Seminars in neurology
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Acute ischemic stroke is a common disorder with a significant impact on morbidity and mortality in the United States. The number of interventions for acute stroke patients has increased over the past 15 years and patients increasingly require intensive care. There are several issues that are specific to ischemic stroke patients in intensive care unit (ICU) settings, including the care of the postthrombolytic stroke patient, respiratory issues in stroke care, evaluation of worsening or change in neurological status, and attention to factors that affect the ischemic penumbra. The management of the stroke patient in the critical care setting is discussed in this article.
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Intracerebral hemorrhage (ICH) accounts for 10 to 15% of all strokes, but results in a disproportionately high morbidity and mortality. Although chronic hypertension accounts for the majority of ICH, other common causes include cerebral amyloid angiopathy, sympathomimetic drugs of abuse, and underlying cerebral vascular anomalies. Validated baseline predictors of clinical outcome after ICH include the Glasgow Coma Scale score, hematoma volume, presence and amount of intraventricular hemorrhage, infratentorial ICH location, and advanced age. ⋯ Basic research has suggested that perihematoma injury is more likely related to toxicity of blood and iron in the brain ("neurohemoinflammation") rather than primary ischemic injury. Current guidelines for ICH treatment emphasize blood pressure management, urgent and rapid correction of coagulopathy, and surgery for cerebellar ICH. Ongoing clinical trials are investigating surgical evacuation of lobar hemorrhage, minimally invasive surgical hematoma evacuation, and aggressive blood pressure lowering.
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The optimum provision of pharmacological sedation of the critically ill neurological patient requires defining the underlying etiology of agitation or need for sedation to determine the optimal agent: pain management, anxiolysis, or treatment of delirium. An appropriate regimen can then be decided upon based on the profiles of action of the several common classes of sedative agents. ⋯ Recognition of an individualized approach is also necessary as patients will vary considerably with respect to the kinetics and pharmacodynamics of sedative therapy. The drug classes often selected for sedation in an intensive care unit will be reviewed as well as the metrics by which physicians can achieve their objectives in a safe manner.
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Seminars in neurology · Nov 2008
ReviewWithdrawal of life-sustaining therapies and brain death in the intensive care unit.
The majority of patients who die in intensive care units (ICUs), do so as a result of the withdrawal of life-sustaining treatments or as a result of brain death. With the increasing shortage of transplantable organs, there is growing interest in both these patient populations and their potential for organ donation after cardiac death (DCD) or death by neurological criteria. ⋯ The medicolegal and ethical considerations, the factors that lead to the decision for withdrawal (with special attention to prognostication of the major neurological diseases encountered in an ICU), the process of withdrawal of life-sustaining treatment itself, and the DCD process will be examined. The medicolegal aspects of brain death will also be examined, with particular focus on the process and the various pitfalls and misconceptions.
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Intracranial hypertension implies profoundly disturbed intracranial physiology. Although a shared manifestation of myriad neurological disorders of patients admitted in the intensive care unit (ICU), the pathways leading to intracranial hypertension vary by etiology. ⋯ Several integrated management paradigms have been used to treat intracranial hypertension. Regrettably, there is a dearth of randomized clinical trials to confirm the efficacy of even our most routine therapeutic strategies.