1
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Anand S, Choudhury SS, Pradhan S, Mulmuley MS. Normotensive state during acute phase of hypertensive intracerebral hemorrhage. J Neurosci Rural Pract 2023; 14:465-469. [PMID: 37692796 PMCID: PMC10483210 DOI: 10.25259/jnrp_168_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 05/18/2023] [Indexed: 09/12/2023] Open
Abstract
Objectives Hypertensive hemorrhage is a leading cause of intracerebral haemorrhage (ICH), although some of these patients may not present with high blood pressure (BP) at the time of ICH. Materials and Methods This retrospective study included patients with history of hypertension presenting with ICH. Patients with systolic BP recording of more than 140 mmHg were included in hypertension group (group I). Patients whose BP rose to hypertension range after fluid correction were included in group II and patients with BP <140 mmHg on consecutive 1-week BP recordings were included in group III. Clinical features including volume of ICH of all the three groups were noted. Outcome in the form of mortality was analyzed. Chi-square test was used for categorical variables and independent t-test for continuous variables. P < 0.05 was considered significant. Results Ninety-two ICH patients with history of hypertension were included in the study. Of them, 20 patients (22%) presented with BP <140 mmHg systolic at the time of ICH. After fluid correction, it rose to hypertensive range in 9 (10%) but remained normal in 11 patients (12%) during consecutive recordings for 1-week post-admission. On comparing normotensive and hypertensive groups, significant difference was seen in survival and volume of ICH. Conclusion There is a subset of hypertensive patients who may present with normal BP recording during acute ICH. The BP rises subsequently with the correction of hypovolemia in some. The volume of hemorrhage in normotensives is relatively small but whether this translates into better prognosis needs further studies.
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Affiliation(s)
- Sucharita Anand
- Department of Neurology, All India Institute of Medical Sciences (AIIMS) Jodhpur, Jodhpur, Rajasthan, India
| | | | - Sunil Pradhan
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Madhura Sanjay Mulmuley
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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2
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Lui A, Kumar KK, Grant GA. Management of Severe Traumatic Brain Injury in Pediatric Patients. FRONTIERS IN TOXICOLOGY 2022; 4:910972. [PMID: 35812167 PMCID: PMC9263560 DOI: 10.3389/ftox.2022.910972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/10/2022] [Indexed: 11/23/2022] Open
Abstract
The optimal management of severe traumatic brain injury (TBI) in the pediatric population has not been well studied. There are a limited number of research articles studying the management of TBI in children. Given the prevalence of severe TBI in the pediatric population, it is crucial to develop a reference TBI management plan for this vulnerable population. In this review, we seek to delineate the differences between severe TBI management in adults and children. Additionally, we also discuss the known molecular pathogenesis of TBI. A better understanding of the pathophysiology of TBI will inform clinical management and development of therapeutics. Finally, we propose a clinical algorithm for the management and treatment of severe TBI in children using published data.
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Affiliation(s)
- Austin Lui
- Touro University College of Osteopathic Medicine, Vallejo, CA, United States
| | - Kevin K. Kumar
- Department of Neurosurgery, Stanford University, Stanford, CA, United States
- Division of Pediatric Neurosurgery, Lucile Packard Children’s Hospital, Palo Alto, CA, United States
| | - Gerald A. Grant
- Department of Neurosurgery, Stanford University, Stanford, CA, United States
- Division of Pediatric Neurosurgery, Lucile Packard Children’s Hospital, Palo Alto, CA, United States
- Department of Neurosurgery, Duke University, Durham, NC, United States
- *Correspondence: Gerald A. Grant,
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3
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Contraindications to the Initiation of Veno-Venous ECMO for Severe Acute Respiratory Failure in Adults: A Systematic Review and Practical Approach Based on the Current Literature. MEMBRANES 2021; 11:membranes11080584. [PMID: 34436348 PMCID: PMC8400963 DOI: 10.3390/membranes11080584] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/19/2021] [Accepted: 07/27/2021] [Indexed: 12/21/2022]
Abstract
