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Rincon F, Mayer SA. Current treatment options for intracerebral hemorrhage. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2008; 10:229-40. [DOI: 10.1007/s11936-008-0025-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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52
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Geocadin RG, Koenig MA, Jia X, Stevens RD, Peberdy MA. Management of brain injury after resuscitation from cardiac arrest. Neurol Clin 2008; 26:487-506, ix. [PMID: 18514823 PMCID: PMC3074242 DOI: 10.1016/j.ncl.2008.03.015] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The devastating neurologic injury in survivors of cardiac arrest has been recognized since the development of modern resuscitation techniques. After numerous failed clinical trials, two trials showed that induced mild hypothermia can ameliorate brain injury and improve survival and functional neurologic outcome in comatose survivors of out-of-hospital cardiac arrest. This article provides a comprehensive review of the advances in the care of brain injury after cardiac arrest, with updates on the process of prognostication, the use of therapeutic hypothermia and adjunctive intensive care unit care for cardiac arrest survivors.
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Affiliation(s)
- Romergryko G Geocadin
- Neurosciences Critical Care Division, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, MD 21287, USA.
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53
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Hänggi D, Steiger HJ. Spontaneous intracerebral haemorrhage in adults: a literature overview. Acta Neurochir (Wien) 2008; 150:371-9; discussion 379. [PMID: 18176774 DOI: 10.1007/s00701-007-1484-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2007] [Accepted: 12/04/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND A large number of reports have analysed epidemiology, pathogenesis, symptomatology, diagnostics and options for medical and surgical treatment of intracerebral haemorrhage. Nevertheless, management still remains controversial. The purpose of the present review is to summarise the clinical data and derive a current updated management concept as a result. METHODS The analysis was based on a Medline search to November 2006 for the term "intracerebral haemorrhage" (ICH). The clinical query functions were optimised for aetiology, diagnosis and therapy to limit the results. A total of 103 articles were found eligible for review. FINDINGS Race, age and sex influence the occurrence of ICH. Moreover, hypertension and alcohol consumption are the paramount risk factors. The most frequent pathophysiological mechanism of ICH seems to be a degenerative vessel wall change and, in consequence, rupture of small penetrating arteries and arterioles of 50-200 microm in diameter. The symptomatology depends on the size of ICH, possible rebleeding and the occurrence of hydrocephalus or seizures. The outcome is worse with concomitant occurrence of intraventricular haemorrhage. Treatment with recombinant factor VIIa (rFVIIa) within four hours after the onset of ICH limits the growth of haematoma, reduces mortality and improves functional outcome. Minimally invasive surgery tends to improve functional outcome. CONCLUSION A systematic knowledge of currently available data on epidemiology, pathogenesis and symptomatology, the use of diagnostics and the different conservative and surgical treatment options can lead to a balanced management strategy for patients with ICH.
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54
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Qureshi AI. Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH): rationale and design. Neurocrit Care 2007; 6:56-66. [PMID: 17356194 DOI: 10.1385/ncc:6:1:56] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/1999] [Revised: 11/30/1999] [Accepted: 11/30/1999] [Indexed: 12/12/2022]
Abstract
This trial is a multicenter open-labeled pilot trial to determine the tolerability and safety of three escalating levels of antihypertensive treatment goals for acute hypertension in 60 subjects with supratentorial intracerebral hemorrhage (ICH). The pilot trial is the natural development of numerous case series evaluating the effect of antihypertensive treatment of acute hypertension in subjects with ICH. The proposed trial will have important public health implications by providing necessary information for a definitive phase III study regarding the efficacy of antihypertensive treatment of acute hypertension in subjects with ICH. The specific aims of the present pilot study are to: (1) Determine the tolerability of the treatment as assessed by achieving and maintaining three different systolic blood pressure goals with intravenous nicardipine infusion for 18 to 24 hours postictus in subjects with ICH who present within 6 hours of symptom onset; (2) Define the safety, assessed by the rate of neurological deterioration during treatment and serious adverse events, of three escalating systolic blood pressure treatment goals using intravenous nicardipine infusion; and (3) Obtain preliminary estimates of the treatment effect using the rate of hematoma expansion (within 24 hours) and modified Rankin scale and Barthel index at 3 months following symptom onset.
