Neurocritical care
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Improvements in technology play an important role in caring for critically ill patients. One example is the advance in ventilator design to facilitate triggering of mechanical breaths. Minimal changes in circuit flow unrelated to respiratory effort can trigger a ventilator breath and may mislead caregivers in recognizing brain death. ⋯ When brain-dead patients who are suitable organ donors are mistakenly identified as having cerebral activity, the diagnosis of brain death is delayed. This delay impacts resource utilization, impedes recovery and function of organs for donation, and adversely affects donor families, potential recipients of organs, and patient donors who may have testing and treatment that cannot be beneficial. Patients with catastrophic brain injury and absent cranial nerve function should undergo immediate formal apnea testing.
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Silent infarction is common in poor-grade subarachnoid hemorrhage (SAH) patients and associated with poor outcome. Invasive neuromonitoring devices may detect changes in cerebral metabolism and oxygenation. ⋯ These data suggest that there may be distinct changes in brain metabolism and oxygenation associated with the development of silent infarction within the monitored vascular territory in poor-grade SAH patients. Larger prospective studies are needed to determine whether treatment triggered by neuromonitoring data has an impact on outcome.
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A pretruncal subarachnoid hemorrhage has been accepted as a "benign" entity. Here we present two patients with delayed cerebral infarction following pretruncal subarachnoid hemorrhage. ⋯ Clinicians should bear in mind the possibility of arterial vasospasm and ensuing cerebral infarction in patients with pretruncal subarachnoid hemorrhage.
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Comparative Study
Comparison of hypertonic saline and mannitol on whole blood coagulation in vitro assessed by thromboelastometry.
Hypertonic saline (HS) is an alternative to mannitol for decreasing intracranial pressure in traumatic brain injury and before craniotomy. Both HS and mannitol may interfere with blood coagulation but their influence on coagulation has not been compared in controlled situations. Therefore, we evaluated different strengths of HS and 15% mannitol on blood coagulation in vitro. ⋯ Blood coagulation is disturbed more by 15% mannitol than by equiosmolar 2.5% saline. This disturbance seems to be attributed to overall clot formation and strength but also to pure fibrin clot firmness. This saline solution might be more favorable than mannitol before craniotomy in patients with a high risk of bleeding.
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Seizures are important neurologic complications of chronic subdural hematoma (CSDH). A better understanding of risk factors of seizures following CSDH is needed to identify the patient who will require treatment. ⋯ Lower mean GCS on admission is independently predictive of seizures, most of which occur within the first three months after CSDH.