(1) Background: Extracorporeal membrane oxygenation (ECMO) is increasingly used for acute respiratory failure with few absolute but many relative contraindications. The provider in charge often has a difficult time weighing indications and contraindications to anticipate if the patient will benefit from this treatment, a decision that often decides life and death for the patient. To assist in this process in coming to a good evidence-based decision, we reviewed the available literature. (2) Methods: We performed a systematic review through a literature search of the MEDLINE database of former and current absolute and relative contraindications to the initiation of ECMO treatment. (3) Results: The following relative and absolute contraindications were identified in the literature: absolute-refusal of the use of extracorporeal techniques by the patient, advanced stage of cancer, fatal intracerebral hemorrhage/cerebral herniation/intractable intracranial hypertension, irreversible destruction of the lung parenchyma without the possibility of transplantation, and contraindications to lung transplantation; relative-advanced age, immunosuppressed patients/pharmacological immunosuppression, injurious ventilator settings > 7 days, right-heart failure, hematologic malignancies, especially bone marrow transplantation and graft-versus-host disease, SAPS II score ≥ 60 points, SOFA score > 12 points, PRESERVE score ≥ 5 points, RESP score ≤ -2 points, PRESET score ≥ 6 points, and "do not attempt resuscitation" order (DN(A)R status). (4) Conclusions: We provide a simple-to-follow algorithm that incorporates absolute and relative contraindications to the initiation of ECMO treatment. This algorithm attempts to weigh pros and cons regarding the benefit for an individual patient and hopefully assists caregivers to make better, informed decisions.
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Ramineni A, Roberts EA, Vora M, Mahboobi SK, Nozari A. Anesthesia Considerations in Neurological Emergencies. Neurol Clin 2021; 39:319-332. [PMID: 33896521 DOI: 10.1016/j.ncl.2021.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Airway obstruction and respiratory failure are common complications of neurological emergencies. Anesthesia is often employed for airway management, surgical and endovascular interventions or in the intensive care units in patients with altered mental status or those requiring burst suppression. This article provides a summary of the unique airway management and anesthesia considerations and controversies for neurologic emergencies in general, as well as for specific commonly encountered conditions: elevated intracranial pressure, neuromuscular respiratory failure, acute ischemic stroke, and acute cervical spinal cord injury.
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Affiliation(s)
- Anil Ramineni
- Department of Neurology, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA
| | - Erik A Roberts
- Boston University School of Medicine, 72 East Concord Street, Boston, MA 02118, USA
| | - Molly Vora
- Boston University School of Medicine, 72 East Concord Street, Boston, MA 02118, USA
| | - Sohail K Mahboobi
- Department of Anesthesiology, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA; Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, USA
| | - Ala Nozari
- Boston University School of Medicine, 72 East Concord Street, Boston, MA 02118, USA; Department of Anesthesiology, Boston Medical Center, 750 Albany Street, Power Plant 2R, Boston, MA 02118, USA.
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5
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Cantone M, Lanza G, Puglisi V, Vinciguerra L, Mandelli J, Fisicaro F, Pennisi M, Bella R, Ciurleo R, Bramanti A. Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: A Narrative Review. Brain Sci 2021; 11:70. [PMID: 33430236 PMCID: PMC7825668 DOI: 10.3390/brainsci11010070] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/02/2021] [Accepted: 01/04/2021] [Indexed: 02/07/2023] Open
Abstract
Hypertensive crisis, defined as an increase in systolic blood pressure >179 mmHg or diastolic blood pressure >109 mmHg, typically causes end-organ damage; the brain is an elective and early target, among others. The strong relationship between arterial hypertension and cerebrovascular diseases is supported by extensive evidence, with hypertension being the main modifiable risk factor for both ischemic and hemorrhagic stroke, especially when it is uncontrolled or rapidly increasing. However, despite the large amount of data on the preventive strategies and therapeutic measures that can be adopted, the management of high BP in patients with acute cerebrovascular diseases presenting at the emergency department is still an area of debate. Overall, the outcome of stroke patients with high blood pressure values basically depends on the occurrence of hypertensive emergency or hypertensive urgency, the treatment regimen adopted, the drug dosages and their timing, and certain stroke features. In this narrative review, we provide a timely update on the current treatment, debated issues, and future directions related to hypertensive crisis in patients referred to the emergency department because of an acute cerebrovascular event. This will also focus greater attention on the management of certain stroke-related, time-dependent interventions, such as intravenous thrombolysis and mechanic thrombectomy.