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Affiliation(s)
- Adnan I Qureshi
- Clinical Research Division, Zeenat Qureshi Stroke Research Center, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, NJ 07103, USA.
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55
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Thompson KM, Gerlach SY, Jorn HKS, Larson JM, Brott TG, Files JA. Advances in the care of patients with intracerebral hemorrhage. Mayo Clin Proc 2007; 82:987-90. [PMID: 17673068 DOI: 10.4065/82.8.987] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Intracerebral hemorrhage (ICH), which comprises 15 percent to 30 percent of all strokes, has an estimated incidence of 37,000 cases per year. One third of patients are actively bleeding when they present to the emergency department, and hematoma growth during the first hours after ICH onset is thought to be a prime determinant of clinical deterioration. Inflammation, as opposed to ischemia, also negatively affects patient condition. Recombinant activated factor VII is emerging as a potential first-line therapy, especially in warfarin-associated hemorrhage. Corticosteroid therapy is not supported by contemporary studies or by current management guidelines. Aggressive blood pressure reduction is under investigation. Surgical intervention has shown no statistically significant benefit over medical management for patients with ICH in general, although subgroup analysis in a large randomized trial suggested potential benefits from surgery for patients with lobar ICH. Not long ago, ICH was considered virtually untreatable. Diligent efforts in both bench and clinical research are generating hope for patients who experience this catastrophic event.
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Affiliation(s)
- Kristine M Thompson
- Department of Emergency Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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56
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Shah QA, Ezzeddine MA, Qureshi AI. Acute hypertension in intracerebral hemorrhage: pathophysiology and treatment. J Neurol Sci 2007; 261:74-9. [PMID: 17550786 DOI: 10.1016/j.jns.2007.04.036] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Non-traumatic or spontaneous intracerebral hemorrhage (ICH) is defined as intra-parenchymal bleeding with or without extension into the ventricles and rarely into the subarachoid space. Primary ICH in most cases is associated with chronic hypertension. Acute hypertension is associated with hematoma expansion, and poor neurological outcome. The treatment of hypertension in acute ICH is a topic of controversy. Experiments have shown an area of ischemia around the hematoma, with the reduction of regional cerebral blood flow (CBF) secondary to compression of microvasculature. Not all scientific results agree with the above findings. Recent studies have shown that CBF decreases in the perihematoma region but with concomitant reduction of cerebral metabolism, which would argue against an area of ischemia in the perihematoma region. Based on the above result, there have been several clinical trials looking at clinical outcome and decrease in hematoma expansion rates with reduction of blood pressure acutely after ICH. The parameters for the blood pressure control are still under investigation. The American Heart Association has put forward guidelines for blood pressure control which have been adopted in the centers around the country. We have described the protocol we use at our center for the blood pressure control in patients with acute ICH.
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Affiliation(s)
- Qaisar A Shah
- Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, MN 55455, USA.
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57
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Geocadin RG, Koenig MA, Stevens RD, Peberdy MA. Intensive care for brain injury after cardiac arrest: therapeutic hypothermia and related neuroprotective strategies. Crit Care Clin 2007; 22:619-36; abstract viii. [PMID: 17239747 DOI: 10.1016/j.ccc.2006.11.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Neurologic injury is the predominant cause of poor functional outcome in patients who are resuscitated from cardiac arrest. The management of these patients in the ICU can be challenging because of the paucity of effective therapies and lack of readily available diagnostic and prognostic tools. After several decades of failed pharmacologic neuroprotection trials, recent and well-designed randomized trials showed that therapeutic hypothermia is an effective neuroprotective measure in comatose survivors of cardiac arrest. Therapeutic hypothermia has been recommended by the International Liaison Committee on Resuscitation and has been incorporated in the American Heart Association CPR Guidelines. The American Academy of Neurology recently enhanced the delivery of care in survivors of cardiac arrest by providing evidence-based practice parameters on the prediction of poor outcome in comatose survivors of cardiac arrest, based on clinical evaluation and diagnostic tests. This article discusses these advances and their potential impact on the care provided in the ICU.
