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Eelco F M Wijdicks
Discovery of the ascending reticular activating system (ARAS) can be attributed to work done in research neuroscientist Horace Magoun's laboratory. Before this finding, most scientists would focus on the diencephalon (and anterior midbrain) but not more caudally. Stimulation of the medial bulbar reticular formation in the pontine and midbrain tegmentum resulted disappearance of synchronized discharge and low-voltage fast activity. The effects were mediated by a thalamic projection system. This finding was a dramatic departure from the early philosophers' ascription of the awake soul to the ventricles (Galen), lumbosacral cord (Plato), pineal gland (Descartes), and even from more modern nineteenth- and twentieth-century hypotheses that the corpus striatum or periaqueductal gray matter housed the "seat of awareness...
February 22, 2019: Neurocritical Care
Ségolène Mrozek, David Rousset, Thomas Geeraerts
PURPOSE OF REVIEW: To describe the pathophysiology and pharmacotherapy of dysnatremia in neurocritical care patients. RECENT FINDINGS: Sodium disorders may affect approximately half of the neurocritical care patients and are associated with worse neurological outcome and increased risk of death. Pharmacotherapy of sodium disorders in neurocritical care patients may be challenging and is guided by a careful investigation of water and sodium balance. SUMMARY: In case of hyponatremia, because of excessive loss of sodium, fluid challenge with isotonic solution, associated with salt intake is the first-line therapy, completed with mineralocorticoids if needed...
April 2019: Current Opinion in Critical Care
Néstor Wainsztein, Federico Rodríguez Lucci
Spreading depolarization in cerebral cortex is associated with swelling of neurons, distortion of dendritic spines, massive ion translocation with a large change of the slow electrical potential, and silencing of brain electrical activity. The term spreading depression represents a wave of spontaneous activity of the electrocorticogram that propagates through contiguous cerebral gray matter at a characteristic velocity. Spreading depression is a consequence of cortical spreading depolarization. Therefore, spreading depolarization is not always accompanied by spreading depression and the terms are not synonymous...
April 2018: Neurosurgery Clinics of North America
Michael George Zaki Ghali, Peter Kan, Gavin W Britz
Arteriovenous malformations have a significant cumulative risk for hemorrhage. Treatment options include observation, microsurgical resection, stereotactic radiosurgery, embolization, and multimodal treatment. Treatment selection and timing are based upon AVM features including size, location in eloquent versus non-eloquent parenchyma, pattern of venous drainage, surgical access, rupture status, and prior treatments. Spetzler-Martin grading is the most commonly used classification system used to select treatment, with grades I and II lesions amenable to surgical resection alone, grade III lesions typically treated via a multimodal approach entailing pre-operative embolization followed by microsurgical resection, and grades IV and V lesions generally observed unless ruptured...
February 5, 2019: World Neurosurgery
Xiuyun Liu, Kais Gadhoumi, Ran Xiao, Nate Tran, Peter Smielewski, Marek Czosnyka, Steven W Hetts, Nerissa Ko, Xiao Hu
OBJECTIVE: Cerebrovascular reactivity (CR) is a mechanism that maintains stable blood flow supply to the brain. Pressure reactivity index (PRx), the correlation coefficient between slow waves of invasive arterial blood pressure (ABP) and intracranial pressure (ICP) has been validated for CR assessment. However, in clinical ward, not every subarachnoid hemorrhage (SAH) patient has invasive ABP monitoring. Pulse transit time (PTT), the propagation time of a pulse wave travelling from the heart to peripheral arteries, has been suggested as a surrogate measure of ABP...
January 23, 2019: Physiological Measurement
Khaled Elzaafarany, Moustafa H Aly, Gyanendra Kumar, Arie Nakhmani
OBJECTIVES: Silent cerebral artery vasospasm in aneurysmal subarachnoid hemorrhage causes serious complications such as cerebral ischemia and death. A transcranial Doppler (TCD) ultrasound system is a noninvasive device that can effectively detect cerebral artery vasospasm as soon as it sets in, even before and in the absence of clinical deterioration. Continuous or even daily TCD monitoring is challenging because of the operator expertise and certification required in the form of a trained sonographer and interpretive experience required in the form of an additionally trained and certified physician to perform these studies...
December 28, 2018: Journal of Ultrasound in Medicine: Official Journal of the American Institute of Ultrasound in Medicine
Shaheryar Hafeez, Ramesh Grandhi
Intrathecal nicardipine has been shown to have some efficacy for the treatment of symptomatic cerebral vasospasm in aneurysmal subarachnoid hemorrhage (aSAH). We performed a PRISMA-based systematic review of intrathecal nicardipine for the treatment of cerebral vasospasm in aneurysmal subarachnoid hemorrhage. A total of 825 articles were reviewed. After duplicates were removed and the search criteria was applied, 9 articles remained that were eligible for inclusion and analysis. 377 patients received a total of 6,596 injections of intrathecal nicardipine for aSAH-related cerebral vasospasm...