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Affiliation(s)
- Mariagiovanna Cantone
- Department of Neurology, Sant’Elia Hospital, ASP Caltanissetta, Via Luigi Russo, 6, 93100 Caltanissetta, Italy;
| | - Giuseppe Lanza
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Via Santa Sofia, 78, 95123 Catania, Italy
- Department of Neurology IC, Oasi Research Institute—IRCCS, Via Conte Ruggero, 73, 94018 Troina, Italy
| | - Valentina Puglisi
- Department of Neurology and Stroke Unit, ASST Cremona, Viale Concordia, 1, 26100 Cremona, Italy; (V.P.); (L.V.)
| | - Luisa Vinciguerra
- Department of Neurology and Stroke Unit, ASST Cremona, Viale Concordia, 1, 26100 Cremona, Italy; (V.P.); (L.V.)
| | - Jaime Mandelli
- Department of Neurosurgery, Sant’Elia Hospital, ASP Caltanissetta, Via Luigi Russo, 6, 93100 Caltanissetta, Italy;
| | - Francesco Fisicaro
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia, 89, 95123 Catania, Italy; (F.F.); (M.P.)
| | - Manuela Pennisi
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia, 89, 95123 Catania, Italy; (F.F.); (M.P.)
| | - Rita Bella
- Department of Medical and Surgical Sciences and Advanced Technologies, University of Catania, Via Santa Sofia, 78, 95123 Catania, Italy;
| | - Rosella Ciurleo
- IRCCS Centro Neurolesi Bonino-Pulejo, S.S. 113, Via Palermo C/da Casazza, 98123 Messina, Italy; (R.C.); (A.B.)
| | - Alessia Bramanti
- IRCCS Centro Neurolesi Bonino-Pulejo, S.S. 113, Via Palermo C/da Casazza, 98123 Messina, Italy; (R.C.); (A.B.)
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6
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Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: A Narrative Review. Brain Sci 2021. [PMID: 33430236 DOI: 10.3390/brainsci11010070.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hypertensive crisis, defined as an increase in systolic blood pressure >179 mmHg or diastolic blood pressure >109 mmHg, typically causes end-organ damage; the brain is an elective and early target, among others. The strong relationship between arterial hypertension and cerebrovascular diseases is supported by extensive evidence, with hypertension being the main modifiable risk factor for both ischemic and hemorrhagic stroke, especially when it is uncontrolled or rapidly increasing. However, despite the large amount of data on the preventive strategies and therapeutic measures that can be adopted, the management of high BP in patients with acute cerebrovascular diseases presenting at the emergency department is still an area of debate. Overall, the outcome of stroke patients with high blood pressure values basically depends on the occurrence of hypertensive emergency or hypertensive urgency, the treatment regimen adopted, the drug dosages and their timing, and certain stroke features. In this narrative review, we provide a timely update on the current treatment, debated issues, and future directions related to hypertensive crisis in patients referred to the emergency department because of an acute cerebrovascular event. This will also focus greater attention on the management of certain stroke-related, time-dependent interventions, such as intravenous thrombolysis and mechanic thrombectomy.
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7
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Leever JD. Unilateral cerebral herniation resulting in combined contralateral superior cerebellar artery territory infarction and mesencephalic injury: Two cases of a severe unrecognized variant of Kernohan notch phenomenon? Radiol Case Rep 2020; 15:250-253. [PMID: 31956382 PMCID: PMC6957800 DOI: 10.1016/j.radcr.2019.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 11/29/2019] [Accepted: 12/11/2019] [Indexed: 11/25/2022] Open
Abstract
A case of unilateral cerebral herniation due to an acute middle cerebral artery territory infarct and a second case of unilateral cerebral herniation due to an acute subdural hematoma are presented in this article. In both instances, the unilateral cerebral herniation resulted in a combined contralateral superior cerebellar artery territory infarction and mesencephalic injury. Unilateral cerebral herniation resulting in a combined contralateral superior cerebellar artery territory infarct and mesencephalic injury is previously undescribed in the literature and likely reflects a severe unrecognized variant of Kernohan notch phenomenon.
