Neurocritical care
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Case Reports
The ketogenic diet for medically and surgically refractory status epilepticus in the neurocritical care unit.
Refractory status epilepticus carries a high risk of morbidity and mortality despite, and at times as a result of, aggressive pharmacologic interventions. Dietary therapies have been used for almost a century in children for controlling medically refractory seizures and status epilepticus and recent studies suggest efficacy and safety in adults as well. ⋯ Dietary therapy should be considered as a treatment option in adult patients with refractory status epilepticus.
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There is some evidence that hyperglycemia increases the rate of poor outcomes in patients with intracerebral hemorrhage (ICH). We explored the relationship between various parameters of serum glucose concentrations measured during acute hospitalization and hematoma expansion, perihematomal edema, and three month outcome among subjects with ICH. ⋯ Decline in serum glucose concentration correlated with reduction in proportion of subjects with hematoma expansion and poor clinical outcome. These results provide a justification for a randomized controlled clinical trial to evaluate the efficacy of aggressive serum glucose reduction in reducing death and disability among patients with ICH.
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The pathogenesis of delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) remains obscure. The authors assessed the relationship of tumor necrosis factor alpha (TNF-α) and TNF-α gene polymorphisms with occurrence of DCI and poor outcome at 3 months. ⋯ It is unlikely that serum TNF-α or TNF-α genotype play an important role in the occurrence of DCI after SAH.
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Direct invasive monitoring of brain tissue oxygenation (PbtO(2)) has been routinely utilized to predict cerebral ischemia and to prevent secondary injury in patients with traumatic brain injury (TBI) and vasospasm secondary to subarachnoid hemorrhage (SAH). The safety and utility of these devices in the pediatric population have been examined in a few small studies. No studies, however, have examined the use of PbtO(2) monitoring in stroke patients. ⋯ There is currently inadequate data to support the application of PbtO(2) monitoring in children with stroke to prevent progressive ischemia and to improve outcome. However, the positive results for these two patients support the need for further study in this area.
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Case Reports
Decompressive laparotomy for refractory intracranial hypertension after traumatic brain injury.
Intracranial hypertension is a crucial modifiable risk factor for poor outcome after traumatic brain injury (TBI). Limited evidence suggests that decompressive laparotomy may be an effective treatment for refractory ICH in patients who have elevated intra-abdominal pressure. ⋯ Elevated intra-abdominal pressure can exacerbate intracranial hypertension in patients with TBI. Recognition of this condition and treatment with decompressive laparotomy may be useful in patients with intracranial hypertension refractory to optimal medical therapy.