causes, and the variable presence of long-tract signs. ⋯ The above findings led us to conclude that Bickerstaff's brainstem encephalitis remains a clinical diagnosis despite advances in electrophysiologic testing and neuroimaging. BBE likely represents part of a spectrum, overlapping with AIDP and MFS. Immunomodulation may be helpful in shortening the clinical course.