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Affiliation(s)
- John D. Leever
- The University of Kansas Medical Center, Department of Radiology, 4000 Cambridge St, Kansas City, KS 66160, USA
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8
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Ong C, Hutch M, Barra M, Kim A, Zafar S, Smirnakis S. Effects of Osmotic Therapy on Pupil Reactivity: Quantification Using Pupillometry in Critically Ill Neurologic Patients. Neurocrit Care 2020; 30:307-315. [PMID: 30298336 DOI: 10.1007/s12028-018-0620-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Osmotic therapy is a critical component of medical management for cerebral edema. While up to 90% of neurointensivists report using these treatments, few quantitative clinical measurements guide optimal timing, dose, or administration frequency. Its use is frequently triggered by a qualitative assessment of neurologic deterioration and/or pupil size, and anecdotally appears to improve pupil asymmetry suggestive of uncal herniation. However, subjective pupil assessment has poor reliability, making it difficult to detect or track subtle changes. We hypothesized that osmotic therapy reproducibly improves quantitative pupil metrics. METHODS We included patients at two centers who had recorded quantitative pupil measurements within 2 h before and after either 20% mannitol or 23.4% hypertonic saline in the neurosciences intensive care unit. The primary outcome was the Neurologic Pupil Index (NPi), a composite metric ranging from 0 to 5 in which > 3 is considered normal. Secondary outcomes included pupil size, percent change, constriction and dilation velocity, and latency. Results were analyzed with Wilcoxon signed-rank tests, Chi-square and multi-level linear regression to control for other edema-reducing interventions. RESULTS Out of 72 admissions (403 paired pupil observations), NPi significantly differed within 2 h of osmotic therapy when controlling for other commonly used interventions in our whole cohort (β = 0.08, p = 0.0168). The effect was most pronounced (β = 0.57) in patients with abnormal NPi prior to intervention (p = 0.0235). CONCLUSIONS Pupil reactivity significantly improves after osmotic therapy in a heterogenous critically ill population when controlling for various other interventions. Future work is necessary to determine dose-dependent effects and clinical utility.
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Affiliation(s)
- C Ong
- Boston University School of Medicine, Boston, USA.
- Brigham and Women's Hospital, Boston, USA.
- Harvard Medical School, Boston, USA.
| | - M Hutch
- Boston University School of Medicine, Boston, USA
| | - M Barra
- Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| | - A Kim
- Brigham and Women's Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| | - S Zafar
- Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| | - S Smirnakis
- Brigham and Women's Hospital, Boston, USA
- Harvard Medical School, Boston, USA
- Jamaica Plain VA Hospital, Boston, USA
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9
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Wang J, Fang Y, Ramesh S, Zakaria A, Putman MT, Dinescu D, Paik J, Geocadin RG, Tahsili-Fahadan P, Altaweel LR. Intraosseous Administration of 23.4% NaCl for Treatment of Intracranial Hypertension. Neurocrit Care 2020; 30:364-371. [PMID: 30397844 DOI: 10.1007/s12028-018-0637-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND/OBJECTIVE Prompt treatment of acute intracranial hypertension is vital to preserving neurological function and frequently includes administration of 23.4% NaCl. However, 23.4% NaCl administration requires central venous catheterization that can delay treatment. Intraosseous catheterization is an alternative route of venous access that may result in more rapid administration of 23.4% NaCl. METHODS Single-center retrospective analysis of 76 consecutive patients, between January 2015 and January 2018, with clinical signs of intracranial hypertension received 23.4% NaCl through either central venous catheter or intraosseous access. RESULTS Intraosseous cannulation was successful on the first attempt in 97% of patients. No immediate untoward effects were seen with intraosseous cannulation. Time to treatment with 23.4% NaCl was significantly shorter in patients with intraosseous access compared to central venous catheter (p < 0.0001). CONCLUSIONS Intraosseous cannulation resulted in more rapid administration of 23.4% NaCl with no immediate serious complications. Further investigations to identify the clinical benefits and safety of hypertonic medication administration via intraosseous cannulation are warranted.
