Neurocritical care
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The computed tomography (CT) appearance of subarachnoid hemorrhage (SAH) without subarachnoid blood has been labeled "pseudo-subarachnoid hemorrhage" (pseudo-SAH) and has been reported with several diffuse intracerebral insults including intrathecal contrast agents, meningitis, generalized cerebral edema, anoxic encephalopathy, and intracranial hypotension. ⋯ Our case suggests that PICA infarction can be associated with the CT finding of pseudo-SAH, thereby mimicking the clinical and radiographic presentation of SAH.
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Intracerebral hemorrhage (ICH) is a devastating form of stroke commonly resulting in severe morbidity and high mortality. Secondary brain injury often occurs in the days following the initial hemorrhage and is associated with significant neurological deterioration. The neurochemistry associated with secondary injury is poorly understood. The purpose of this study is to characterize the neurochemical changes in perihematomal tissue during frameless minimally invasive evacuation of spontaneous hematomas. ⋯ This study reports that elevated levels of glutamate are found in the perihematomal region after ICH and are decreased during hematoma drainage. Conversely, ischemic LPRs are not found in perihematomal regions and were unchanged during hematoma drainage. These data suggest that excitotoxicity related to glutamate may have an important impact on secondary injury. The data failed to support the role of ischemia in secondary perihematomal damage.
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Case Reports
Isolated third nerve palsy associated with a ruptured anterior communicating artery aneurysm.
An oculomotor palsy in the setting of aneurysmal subarachnoid hemorrhage is often due to compression by a posterior communicating artery aneurysm. Anterior communicating artery (ACOM) aneurysms may produce ophthalmologic symptoms of the anterior visual pathways, but rarely ever lead to a 3rd nerve palsy. This report describes a rare case of an isolated oculomotor palsy in a patient who experienced subarachnoid hemorrhage from an ACOM aneurysm. ⋯ In very rare circumstances, an ACOM aneurysm may produce an isolated third nerve palsy. The etiology of the palsy is likely related to clot formation and/or irritating blood products.
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The crucial importance of monitoring both the infarcted and non-infarcted hemispheres in management of space occupying middle cerebral artery (MCA) infarction is increasingly recognized, but optimal technique is debated. We investigated the potential for bilateral Near Infrared Spectroscopy (NIRS) to non-invasively provide relevant information on intracranial oxygenation. ⋯ Bilateral NIRS may provide more useful information on cerebral oxygenation than unilateral measurements and its clinical validity to help predict worsening of brain swelling should be investigated further.
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Hyponatremia, defined as a serum sodium concentration ([Na+]) less than 135 mEq/L, is commonly caused by elevated levels of the hormone arginine vasopressin (AVP), which causes water retention. The principal organ affected by disease-related morbidity is the brain. The neurologic complications associated with hyponatremia are attributable to cerebral edema and increased intracranial pressure, caused by the osmotically driven movement of water from the extracellular compartment into brain cells. ⋯ Two other agents, tolvaptan and lixivaptan, are being evaluated in patients with euvolemic and hypervolemic hyponatremia. The AVP-receptor antagonists block the effects of elevated AVP and promote aquaresis, the electrolyte-sparing excretion of water, resulting in the correction of serum [Na+]. These agents may also have intrinsic neuroprotective effects.