Neurocritical care
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In this article, we review technologies available for direct monitoring of cerebral oxygenation and metabolic status, including jugular venous oxygen saturation, brain tissue oxygen tension, transcranial cerebral oximetry with near-infrared spectroscopy, Positron emission tomography oxidative metabolism, single-photon emission computed tomography/computed tomography perfusion and functional imaging, and cerebral metabolite measurement using microdialysis. We also introduce a novel method of monitoring cerebral perfusion that may substitute for direct monitoring of oxygenation in the future.
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Pneumonia is an important cause of morbidity following severe traumatic brain injury (TBI). However, previous studies have been limited by inclusion of specific patient subgroups or by selection bias. The primary objective of this study was to describe the incidence, risk factors for, and outcome of ventilator-associated pneumonia in an unselected population-based cohort of patients with severe TBI. An additional goal was to define the relationship of ventilator-associated pneumonia (VAP) with nonneurological organ dysfunction. ⋯ VAP occurs frequently and is associated with significant morbidity in patients with severe TBI.
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Fulminant hepatic encephalopathy has a high mortality. ⋯ Cerebral microdialysis, by enabling continuous on-line monitoring of substrate delivery and metabolism, may have a role in the management of patients with fulminant hepatic failure.
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The combination of induced hypertension, hypervolemia, and hemodilution (triple-H therapy) is often utilized to prevent and treat cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH). Although this paradigm has gained widespread acceptance over the past 20 years, the efficacy of triple-H therapy and its precise role in the management of the acute phase of SAH remains uncertain. In addition, triple-H therapy may carry significant medical morbidity, including pulmonary edema, myocardial ischemia, hyponatremia, renal medullary washout, indwelling catheter-related complications, cerebral hemorrhage, and cerebral edema. This review examines the evidence underlying the implementation of triple-H therapy, and makes practical recommendations for the use of this therapy in patients with aneurysmal SAH.
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Comparative Study
Clipping or coiling of ruptured cerebral aneurysms and shunt-dependent hydrocephalus.
Hydrocephalus may develop either early in the course of aneurysmal subarachnoid hemorrhage (SAH) or after the first 2 weeks. Because the amount of SAH is a predictor of hydrocephalus, the two available aneurysmal treatments, clipping or coiling, may lead to differences in the need for cerebrospinal fluid (CSF) diversion, as only surgery permits clot removal. ⋯ One-third of patients admitted with aneurysmal SAH require temporary or permanent CSF diversion. Permanent shunting was found to be associated with coiling in our patient population.