Curr Treat Option Ne
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Therapeutic hypothermia (TH), which prevents and ameliorates the cascade of secondary neurologic injury after the return of spontaneous circulation, is the most effective neuroprotective therapy for encephalopathic survivors of cardiac arrest. Despite the compelling efficacy of TH, most patients who survive cardiac arrest long enough to be hospitalized will nonetheless suffer a poor neurologic outcome. Attention to the details of therapy and an integrated approach involving emergency medicine, neurology, cardiology, critical care medicine, and palliative care are likely to yield the best results. ⋯ In the intensive care unit, cerebral perfusion must be optimized, metabolic homeostasis achieved, and neuromonitoring used during the dangerous decooling phase. Cardiac arrest is always a life-altering event for patients and their families. Even after cardiac arrest survivors have been stabilized and treated, physicians must recogonize and embrace their role in facilitating a variety of difficult transitions: to organ donation, end-of-life care, nursing or rehabilitation placement, or home.
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Malignant middle cerebral artery infarction is associated with up to 80% mortality due to ischemic edema and brain herniation. No medical therapy has proven its efficacy in efficiently and durably reducing brain edema and improving patients' outcome. Decompressive surgery by a large hemicraniectomy with durotomy has been suggested as a life-saving emergency procedure. ⋯ Recently the results of a pooled analysis of three European randomized trials (DECIMAL, DESTINY, and HAMLET) of early (= 48 hours) decompressive large hemicraniectomy in patients less than 60 years of age showed that, compared with medical therapy alone, there was a 50% (95% CI, 33%-67%) absolute risk reduction (ARR) of death, with more patients surviving with a slight to moderate disability (modified Rankin score of 2 or 3) (ARR of 23% ) or with a slight to moderately severe disability (modified Rankin score of 2, 3, or 4) (ARR of 51% ). About 5% of all patients in each therapeutic group were left with a severe residual disability (Rankin 5). These data indicate that early decompressive hemicraniectomy should be considered and fully discussed with the relatives of selected patients with a malignant hemispheric infarction.
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Successful critical care management of patients with aneurysmal subarachnoid hemorrhage (SAH) requires a thorough understanding of the disease and its complications and a familiarity with modern multimodality neuromonitoring technology. This article reviews the natural history of aneurysmal SAH and strategies for disease management in the acute setting, including available tools for monitoring brain function. Intensive care management of patients with SAH focuses on prevention of further neurologic injury. ⋯ There is increasing awareness of extracerebral complications, including electrolyte disturbances (eg, cerebral salt wasting) and cardiac dysfunction. Prompt recognition and treatment of these disorders maximizes the odds of a good functional outcome. Technologic advances hold the promise of improved detection and treatment of secondary neurologic insults.
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Chronic congestive heart failure is a highly prevalent and progressive disorder associated with excess morbidity and mortality; it has huge economic impact. Left heart failure may be systolic or may occur as isolated diastolic dysfunction. The diastolic form predominates in older people. ⋯ For restless legs syndrome with or without periodic limb movements, pramipexole and ropinirole have been approved. Treatment of insomnia comorbid with heart failure depends on the cause. In the absence of any known cause, a trial of ramelteon is the first choice.
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Delirium is a complex neuropsychiatric syndrome presenting primarily with disturbances of cognition, perception and sensorium, alertness, sleep/wake cycle, and psychomotor behavior in the context of a medical etiology. The presentation can be quite variable among patients and even within a given patient because of its waxing and waning course. This variability and overlap with other psychiatric syndromes has led to substantial underrecognition and undertreatment in clinical settings. ⋯ Similarly, research is warranted that focuses on preventing delirium, potentially by identifying susceptible patients and intervening early. It is particularly challenging to devise cost-effective interventions for preventing and identifying delirium early in its course, given the rapid pace and resource limitations in inpatient and intensive care settings, and current data do not clearly indicate that such systems have proven benefit. Still, the indisputable health and financial costs of delirium indicate that prevention and identification should be a high priority.