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Affiliation(s)
- Romergryko G Geocadin
- Department of Neurology, Johns Hopkins School of Medicine, Meyer 8-140, Baltimore, MD 21287, USA.
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58
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Qureshi AI, Ezzeddine MA, Nasar A, Suri MFK, Kirmani JF, Hussein HM, Divani AA, Reddi AS. Prevalence of elevated blood pressure in 563,704 adult patients with stroke presenting to the ED in the United States. Am J Emerg Med 2007; 25:32-8. [PMID: 17157679 PMCID: PMC2443694 DOI: 10.1016/j.ajem.2006.07.008] [Citation(s) in RCA: 303] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2006] [Revised: 07/05/2006] [Accepted: 07/10/2006] [Indexed: 01/15/2023] Open
Abstract
PURPOSE The aim of this study was to estimate the prevalence of elevated blood pressure in adult patients with acute stroke in the United States (US). METHODS Patients with stroke were classified by initial systolic blood pressure (SBP) into 4 categories using demographic, clinical, and treatment data from the National Hospital Ambulatory Medical Care Survey, the largest study of use and provision of emergency department (ED) services in the United States. We also compared the age-, sex-, and ethnicity-adjusted rates of elevated blood pressure strata, comparable with stages 1 and 2 hypertension in the US population. RESULTS Of the 563704 patients with stroke evaluated, initial SBP was below 140 mm Hg in 173120 patients (31%), 140 to 184 mm Hg in 315207 (56%), 185 to 219 mm Hg in 74586 (13%), and 220 mm Hg or higher in 791 (0.1%). The mean time interval between presentation and evaluation was 40 +/- 55, 33 +/- 39, 25 +/- 27, and 5 +/- 1 minutes for increasing SBP strata (P = .009). A 3- and 8-fold higher rate of elevated blood pressure strata was observed in acute stroke than the existing rates of stages 1 and 2 hypertension in the US population. Labetalol and hydralazine were used in 6126 (1%) and 2262 (0.4%) patients, respectively. Thrombolytics were used in 1283 patients (0.4%), but only in those with SBP of 140 to 184 mm Hg. CONCLUSIONS In a nationally representative large data set, elevated blood pressure was observed in over 60% of the patients presenting with stroke to the ED. Elevated blood pressure was associated with an earlier evaluation; however, the use of thrombolytics was restricted to patients with ischemic stroke with SBP below 185 mm Hg.
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Affiliation(s)
- Adnan I Qureshi
- Epidemiological and Outcomes Research Division, Zeenat Qureshi Stroke Research Center, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, NJ 07103, USA.
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59
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Abstract
Head trauma is a common and devastating injury. Along with a high mortality rate, the long-term morbidity is consequential for both the individual patient and society. A thorough knowledge of the clinical approach will assist the emergency physician in providing optimal care and helping to minimize secondary brain injury. Using a case-based scenario, the initial management strategies along with rational evidence-based treatments are reviewed.
