Neurocritical care
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Intracerebral hemorrhage (ICH) is associated with the highest mortality of all strokes. Admission to a Neurosciences Critical Care Unit (NCCU) compared to a general ICU has been associated with reduced mortality following ICH. Such association has led to several hospitals transferring ICH patients to Neuro-ICUs in tertiary care centers. However, delays in optimizing ICH management prior to and during transfer can lead to deleterious consequences. To compare functional outcomes in ICH patients admitted to our NCCU directly from the ED versus inter-hospital transfer admissions. ⋯ Patients with ICH brought directly to our ED had significantly better outcomes than IHT; we hypothesize this may be caused by delays in optimizing management prior to arrival at the facility with a dedicated Neuro-ICU. Nevertheless, other equally plausible hypotheses need to be prospectively tested.
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Cerebral arterial vasospasm and delayed ischemic neurological deficits are significant contributors to morbidity and mortality following aneurysmal subarachnoid hemorrhage. Additional treatment modalities are needed. Intraventricular nicardipine has been suggested as a potential therapy for the treatment of cerebral vasospasm. It is an appealing option for multiple reasons: many of these patients already have ventricular drains in place, it can be safely administered at the bedside, and can be used in patients for whom conventional therapies are either not effective or not tolerated. ⋯ Intraventricular nicardipine was associated with a significant and sustained reduction in mean cerebral blood flow velocity as measured by transcranial Doppler when used in the treatment of suspected cerebral vasospasm following aneurysmal subarachnoid hemorrhage. We do not find significant safety concerns related to elevations of intracranial pressure or ventricular catheter related infections. Further prospective studies are warranted to better determine the efficacy and safety of this therapy.
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Critical care management of patients with severe acute brain injury has undergone tremendous advances. Neurosurgeons and neurointensivists have a large armamentarium of invasive monitoring devices available to help detect secondary brain injury and guide therapy. No consensus exists regarding patient specific selection of monitoring devices, the placement of devices in relation to injured brain tissue, or the preferred insertion technique. Here we review our experience in a consecutive series of acutely brain injured patients who underwent multimodality monitoring. ⋯ Collaboration among institutions is necessary to establish practice guidelines for the choice and placement of multimodal monitors. Further advancement in device technology is needed to improve insertion techniques, inter-device compatibility, and device durability. Multimodality data needs to be analyzed to determine the preferable device location.
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Although electrocardiographic (ECG) abnormalities are well known in ischemic stroke and subarachnoid hemorrhage, these changes have only rarely been investigated systematically in patients with intracerebral hemorrhage (ICH). The purpose of this study is to investigate the prevalence and type of ECG abnormalities in a consecutive series of ICH patients, and their possible association with pre-defined neurological and radiological parameters. ⋯ In ICH patients ECG abnormalities are common. QTc prolongation seems associated with insular cortex involvement, with the presence of intraventricular blood, and with hydrocephalus. A larger cohort of continuously monitored ICH patients is necessary to investigate whether these ECG abnormalities are associated with poor outcome or death.
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Comparative Study
Comparison of hematoma shape and volume estimates in warfarin versus non-warfarin-related intracerebral hemorrhage.
Hematoma volume is a major determinant of outcome in patients with intracerebral hemorrhage (ICH). Accurate volume measurements are critical for predicting outcome and are thought to be more difficult in patients with oral anticoagulation-related ICH (OAT-ICH) due to a higher frequency of irregular shape. We examined hematoma shape and methods of volume assessment in patients with OAT-ICH. ⋯ Hematoma shape was not statistically significantly different in patients with OAT-ICH. Among bedside approaches, the standard ABC/2 method offers reasonable approximation of hematoma volume in OAT-ICH and non-OAT-ICH.