Neurocritical care
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Comparative Study
"Optimal cerebral perfusion pressure" in poor grade patients after subarachnoid hemorrhage.
Cerebrovascular pressure reactivity depends on cerebral perfusion pressure (CPP), with the optimal CPP (CPPopt) defined as pressure at which cerebrovascular reactivity is functioning optimally, reaching minimal value of pressure reactivity index (PRx). The study investigates the association between vasospasm, PRx, and CPPopt in poor grade patients (WFNS 4&5) after subarachnoid hemorrhage (SAH). ⋯ Most WFNS 4&5 grade SAH patients with PRx below zero at optimal CPP during the first 48 h after ictus survived. Optimal CPP increases during vasospasm.
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Ornithine transcarbamylase deficiency (OTCD) is the most common of the urea cycle disorders and results in an accumulation of ammonia and its metabolites. Excess ammonia in the brain is metabolized to glutamine, which increases intracellular osmolarity and contributes to cytotoxic edema. ⋯ Aggressive multimodality management of the patient coupled with bifrontal decompressive hemicraniectomy was a life-saving measure, offering the patient a reasonable outcome. At 6 month follow-up she had moderate disability on the Glasgow Outcome Score associated with cognitive difficulties.
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Comparative Study
Trends in surgical management and mortality of intracerebral hemorrhage in the United States before and after the STICH trial.
The Surgical Trial in Intracerebral Hemorrhage (STICH) showed no overall benefit from early surgery compared with initial conservative treatment for intracerebral hemorrhage (ICH). We hypothesized that the STICH trial findings would lead to a reduction in the rates of surgery for ICH in the United States. Using a national hospital database, we determined trends in surgery for ICH before and after publication of STICH. We also determined trends in ICH mortality during the study period. ⋯ The rate of surgery among ICH discharges in the United States has remained stable in the past decade. While in-hospital ICH mortality decreased, controlled clinical trials are needed to determine which ICH patients would benefit from surgery, and if decreasing in-hospital mortality is associated with decreased longer term mortality and improved functional outcomes.
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Comparative Study
The TRACH score: clinical and radiological predictors of tracheostomy in supratentorial spontaneous intracerebral hemorrhage.
Spontaneous intracerebral hemorrhage (sICH) continues to have high morbidity and mortality. Patients with sICH and poor mental status are at high risk of airway compromise and frequently require intubation. The traditional ventilatory weaning parameters are not reliable in patients with brain pathology. The objective of this study is to identify clinical and radiological predictors for tracheostomy in mechanically ventilated patients with sICH and to develop a scale that will accurately predict the need for tracheostomy in these patients. ⋯ The TRACH Score is a practical clinical grading scale that will allow physicians to identify patients who will be needing tracheostomy. Application of this scale could have significant impact on length of stay and cost of hospitalization.
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Traumatic injuries to the cervical spine cause significant disability. Much of the morbidity and mortality that occurs in patients afflicted with cervical spinal cord injury (SCI) occurs early after injury due to primary neurologic dysfunction, systemic inflammation, concomitant injuries, treatments to prevent and ameliorate secondary insults, and prolonged immobilization. This study was undertaken to determine the incidence of organ dysfunction and failure using validated measures: the Multiple Organ Dysfunction Score (MODS) and the Sequential Organ Failure Assessment (SOFA). We also sought to determine if certain patient or injury characteristics were associated with the development of organ dysfunction and failure. ⋯ This study is the first to describe the incidence of organ dysfunction and failure in patients with isolated acute traumatic cervical SCI using validated organ system dysfunction scores. Respiratory, cardiovascular, neurologic, renal, hepatic, and hematologic dysfunction occurred commonly both on admission and over the ICU stay. Respiratory, cardiovascular, and neurologic failure were frequently found, while renal, hepatic, and hematologic failures were uncommon. Multiple organ failure occurred in the majority of patients. ASIA motor score and AIS were found to strongly correlate with the development of organ dysfunction and failure. Level of injury should be used with caution when describing the risk of complications and the need for medical interventions.