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Affiliation(s)
- Steven Rosonke
- New York University School of Medicine, Department of Emergency Medicine, New York University Hospital, Bellevue Hospital Center, NYU/Bellevue Emergency Medicine Residency, 1st Avenue and 27th Street, New York, NY 10016, USA
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60
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Soustiel JF, Vlodavsky E, Zaaroor M. Relative effects of mannitol and hypertonic saline on calpain activity, apoptosis and polymorphonuclear infiltration in traumatic focal brain injury. Brain Res 2006; 1101:136-44. [PMID: 16787640 DOI: 10.1016/j.brainres.2006.05.045] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2005] [Revised: 04/30/2006] [Accepted: 05/08/2006] [Indexed: 11/21/2022]
Abstract
The purpose of this study was to compare the relative effects of mannitol and hypertonic saline (HTS) on calpain activity, apoptosis and neuroinflammatory response induced by experimental cortical contusion. Four groups of 5 Sprague-Dawley male rats were submitted to focal brain injury produced by exposing the parietal cortex to dynamic cortical deformation. Groups were defined by rescucitation fluids administered 30 min post-injury as follows: group 1-0.9% normal saline 2 ml/kg; group 2-mannitol 20% 0.5 g/kg; group 3-HTS 2 ml/kg; group 4-HTS 4 ml/kg. At 72 h, animals were sacrificed. Paraffin-mounted sections of were stained for mu-Calpain, TUNEL, active caspase 3 and myeloperoxidase. There was no difference in the lesion size between the different groups. In contrast, there was a significant reduction in calpain and apoptosis activity and in the neuroinflammatory response in animals receiving HTS. Although mannitol proved to significantly decrease the neuroinflammatory response and calpain activity, it did not affect apoptosis, and its effect was significantly less than that of HTS. Importantly, the effect of HTS was mostly independent from the infused volume. Our results show that HTS promotes cell survival and reduces secondary brain damage following TBI. This protective effect was evidenced at rather small infused volumes, proved to encompass several cellular and molecular mechanisms involved in secondary cell death and could not be related to relief of intracranial pressure. These findings suggest that the high osmolality of HTS may have protective effects besides its impact on brain edema.
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Affiliation(s)
- Jean F Soustiel
- Acute Brain Injury Research Laboratory and B. Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
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61
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Abstract
Apart from management in a specialised stroke or neurological intensive care unit, until very recently no specific therapies improved outcome after intracerebral haemorrhage (ICH). In a recent phase II trial, recombinant activated factor VII (eptacog alfa) reduced haematoma expansion, mortality, and disability when given within 4 h of ICH onset; a phase III trial (the FAST trial) is now in progress. Ventilatory support, blood-pressure reduction, intracranial-pressure monitoring, osmotherapy, fever control, seizure prophylaxis, and nutritional supplementation are the cornerstones of supportive care in intensive care units. Ventricular drainage should be considered in all stuporous or comatose patients with intraventricular haemorrhage and acute hydrocephalus. Given the lack of benefit seen in a the recent STICH trial, emergency surgical evacuation within 72 h of onset should be reserved for patients with large (>3 cm) cerebellar haemorrhages, or those with large lobar haemorrhages, substantial mass effect, and rapidly deteriorating condition.
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Affiliation(s)
- Stephan A Mayer
- Neurological Intensive Care Unit, Division of Stroke and Critical Care, Department of Neurology Columbia University, New York, NY 10032, USA.
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62
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Abstract
Although recent studies have shown that the timing of volume replacement deserves careful consideration (56), which fluid to use is less clear, with the perennial debate of crystalloid v colloid and now colloid v colloid still unresolved. This review has examined three sugar solutions, two colloids and one crystalloid. In general, all three agents are unhelpful in the immediate resuscitation of hypovolaemic trauma by virtue of a combination of pathophysiology and side effects. Dextran solutions and mannitol are useful in specific situations.
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Affiliation(s)
- D Parkhouse
- Medical Regiment, 16 Air Assault Brigade, Goojerat Barracks, Colchester.