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Affiliation(s)
- Jing Wang
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Yun Fang
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Subhashini Ramesh
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Asma Zakaria
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Maryann T Putman
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Dan Dinescu
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - James Paik
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Romergryko G Geocadin
- Neurocritical Care Unit Division, Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Pouya Tahsili-Fahadan
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA.,Neurocritical Care Unit Division, Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Laith R Altaweel
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA. .,Neuroscience Research, Neuroscience and Spine Institute, INOVA Fairfax Hospital, Falls Church, VA, USA.
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10
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Poblete RA, Zheng L, Arenas M, Vazquez A, Yu D, Emanuel BA, Kim-Tenser MA, Sanossian N, Mack W. Older Age Is Not Associated with Worse Outcomes Following Decompressive Hemicraniectomy for Spontaneous Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2019; 28:104320. [PMID: 31395424 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 07/12/2019] [Accepted: 07/23/2019] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Decompressive hemicraniectomy (DHC) is commonly offered after large spontaneous intracerebral hemorrhage (ICH) as a life-saving measure. Based on limited available evidence, surgery is sometimes avoided in the elderly. The association between age and outcomes following DHC in spontaneous ICH remains largely understudied. OBJECTIVE The goal of this study is to investigate the influence of older age on outcomes of patients who undergo DHC for spontaneous ICH. METHODS In this retrospective cohort study, inpatient data were obtained from the United States Nationwide Inpatient Sample from 2000 to 2011. Using International Classification of Diseases, ninth revision designations, patients with a primary diagnosis of nontraumatic ICH who underwent DHC were identified. The primary outcome of interest was the association of age to inpatient mortality and poor outcome. Subjects were grouped by age: 18-50, 51-60, 61-70, and more than 70 years. Sample characteristics were compared across age groups using χ2 testing, and univariate and multivariate Poisson Regression was performed using a generalized equation to estimate rate ratios for primary and secondary outcomes. RESULTS One thousand one hundred and forty four patient cases were isolated. Death occurred in an estimated 28.9% and poor outcome in 86.4%. In multivariate Poisson regression models, there was no difference in hospital mortality or poor outcome by age group. Although younger patients were more likely to be diagnosed with herniation, total complication rate was similar between age groups. CONCLUSIONS Our study results do not provide evidence that age independently predicts in-hospital mortality or poor outcomes. The true influence of age on outcomes is unclear, and further study is needed to determine which factors may be best in selecting candidates for DHC following spontaneous ICH.
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Affiliation(s)
- Roy A Poblete
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California.
| | - Ling Zheng
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Marcela Arenas
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Alejandro Vazquez
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Derek Yu
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Benjamin A Emanuel
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - May A Kim-Tenser
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Nerses Sanossian
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - William Mack
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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11
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Papangelou A, Zink EK, Chang WTW, Frattalone A, Gergen D, Gottschalk A, Geocadin RG. Automated Pupillometry and Detection of Clinical Transtentorial Brain Herniation: A Case Series. Mil Med 2019; 183:e113-e121. [PMID: 29315412 DOI: 10.1093/milmed/usx018] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 10/24/2017] [Indexed: 11/14/2022] Open
Abstract
Introduction Transtentorial herniation (TTH) is a life-threatening neurologic condition that typically results from expansion of supratentorial mass lesions. A change in bedside pupillary examination is central to the clinical diagnosis of TTH. Materials and. Methods To quantify the changes in the pupillary examination that precede and accompany TTH and its treatment, we evaluated 12 episodes of herniation in three patients with supratentorial mass lesions using automated pupillometry (NeurOptics, Inc., Irvine, CA). Herniation was defined clinically by the onset of fixed and dilated pupils in association with decreased levels of consciousness. Automated pupillometry was measured simultaneously with the bedside clinical examination, but the clinical team was blinded to these results and could not act on the data. Data from the pupillometer were downloaded 1-2 times per week onto a secured laptop, and data processing was facilitated by the use of Mathematica 8.0. Results Neurologic Pupil Index measurements, values generated by the pupillometer based on an algorithm that incorporates pupillary size and reactivity in a normal population, were found to be abnormal before 73% of TTHs. This abnormality occurred at a median of 7.4 h before TTH. All episodes of TTH were reversed after clinical intervention at a median of 43 min after the event. The value did not fall to 0 in 42% of clinical herniations, but it did decrease to very abnormal values of 0.5-0.8. Conclusions The potential of automated pupillometry to guide the management of severely injured neurologic patients is intriguing and warrants further study in the critical care unit and beyond. The utility of a portable device in the combat setting may allow for triage of patients with severe neurologic injury.
