Neurosurgery clinics of North America
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Neurosurg. Clin. N. Am. · Apr 2010
ReviewCerebral salt wasting: pathophysiology, diagnosis, and treatment.
Cerebral salt wasting (CSW) is a syndrome of hypovolemic hyponatremia caused by natriuresis and diuresis. The mechanisms underlying CSW have not been precisely delineated, although existing evidence strongly implicates abnormal elevations in circulating natriuretic peptides. ⋯ Volume status, but not serum and urine electrolytes and osmolality, is crucial for making this distinction. Volume and sodium repletion are the goals of treatment of patients with CSW, and this can be performed using some combination of isotonic saline, hypertonic saline, and mineralocorticoids.
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Cerebral vasospasm is a cause of significant morbidity and mortality in patients with subarachnoid hemorrhage (SAH). Most cases of vasospasm can be managed medically. Medical strategies for treatment include hemodynamic augmentation to improve cerebral perfusion pressure and medical therapy to prevent or reduce cerebral vasospasm. ⋯ Balloon angioplasty is an effective technique in treating vasospasm and results in durable clinical improvement. It should be used judiciously, however, given a small risk of vessel rupture associated with intracranial angioplasty. The goal of angioplasty should be improvement of vessel caliber to augment flow rather than to achieve a picture-perfect result.
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Neurosurg. Clin. N. Am. · Apr 2010
ReviewNoninvasive imaging techniques in the diagnosis and management of aneurysmal subarachnoid hemorrhage.
Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating condition, requiring prompt diagnosis and therapeutic intervention as well as close monitoring for the development of complications including vasospasm (VS). Although digital subtraction angiography is still considered the gold standard for the diagnosis of aSAH (and vasospasm), new and less invasive modalities are emerging including ultrasound, CT, CT angiography and CT perfusion, and MR imaging. The current evidence for the use of these newer modalities is described for the diagnosis of aSAH and the management of its sequelae including VS.
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Neurosurg. Clin. N. Am. · Apr 2010
ReviewRisk factors and medical management of vasospasm after subarachnoid hemorrhage.
Vasospasm is a major cause of morbidity and mortality following aneurysmal subarachnoid hemorrhage. This article reviews the risk factors for vasospasm; the various methods for diagnosing vasospasm including the conventional 4-vessel angiography, computed tomographic angiography, and computed tomographic perfusion; the methods to detect vasospasm before clinical onset (including transcranial Doppler ultrasonography); and the recent emergence of multimodality monitoring. A discussion of medical treatment options in the setting of vasospasm is also included; the prophylactic use of "neuroprotectants" such as nimodipine, statins, and magnesium and the role of hemodynamic augmentation in vasospasm amelioration, including the use of inotropic support in addition to traditional triple-H therapy, are discussed.
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Aneurysmal subarachnoid hemorrhage (aSAH) is a neurosurgical catastrophe. It affects 33,000 patients in the United States annually and has a mortality rate of 50% to 60% at 30 days. Half of the survivors are dependent. ⋯ The cost impact factor of this condition is high from a financial perspective as well as from a patient perspective. Care givers show increased morbidity when compared with the nonaffected community. Early aggressive treatment of good grade patients seems to provide the best outcome for this serious condition.