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63
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Skoglund TS, Nellgård B. Long-time outcome after transient transtentorial herniation in patients with traumatic brain injury. Acta Anaesthesiol Scand 2005; 49:337-40. [PMID: 15752399 DOI: 10.1111/j.1399-6576.2005.00624.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND This study investigates mortality and morbidity in patients with traumatic brain injury (TBI) who developed episode(s) of transtentorial herniation. The transtentorial herniation was defined as a deterioration of consciousness accompanied by uni- or bilateral pupil dilatation. METHODS The medical records of all patients with traumatic brain injury admitted during 1999 to the Neuro- or General Intensive Care Units at Sahlgrenska University Hospital were analyzed, and patients with at least one episode of transtentoryal herniation were included. Information regarding patient age, gender, type of trauma, initial GCS, precipitating reason for herniation, uni-/bilateral pupil dilatation, treatment(s) and outcome after at least 6 months, assessed with the Glasgow Outcome Scale (GOS), was collected from medical records. RESULTS The study included 27 patients, average age 44 years (range 6-81), with a male proportion of 81%. The majority of the patients were victims of traffic accidents and falls. The results demonstrated that 16/27(59%) of the patients had a favorable outcome (GOS 4/5), 4/27(15%) were severely disabled (GOS 3), none was vegetative (GOS 2) and 7/27(26%) died (GOS 1). When analyzing patient subgroups, best outcome was found in children where 3/4 (75%) had a GOS 4/5. CONCLUSION Transtentorial herniation is a serious consequence of supratentorial edema/mass lesions in patients with TBI. However, with aggressive neurointensive care and neurosurgical treatments we found a 59% patient incidence of a favorable outcome.
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Affiliation(s)
- T S Skoglund
- Department of Neurosurgery, Sahlgrenska University Hospital, S-413 Göteborg, Sweden.
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64
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Gupta R, Connolly ES, Mayer S, Elkind MSV. Hemicraniectomy for Massive Middle Cerebral Artery Territory Infarction. Stroke 2004; 35:539-43. [PMID: 14707232 DOI: 10.1161/01.str.0000109772.64650.18] [Citation(s) in RCA: 236] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Hemicraniectomy and durotomy have been proposed in many small series to relieve intracranial hypertension and tissue shifts in patients with large hemispheric infarcts, thereby preventing death from herniation. Our objective was to review the literature to identify patients most likely to benefit from hemicraniectomy. METHODS All available individual cases from the English literature were reviewed and analyzed to determine whether age, vascular territory of infarction, side of infarction, reported time to surgery, and signs of herniation predict outcome in patients after hemicraniectomy. All studies included were retrospective and uncontrolled; there were no randomized controlled trials. RESULTS Of 15 studies screened, 12 studies describing 129 patients met the criteria for analysis; 9 patients treated at our institution were added, for a total of 138 patients. After a minimum follow-up of 4 months, 10 patients (7%) were functionally independent, 48 (35%) were mildly to moderately disabled, and 80 (58%) died or were severely disabled. Of 75 patients who were >50 years of age, 80% were dead or severely disabled compared with 32% of 63 patients <or=50 years of age (P<0.00001). The timing of surgery, hemisphere infarcted, presence of signs of herniation before surgery, and involvement of other vascular territories did not significantly affect outcome. CONCLUSIONS Age may be a crucial factor in predicting functional outcome after hemicraniectomy in patients with large middle cerebral artery territory infarction.
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Affiliation(s)
- Rishi Gupta
- Department of Neurology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
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65
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Le Roux PD, Winn HR. Standards for Surgical Treatment of Cerebrovascular Disease, Circa 2000. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50088-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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66
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67
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68
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Abstract
Traumatic brain injury (TBI) is a major cause of disability and death in most Western nations and consumes an estimated $100 billion annually in the United States alone. In the last 2 decades, the management of TBI has evolved dramatically, as a result of a more thorough understanding of the physiologic events leading to secondary neuronal injury as well as advances in the care of critically ill patients. However, it is likely that many patients with TBI are not treated according to current treatment principles. This article presents an overview of the current management of patients with TBI.
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Affiliation(s)
- Paul E Marik
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA.