January 3, 2019: Neurocritical Care
Eric Michael Liotta, Anna L Romanova, Bryan D Lizza, Laura J Rasmussen-Torvik, Minjee Kim, Brandon Francis, Rajbeer Singh Sangha, Timothy J Carroll, Daniel Ganger, Daniela P Ladner, Andrew M Naidech, James J Paparello, Shyam Prabhakaran, Farzaneh A Sorond, Matthew B Maas
OBJECTIVES: We sought to determine the effect of acute electrolyte and osmolar shifts on brain volume and neurologic function in patients with liver failure and severe hepatic encephalopathy. DESIGN: Retrospective analysis of brain CT scans and clinical data. SETTING: Tertiary care hospital ICUs. PATIENTS: Patients with acute or acute-on-chronic liver failure and severe hepatic encephalopathy. INTERVENTIONS: Clinically indicated CT scans and serum laboratory studies...
February 2018: Critical Care Medicine
Mohammed F Sheikh, Nazri Unni, Banwari Agarwal
Cerebral oedema and Intracranial Hypertension (ICH) are serious complications of acute liver failure affecting approximately 30% of patients, resulting in neurological injury or death. Multiple pathogenetic mechanisms contribute to the pathogenesis of HE including circulating neurotoxins such as ammonia, systemic and neuro-inflammation, infection and cerebral hyperaemia due to loss of cerebral vascular autoregulation. Early recognition and diagnosis is often difficult as clinical signs of elevated Intracranial Pressure (ICP) are not uniformly present and maybe masked by other organ support...
December 2018: Journal of Clinical and Experimental Hepatology
Robert K Laundon, Laszlo Littmann
Subarachnoid hemorrhage (SAH) is occasionally associated with the electrocardiographic (ECG) pattern of ST-segment elevation myocardial infarction (STEMI). Missing the true clinical diagnosis can result in inappropriate and harmful interventions. We report the case of a 40-year-old female who was found down. The ECG was diagnostic for acute lateral STEMI. Further analysis of the ECG showed marked prolongation of the QT interval and the "spiked helmet sign" (SHS). The patient was ruled out for myocardial infarction and a head CT demonstrated a massive SAH with acute hemorrhage into the ventricles...
January 2019: Journal of Electrocardiology
Mohammad S Ibrahim, Bennson Samuel, Wazim Mohamed, Kushak Suchdev
A number of neurologic disorders can cause cardiac dysfunction by involving the conductive system and contractile apparatus of the heart. This is especially prominent in the neurocritical care setting where the spectrum of cardiac dysfunction due to acute neurologic injury ranges from trivial and isolated electrocardiographic changes to malignant arrhythmias and sudden death (Table 1). The mechanism of these cardiac complications is complex and not fully understood. An understanding of the neuroanatomical structures and pathways is of immense importance to comprehend the underlying pathophysiology that culminates as cardiac damage and dysregulation...
November 27, 2018: Neurocritical Care
Jan F Scheitz, Christian H Nolte, Wolfram Doehner, Vladimir Hachinski, Matthias Endres
Cardiac complications are a frequent medical problem during the first few days after an ischaemic stroke, and patients present with a broad range of symptoms including myocardial injury, cardiac dysfunction, and arrhythmia, with varying overlap between these three conditions. Evidence from clinical and neuroimaging studies and animal research suggests that these cardiac disturbances share the same underlying mechanisms. Although the exact cascade of events has yet to be elucidated, stroke-induced functional and structural alterations in the central autonomic network, with subsequent dysregulation of normal neural cardiac control, are the assumed pathophysiology...
December 2018: Lancet Neurology
Alejandro A Rabinstein
PURPOSE OF REVIEW: This article discusses the diagnostic and therapeutic approach to patients who are comatose and reviews the current knowledge on prognosis from various causes of coma. This article also provides an overview of the principles for determination of brain death as well as advice on how to avoid common pitfalls. RECENT FINDINGS: Technologic advances have refined our understanding of the physiology of consciousness and the spectrum of disorders of consciousness; they also promise to improve our prognostic accuracy...
December 2018: Continuum: Lifelong Learning in Neurology
Jessica Seidelman, Sarah S Lewis
In this review article, we discuss the epidemiology, microbiology, diagnosis, treatment and prevention of infections associated with cerebrospinal fluid shunts, cerebrospinal fluid drains, and deep brain stimulators. We also briefly discuss prevention strategies with appropriate antibiotics, devices, and operating room practices to decrease the risk of these infections.