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Affiliation(s)
- Alexander Papangelou
- Department of Anesthesiology, Emory University Hospital, 1364 Clifton Road NE, Atlanta GA 30322
| | - Elizabeth K Zink
- The Johns Hopkins Hospital Department of Neuroscience Nursing, 600N Wolfe Street, Baltimore MD 21287
| | - Wan-Tsu W Chang
- Department of Neurology, University of Maryland Medical Systems, 22S Greene Street, G7K55, Baltimore MD 21201.,Department of Emergency Medicine, University of Maryland Medical Systems, 22S Greene Street, G7K55, Baltimore MD 21201
| | - Anthony Frattalone
- Department of Neurology, San Antonio Military Medical, Center, 3551 Roger Brooke Drive, San Antonio TX 78219.,Department of Trauma Critical Care, San Antonio Military Medical Center, 3551 Roger Brooke Drive, San Antonio TX 78219
| | - Daniel Gergen
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600N Wolfe Street, Baltimore MD 21287
| | - Allan Gottschalk
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600N Wolfe Street, Baltimore MD 21287.,Department of Neurosurgery, Johns Hopkins University School of Medicine, 600N Wolfe Street, Baltimore MD 21287
| | - Romergryko G Geocadin
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600N Wolfe Street, Baltimore MD 21287.,Department of Neurosurgery, Johns Hopkins University School of Medicine, 600N Wolfe Street, Baltimore MD 21287.,Department of Neurology, Johns Hopkins University School of Medicine, 600N Wolfe Street, Baltimore MD 21287
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12
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Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines. Pediatr Crit Care Med 2019; 20:S1-S82. [PMID: 30829890 DOI: 10.1097/pcc.0000000000001735] [Citation(s) in RCA: 164] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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13
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Munakomi S, Agrawal A. Advancements in Managing Intracerebral Hemorrhage: Transition from Nihilism to Optimism. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1153:1-9. [PMID: 30888664 DOI: 10.1007/5584_2019_351] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
There have been significant advancements in the management of intracerebral hemorrhage (ICH) stemming from new knowledge on its pathogenesis. Major clinical trials, such as Surgical Trial in Lobar Intracerebral Hemorrhage (STICH I and II), have shown only a small, albeit clinically relevant, advantage of surgical interventions in specific subsets of patients suffering from ICH. Currently, the aim is to use a minimally invasive and safe trajectory in removing significant brain hematomas with the aid of neuro-endoscopy or precise guidance through neuro-navigation, thereby avoiding a collateral damage to the surrounding normal brain tissue. A fundamental rational to such approach is to safely remove hematoma, preventing the ongoing mass effect resulting in brain herniation, and to minimize deleterious effects of iron released from hematoma to brain cells. The clot lysis process is facilitated with the adjunctive use of recombinant tissue plasminogen activator and sonolysis. Revised recommendations for the management of ICH focus on a holistic approach, with special emphasis on early patient mobilization and graded rehabilitative process. There has been a paradigm shift in the management algorithm, putting emphasis on early and safe removal of brain hematoma and then focusing on the improvement of patients' quality of life. We have made significant progress in transition from nihilism toward optimism, based on evidence-based management of such a severe global health scourge as intracranial hemorrhage.
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Affiliation(s)
- Sunil Munakomi
- Department of Neurosurgery, Nobel Medical College and Teaching Hospital, Biratnagar, Nepal.
