Current neurology and neuroscience reports
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Curr Neurol Neurosci Rep · Nov 2013
ReviewDecompressive craniectomy for management of traumatic brain injury: an update.
Decompressive craniectomy (DC) for the management of severe traumatic brain injury (TBI) has a long history but remains controversial. Although DC has been shown to improve both survival and functional outcome in patients with malignant cerebral infarctions, evidence of benefit in patients with TBI is decidedly more mixed. Craniectomy can clearly be life-saving in the presence of medically intractable elevations of intracranial pressure. ⋯ Still, the only randomized trial of DC in TBI failed to demonstrate any benefit. Studies of therapies for TBI, including hemicraniectomy, are challenging owing to the inherent heterogeneity in the pathophysiology observed in this disease. Craniectomy can be life-saving for patients with severe TBI, but many questions remain regarding its ideal application, and the outcome remains highly correlated with the severity of the initial injury.
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Iatrogenic fungal infections of the central nervous system had been considered a medical curiosity. Generally, they are a rare isolated complication of neurosurgical procedures, but periodically these infections are observed in larger populations as a result of exposure to contaminated materials during diagnostic or therapeutic procedures. In the last year, an epidemic of iatrogenic fungal central nervous system disease accompanied the use of fungal-contaminated compounded methylprednisolone distributed by one facility, heightening the attention given to this infectious disorder. ⋯ An assay for β-D-glycan has been proposed as an effective adjunctive test for E. rostratum infection. The current therapeutic recommendation is a 6 mg/kg dose of voriconazole every 12 h followed by liposomal amphotericin B. In some instances, surgical debridement and drainage may be necessary.
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Curr Neurol Neurosci Rep · Nov 2013
ReviewConscious awareness in patients in vegetative states: myth or reality?
Do vegetative state (VS) and minimally conscious state (MCS) patients experience emotions and have conscious awareness of themselves and their surroundings? Can neuroimaging clarify these questions? Neuroimaging responses to stimuli are classified into four levels: level 0 indicates no response; level 1 indicates responses limited to the primary sensory cortices; level 2 indicates activation of primary sensory cortices and higher-order associative areas; level 3 indicates activation of cortical regions to either mental imagery tasks or high-level language stimuli requiring distinction of ambiguous from unambiguous words. Level 0 or level 1 was noted in 125 of 193 VS patients (65 %) and 46 of 121 MCS patients (38 %), suggesting no evidence of conscious awareness. ⋯ These data may denote the presence of conscious awareness or may simply identify neuronal processing without phenomenological awareness. The pro and cons of these conflicting interpretations are discussed.
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Coagulopathy is often observed after traumatic brain injury (TBI), but the pathogenic mechanisms of this phenomenon remain elusive. Brain injury is the leading cause of trauma deaths, and the development of coagulopathy after TBI is associated with increased morbidity and mortality in these patients. ⋯ Some theories of its pathogenesis include massive release of tissue factor, altered protein C homeostasis, microparticle upregulation, and platelet hyperactivity. This article aims to examine the coagulopathy associated with blunt head injury, to review its effect on progression of hemorrhagic injury, and to discuss the possible relevant pathophysiological mechanisms.