December 2018: Infectious Disease Clinics of North America
Babikir Kheiri, Mohammed Osman, Ahmed Abdalla, Tarek Haykal, Bakr Swaid, Sahar Ahmed, Adam Chahine, Mustafa Hassan, Ghassan Bachuwa, Mohammed Al Qasmi, Deepak L Bhatt
Recurrent stroke is common immediately following a transient ischemic attack (TIA) or ischemic stroke. Dual antiplatelet therapy (DAPT) with clopidogrel and aspirin may provide greater protection against subsequent stroke than monotherapy. Electronic databases were searched for randomized clinical trials (RCTs) comparing DAPT with monotherapy in ischemic stroke/TIA. Sixteen RCTs with a total of 29,032 patients were included. Compared with monotherapy, DAPT was associated with significantly lower rates of any stroke (risk ratio [RR] 0...
December 3, 2018: Journal of Thrombosis and Thrombolysis
Cory J Rice, Sung-Min Cho, Lucy Q Zhang, Catherine Hassett, Randall C Starling, Ken Uchino
BACKGROUND: Ischemic and hemorrhagic strokes are frequent complications among those with left ventricular assist device (LVAD). Scarce data exist regarding the prevalence of acute large vessel occlusion (LVO) and treatment of acute ischemic stroke (AIS) in this setting. METHODS: We reviewed prospectively collected data of LVAD patient registry from a single, tertiary center from October 2004 to November 2016. Among those with AIS complications, patients were divided into early stroke (during implantation hospitalization) and late stroke (post-discharge) groups, and neuroimaging was reviewed and data on acute stroke therapy were collected...
2018: Cerebrovascular Diseases
Chloe E Hill, Leah J Blank, Dylan Thibault, Kathryn A Davis, Nabila Dahodwala, Brian Litt, Allison W Willis
OBJECTIVE: To characterize continuous EEG (cEEG) use patterns in the critically ill and to determine the association with hospitalization outcomes for specific diagnoses. METHODS: We performed a retrospective cross-sectional study with National Inpatient Sample data from 2004 to 2013. We sampled hospitalized adult patients who received intensive care and then compared patients who underwent cEEG to those who did not. We considered diagnostic subgroups of seizure/status epilepticus, subarachnoid or intracerebral hemorrhage, and altered consciousness...
January 1, 2019: Neurology
Steve S Cho, Sung-Eun Kim, Heung Cheol Kim, Won Jin Kim, Jin Pyeong Jeon
OBJECT: Clazosentan, an endothelin-receptor-antagonist, reduced vasospasm and delayed-ischemic-neurological-deficit (DIND) but did not improve outcome following subarachnoid hemorrhage (SAH) in clinical trials. However, a lack of dose-dependent analysis and potential overestimation of clazosentan's effect are concerning. We employ stratified analysis and trial-sequential-analysis (TSA) of existing data to investigate the effects of clazosentan on SAH outcome. METHODS: Studies from PubMed, EMBASE, and Cochrane were reviewed for eligibility...
November 30, 2018: World Neurosurgery
Lin Zhao, Yu-Peng Wu, Jin-Long Qi, Yong-Qiang Liu, Kai Zhang, Wen-Ling Li
BACKGROUND: Early and/or late onset in patients with brain injury (BI) is associated with a poorer prognosis, and phenytoin (PHT) is standard of care to prevent seizures. Levetiracetam (LEV), an alternative antiepileptic drug, is associated with less cognitive disruption. The purpose of this study was to evaluate the safety and efficacy of LEV in the prevention of brain traumatic seizures with the standard drug PHT. METHODS: Search the publications on comparison the safety and efficacy of LEV against the standard agent PHT in prevention of traumatic seizures in BI to January 2018...
November 2018: Medicine (Baltimore)
Christopher Mares, Jehane H Dagher, Mona Harissi-Dagher
The most common symptom of post-concussive syndrome (PCS) is post-traumatic headache (PTH) accompanied by photophobia. Post-traumatic headache is currently categorized as a secondary headache disorder with a clinical phenotype described by its main features and resembling one of the primary headache disorders: tension, migraine, migraine-like cluster. Although PTH is often treated with medication used for primary headache disorders, the underlying mechanism for PTH has yet to be elucidated. The goal of this narrative literature review is to determine the current level of knowledge of these PTHs and photophobia in mild traumatic brain injury (mTBI) in order to guide further research and attempt to discover the underlying mechanism to both symptoms...
January 2019: Canadian Journal of Neurological Sciences. le Journal Canadien des Sciences Neurologiques
2018-12-07 03:38:11
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