Neurocritical care
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Prognostic determination of patients in coma after resuscitation from cardiac arrest is both common and difficult. We explored clinical and electrophysiological testing to determine their associations with favorable and poor outcomes. ⋯ It seems unlikely that any single test will prove to have 100% predictive value for outcome; further studies combining clinical, EEG, and SSEP testing are warranted.
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Transcranial Dopplers (TCDs) have been used to monitor cerebral blood flow velocities in subarachnoid hemorrhage (SAH).The purpose of our two-part study was to compare the reliability of relative increases in flow velocities with conventionally used absolute flow velocity indices and to correct for hyperemia-induced flow velocity change. ⋯ Relative changes in flow velocities in patients with aneurysmal SAH correlated better with clinically significant vasospasm than absolute flow velocity indices. Correction for hyperemia improved predictive value of TCD in vasospasm.
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Decompressive hemicraniectomy in large hemispheric infarctions has been reported to lower mortality and improve the unfavorable outcomes. Hematoma volume is a powerful predictor of 30-day mortality in patients with intracerebral hemorrhage (ICH). Hematoma volume adds to intracranial volume and may lead to life-threatening elevation of intracranial pressure. ⋯ Decompressive hemicraniectomy with hematoma evacuation is life-saving and improves unfavorable outcomes in a select group of young patients with large right hemispherical ICH.
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Paradoxical embolus should be suspected in young patients with cerebrovascular events who do not have any vascular risk factors. There is significant controversy as to how best to treat his phenomenon. ⋯ This case emphasizes the potential complications of the use of central lines in ICUs, particularly in patients with diabetic ketoacidosis in whom sluggish blood flow may predispose to a procoagulant state.
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Decompressive craniectomy has demonstrated efficacy in reducing morbidity and mortality in critically ill patients with massive hemispheric cerebral infarction. However, little is known about the patterns of functional recovery that exist in patients after decompressive craniectomy, and controversy still exists as to whether craniotomy and infarct resection ("strokectomy") are appropriate alternatives to decompression alone. We therefore used functional magnetic resonance imaging (f-MRI) to assess the extent and location of functional recovery in patients after decompressive craniectomy for massive ischemic stroke. ⋯ After massive hemispheric cerebral infarction requiring decompressive craniectomy, patients may experience functional recovery as a result of activation in both the infarcted and contralateral hemispheres. The evidence of functional recovery in peri-infarct regions suggests that decompression alone may be preferable to strokectomy where the risk of damage to adjacent nonischemic brain may be greater.