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69
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Aiyagari V, Diringer MN. Management of large hemispheric strokes in the neurological intensive care unit. Neurologist 2002; 8:152-62. [PMID: 12803687 DOI: 10.1097/00127893-200205000-00002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with large hemispheric strokes frequently develop neurologic deterioration secondary to cerebral edema. Despite supportive care in the intensive care unit and traditional forms of therapy for cerebral edema, they have a high morbidity and mortality. New forms of therapy are being investigated to improve outcome in these patients. REVIEW SUMMARY This article begins with a discussion of the clinical and radiologic features of large hemispheric strokes. The role of increased intracranial pressure in neurologic deterioration and the predictors of outcome in these patients are reviewed. The various therapeutic options for management of cerebral edema in these patients, including the role of osmotic therapy, hypothermia, and hemicraniectomy, are explored. CONCLUSIONS Neurologic deterioration in patients with large hemispheric strokes necessitates admission to the intensive care unit for management of the airway, blood pressure, and cerebral edema. New promising therapies, such as hemicraniectomy and hypothermia, need to be further evaluated to define their role in the management of these patients.
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Affiliation(s)
- Venkatesh Aiyagari
- Neurology/Neurosurgery Intensive Care Unit, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
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70
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Qureshi AI, Wilson DA, Traystman RJ. Treatment of transtentorial herniation unresponsive to hyperventilation using hypertonic saline in dogs: effect on cerebral blood flow and metabolism. J Neurosurg Anesthesiol 2002; 14:22-30. [PMID: 11773819 DOI: 10.1097/00008506-200201000-00005] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We tested the hypothesis that transtentorial herniation (TTH) represents a state of cerebral ischemia that can be reversed by hypertonic saline. Because of the high mortality associated with TTH, new therapeutic strategies need to be developed for rapid and effective reversal of this process. We produced TTH (defined by acute dilatation of one or both pupils) by creating supratentorial intracerebral hemorrhage with autologous blood injection in seven mongrel dogs anesthetized using intravenous pentobarbital and fentanyl. We measured serial rCBF (regional cerebral blood flow) using radiolabeled microspheres in regions around and distant to the hematoma. Cerebral oxygen extraction and oxygen consumption (CMRO2) were measured by serial sampling of cerebral venous blood from the sagittal sinus. Mean arterial pressure (MAP) and intracranial pressure (ICP) were continuously monitored. TTH was successfully reversed over a mean period of 25.7 +/- 4.9 minutes after intravenous administration of 23.4% sodium chloride (1.4 mL/kg) in all animals. All measurements were recorded 15, 30, 60, and 90 minutes after administration of 23.4% sodium chloride. Compared to prehematoma ICP (14.1 +/- 1.7 mm Hg, mean +/- SE), elevation in ICP was observed during TTH (36.2 +/- 7.2 mm Hg) with no change in cerebral perfusion pressure (CPP) (80.4 +/- 4.7 vs. 76.7 +/- 10.1 mm Hg) because of concomitant elevation in mean arterial pressure. Compared to baseline values, there was a reduction in rCBF (mL/100 gm/min +/- SE) in brainstem (12.1 +/- 2.0 vs. 21.4 +/- 1.4), gray matter (18.2 +/- 2.1 vs. 31.4 +/- 1.8), and white matter (8.6 +/- 1.7 vs.18.7 +/- 0.9) in the hemisphere contralateral to the hematoma; and gray matter (12.9 +/- 2.9 vs. 27.9 +/- 2.2) and white matter (8.3 +/- 2.0 vs.19.9 +/- 1.0) in the ipsilateral hemisphere distant from the hematoma. Administration of 23.4% sodium chloride resulted in reduced ICP at 15 minutes (12.7 +/- 1.4) and 30 minutes (15.6 +/- 3.1) after administration. RCBF values were restored in all regions studied after administration of 23.4% sodium chloride with an increase in CMRO2 (1.8 +/- 0.4 vs. 3.9 +/- 0.7 mL O2 /100 gm/min). Compared with baseline values, rCBF increased in the ipsilateral (31.7 +/- 2.5 vs. 63.4 +/- 11.7) and contralateral (28.7 +/- 1.9 vs. 45.5 +/- 5.7) thalamus at 15 minutes after administration of 23.4% sodium chloride. TTH represented a state of ischemia in brainstem and supratentorial gray and white matter in the presence of adequate CPP, suggesting mechanical compression of vessels at the level of tentorium. Hypertonic saline reversed TTH, and restored both rCBF and CMRO2, although hyperemia was observed immediately after reversal of TTH. Administration of hypertonic saline may preserve neurologic function during the interim period between TTH and surgical intervention.
