Neurocritical care
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Since the establishment of the concept of declaring death by brain criteria, a large extent of variability in the determination of brain death has been reported. There are no standardized practical guidelines, and major differences exist in the requirements for the declaration of brain death throughout the USA and internationally. The American Academy of Neurology published evidence-based practice parameters for the determination of brain death in adults in 1995, requiring the irreversible absence of clinical brain function with the cardinal features of coma, absent brainstem reflexes, and apnea, as well as the exclusion of reversible confounders. ⋯ Every step in the determination of brain death bears potential pitfalls which can lead to errors in the diagnosis of brain death. These pitfalls are presented here, and possible solutions identified. Suggestions are made for improvement in the standardization of the declaration of brain death.
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To identify prognostic factors for vasospasm, hydrocephalus, and clinical outcomes in patients with angiographically negative, non-traumatic, diffuse subarachnoid hemorrhage (d-SAH). ⋯ The angiographically negative d-SAH pattern is associated with worse presentations and outcome. These patients are at increased risk for vasospasm and hydrocephalus requiring aggressive treatment and should therefore be cared for with a higher level of surveillance.
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Excessive use of adrenergic agents may result in stunned myocardium. ⋯ IABP counterpulsation may be one therapeutic option for patients with vasospasm after SAH when high doses of vasopressors can induce severe myocardial dysfunction. However, this invasive device may not be sufficient to maintain adequate cerebral perfusion and fatal embolic events can complicate the clinical course.
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Delayed ischemic neurological deficit associated to cerebral vasospasm is the most common cause of sequelae and death that follows the rupture of an aneurysm. The objective of this study was to evaluate the safety and efficacy of intra-arterial Milrinone in patients with symptomatic refractory cerebral vasospasm. ⋯ Intra-arterial Milrinone infusion seems to be a safe and effective treatment for patients who develop refractory symptomatic cerebral vasospasm following aneurysmal subarachnoid hemorrhage.
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Case Reports
Intra-arterial air thrombogenesis after cerebral air embolism complicating lower extremity sclerotherapy.
Cerebral arterial gas embolism is a potentially life-threatening event. Intraarterial air can occlude blood flow directly or cause thrombosis. Sclerotherapy is an extremely rare cause of cerebral arterial gas embolism. ⋯ We provide radiological evidence of hyperbaric oxygen therapy resolving intraarterial air but also demonstrate the thrombogenic potential of this procedural complication.