| | - Amit Agrawal
- Department of Neurosurgery, Narayana Medical College, Nellore, Andra Pradesh, India
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14
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Woo PY, Yip AS, Mak CH, Wong AK, Wong HT, Chan KY, Kwok JC. Bedside external ventricular drain placement for haemorrhagic stroke patients with brain herniation and acute hydrocephalus: A case series. SURGICAL PRACTICE 2018. [DOI: 10.1111/1744-1633.12338] [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]
Affiliation(s)
- Peter Y.M. Woo
- Department of Neurosurgery; Kwong Wah Hospital; Hong Kong
| | - Ada S.M. Yip
- Department of Neurosurgery; Kwong Wah Hospital; Hong Kong
| | | | | | - Hoi-Tung Wong
- Department of Neurosurgery; Kwong Wah Hospital; Hong Kong
| | - Kwong-Yau Chan
- Department of Neurosurgery; Kwong Wah Hospital; Hong Kong
| | - John C.K. Kwok
- Department of Neurosurgery; Kwong Wah Hospital; Hong Kong
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15
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Qureshi AI, Qureshi MH. Acute hypertensive response in patients with intracerebral hemorrhage pathophysiology and treatment. J Cereb Blood Flow Metab 2018; 38:1551-1563. [PMID: 28812942 PMCID: PMC6125978 DOI: 10.1177/0271678x17725431] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Acute hypertensive response is a common systemic response to occurrence of intracerebral hemorrhage which has gained unique prominence due to high prevalence and association with hematoma expansion and increased mortality. Presumably, the higher systemic blood pressure predisposes to continued intraparenchymal hemorrhage by transmission of higher pressure to the damaged small arteries and may interact with hemostatic and inflammatory pathways. Therefore, intensive reduction of systolic blood pressure has been evaluated in several clinical trials as a strategy to reduce hematoma expansion and subsequent death and disability. These trials have demonstrated either a small magnitude benefit (second intensive blood pressure reduction in acute cerebral hemorrhage trial and efficacy of nitric oxide in stroke trial) or no benefit (antihypertensive treatment of acute cerebral hemorrhage 2 trial) with intensive systolic blood pressure reduction compared with modest or standard blood pressure reduction. The differences may be explained by the variation in intensity of systolic blood pressure reduction between trials. A treatment threshold of systolic blood pressure of ≥180 mm with the target goal of systolic blood pressure reduction to values between 130 and 150 mm Hg within 6 h of symptom onset may be best supported by current evidence.
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Abstract
Airway management and ventilation are central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Furthermore, intubation, ventilation, and sedative choices directly affect brain perfusion. Therefore, Airway, Ventilation, and Sedation was chosen as an Emergency Neurological Life Support protocol. Topics include airway management, when and how to intubate with special attention to hemodynamics and preservation of cerebral blood flow, mechanical ventilation settings and the use of sedative agents based on the patient's neurological status.
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17
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The Use of Mannitol and Hypertonic Saline Therapies in Patients with Elevated Intracranial Pressure: A Review of the Evidence. Nurs Clin North Am 2017; 52:249-260. [PMID: 28478873 DOI: 10.1016/j.cnur.2017.01.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Patients with increased intracranial pressure generally require pharmacologic therapies and often more definitive treatments, such as surgical intervention. The overall goal of these interventions is to maintain or re-establish adequate cerebral blood flow and prevent herniation. Regardless of the cause of increased intracranial pressure, osmotherapy is considered the mainstay of medical therapy, and should be administered as soon as possible. This article reviews the history of hyperosmolar and hypertonic therapies, the Monro-Kellie hypothesis, and types of cerebral edema. Pharmacologic properties, clinical applications, complications, recommended monitoring during therapy, and risks versus benefits are also discussed.
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18
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Ragland J, Lee K. Critical Care Management and Monitoring of Intracranial Pressure. JOURNAL OF NEUROCRITICAL CARE 2016. [DOI: 10.18700/jnc.160101] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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19
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Majidi S, Suarez JI, Qureshi AI. Management of Acute Hypertensive Response in Intracerebral Hemorrhage Patients After ATACH-2 Trial. Neurocrit Care 2016; 27:249-258. [DOI: 10.1007/s12028-016-0341-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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20
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Mittal MK, LacKamp A. Intracerebral Hemorrhage: Perihemorrhagic Edema and Secondary Hematoma Expansion: From Bench Work to Ongoing Controversies. Front Neurol 2016; 7:210. [PMID: 27917153 PMCID: PMC5116572 DOI: 10.3389/fneur.2016.00210] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 11/08/2016] [Indexed: 12/30/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is a medical emergency, which often leads to severe disability and death. ICH-related poor outcomes are due to primary injury causing structural damage and mass effect and secondary injury in the perihemorrhagic region over several days to weeks. Secondary injury after ICH can be due to hematoma expansion (HE) or a consequence of repair pathway along the continuum of neuroinflammation, neuronal death, and perihemorrhagic edema (PHE). This review article is focused on PHE and HE and will cover the animal studies, related human studies, and clinical trials relating to these mechanisms of secondary brain injury in ICH patients.