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Affiliation(s)
- Adnan I Qureshi
- Department of Neurology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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71
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Salazar JD, Wityk RJ, Grega MA, Borowicz LM, Doty JR, Petrofski JA, Baumgartner WA. Stroke after cardiac surgery: short- and long-term outcomes. Ann Thorac Surg 2001; 72:1195-201; discussion 1201-2. [PMID: 11603436 DOI: 10.1016/s0003-4975(01)02929-0] [Citation(s) in RCA: 167] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Stroke remains a devastating complication of cardiac surgery, but stroke prevention remains elusive. Evaluation of early and long-term clinical outcomes and brain-imaging findings may provide insight into stroke prognosis, etiology, and prevention. METHODS Five thousand nine hundred seventy-one cardiac surgery patients were prospectively studied for clinical evidence of stroke. Stroke and nonstroke patients were compared by early outcomes. Data collected for stroke patients included brain imaging results, long-term functional status, and survival. Outcome predictors were then determined. RESULTS Stroke was diagnosed in 214 (3.6%) patients. Brain imaging demonstrated acute infarction in 72%; embolic in 83%, and watershed in 24%. Survival for stroke patients was 67% at 1 year and 47% at 5 years. Independent predictors of survival were cerebral infarct type, creatinine elevation, cardiopulmonary bypass time, preoperative intensive care days, postoperative awakening time, and postoperative intensive care days. Long-term disability was moderate to severe in 69%. CONCLUSIONS Stroke after cardiac surgery has profound repercussions that are independently related to infarct type and clinical factors. These data are essential for clinical decision making and prognosis determination.
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Affiliation(s)
- J D Salazar
- Department of Neurology, The Johns Hopkins University, Baltimore, Maryland, USA
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72
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Coplin WM, Cullen NK, Policherla PN, Vinas FC, Wilseck JM, Zafonte RD, Rengachary SS. Safety and feasibility of craniectomy with duraplasty as the initial surgical intervention for severe traumatic brain injury. THE JOURNAL OF TRAUMA 2001; 50:1050-9. [PMID: 11426120 DOI: 10.1097/00005373-200106000-00013] [Citation(s) in RCA: 108] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Decompressive craniectomy has historically served as a salvage procedure to control intracranial pressure after severe traumatic brain injury. We assessed the safety and feasibility of performing craniectomy as the initial surgical intervention. METHODS Of 29 consecutive patients undergoing emergent decompression for severe traumatic brain injury with horizontal midline shift greater than explained by a removable hematoma, 17 had traditional craniotomy with or without brain resection and 12 underwent craniectomy. RESULTS The craniectomy group had lower Glasgow Coma Scale scores at surgery (median, 4 vs. 7; p = 0.04) and more severe radiographic injuries (using specific measures). Mortality, Glasgow Outcome Scale scores, Functional Independence Measures, and length of stay in both the acute care setting and the rehabilitation phase were similar between the surgical groups. CONCLUSION Despite more severe injury severity, patients undergoing initial craniectomy had outcomes similar to those undergoing traditional surgery. A randomized evaluation of the effect of early craniectomy on outcome is warranted.
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Affiliation(s)
- W M Coplin
- Department of Neurology, Wayne State University School of Medicine, 4201 St Antoine-8D, Detroit, MI 48201, USA.
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Affiliation(s)
- A I Qureshi
- Department of Neurology, Johns Hopkins Hospital, Baltimore, USA.
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