Neurocritical care
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To describe a technique for the induction of hypothermia and its complications for the treatment of acute ischemic stroke. ⋯ Surface cooling for the treatment of acute ischemic stroke can be performed rapidly with early neuromuscular paralysis. Advanced age and prolonged hypothermia may be associated with an increased risk of complications.
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Excessive hypertension can challenge the brain's capacity to autoregulate cerebral blood flow, and can aggravate increased intracranial pressure (ICP) and cerebral edema. Hypotension may worsen ischemic damage in marginally perfused tissue, and in some cases can trigger cerebral vasodilation and ICP plateau waves. There is a lack of high-quality data regarding optimal BP management in these conditions. ⋯ To reduce BP, labetalol, esmolol, and nicardipine best meet these criteria. Sodium nitroprusside should be avoided in most neurological emergencies because of its tendency to raise ICP and cause toxicity with prolonged infusion. To elevate BP, the preferred agents are phenylephrine, dopamine, and norepinephrine.
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Case Reports
Continuous bleeding from a basilar terminus aneurysm imaged with CT angiography and conventional angiography.
We report a case of fatal subarachnoid hemorrhage from nontraumatic rupture of an aneurysm at the basilar terminus in which both computed tomography angiography and conventional angiography showed evidence of active bleeding. The time period from initial ictus to CT angiography was 30-50 minutes and to conventional angiography was 120-140 minutes. This case illustrates that aneurysmal bleeding is not necessarily as brief as a few seconds and can last up to 30 to 50 minutes and perhaps longer. Continued bleeding from an intracranial aneurysm is a rare event that can be recognized using computed tomography angiography and likely indicates a poor prognosis.
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The acceptance of brain death by society has allowed for the discontinuation of "life support" and the transplantation of organs. The standard clinical criteria for brain death, when rigorously applied, ensure that the brainstem is destroyed. Because more rostral structures are more vulnerable than the brainstem, these are almost invariably devastated when brainstem function is irreversibly lost as a result of whole brain insults. ⋯ Ancillary tests are also required in very young children. In addition, some societies require their use as a matter of principle. Only tests of whole-brain perfusion adequately serve these purposes.
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We evaluated the effect of induced hypothermia on biochemical parameters in patients with severe traumatic brain injury. ⋯ Hypothermia of 33 degrees for 48-72 hours does not appear to increase the risk for coagulopathy and infections, although hypothermic patients exhibited significant increments in inflammatory markers such as C-reactive protein and white blood counts after rewarming.