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Affiliation(s)
- Manoj K Mittal
- Department of Neurology, University of Kansas Medical Center , Kansas City, KS , USA
| | - Aaron LacKamp
- Department of Anesthesiology, University of Kansas Medical Center , Kansas City, KS , USA
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21
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Abstract
Airway management and ventilation are central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Furthermore, intubation, ventilation, and sedative choices directly affect brain perfusion. Therefore, airway, ventilation, and sedation was chosen as an emergency neurological life support protocol. Topics include airway management, when and how to intubate with special attention to hemodynamics and preservation of cerebral blood flow, mechanical ventilation settings, and the use of sedative agents based on the patient's neurological status.
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22
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Arab D, Yahia AM, Qureshi AI. Cardiovascular Manifestations of Acute Intracranial Lesions: Pathophysiology, Manifestations, and Treatment. J Intensive Care Med 2016; 18:119-29. [PMID: 14984630 DOI: 10.1177/0885066603251202] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of this article was to review the effects of acute intracranial lesions on myocardial function. The authors reviewed scientific and clinical literature retrieved from a computerized MEDLINE search from January 1965 through January 2002. Pertinent literature was referenced, including clinical and laboratory investigations, to demonstrate the effects of acute intracranial lesions on the cardiovascular system. The literature was reviewed to summarize the mechanisms of cardiac damage and clinical manifestations and treatment of cardiovascular dysfunction caused by acute intracranial lesions. Myocardial damage and rhythm disturbances were shown to occur with acute intracranial neurological disease. The subgroup of patients used in this study formed a substantial pool of cardiac donors for cardiac transplantation. The pathophysiology of myocardial dysfunction and the optimal management continues to be a source of debate. In this article, the authors will review the anatomy, the available evidence of the pathophysiology, and the management of this complex group of patients. They will also discuss areas that need to be further investigated. Cardiovascular effects of acute intracranial lesions are common and contribute to increased morbidity and mortality.
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Affiliation(s)
- Dinesh Arab
- Department of Medicine, Division of Cardiology, Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo 14209-1194, USA
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Kowalski RG, Buitrago MM, Duckworth J, Chonka ZD, Puttgen HA, Stevens RD, Geocadin RG. Neuroanatomical predictors of awakening in acutely comatose patients. Ann Neurol 2015; 77:804-16. [PMID: 25628166 DOI: 10.1002/ana.24381] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 01/14/2015] [Accepted: 01/21/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Lateral brain displacement has been associated with loss of consciousness and poor outcome in a range of acute neurologic disorders. We studied the association between lateral brain displacement and awakening from acute coma. METHODS This prospective observational study included all new onset coma patients admitted to the Neurosciences Critical Care Unit (NCCU) over 12 consecutive months. Head computed tomography (CT) scans were analyzed independently at coma onset, after awakening, and at follow-up. Primary outcome measure was awakening, defined as the ability to follow commands before hospital discharge. Secondary outcome measures were discharge Glasgow Coma Scale (GCS), modified Rankin Scale, Glasgow Outcome Scale, and hospital and NCCU lengths of stay. RESULTS Of the 85 patients studied, the mean age was 58 ± 16 years, 51% were female, and 78% had cerebrovascular etiology of coma. Fifty-one percent of patients had midline shift on head CT at coma onset and 43 (51%) patients awakened. In a multivariate analysis, independent predictors of awakening were younger age (odds ratio [OR] = 1.039, 95% confidence interval [CI] = 1.002-1.079, p = 0.040), higher GCS score at coma onset (OR = 1.455, 95% CI = 1.157-1.831, p = 0.001), nontraumatic coma etiology (OR = 4.464, 95% CI = 1.011-19.608, p = 0.048), lesser pineal shift on follow-up CT (OR = 1.316, 95% CI = 1.073-1.615, p = 0.009), and reduction or no increase in pineal shift on follow-up CT (OR = 11.628, 95% CI = 2.207-62.500, p = 0.004). INTERPRETATION Reversal and/or limitation of lateral brain displacement are associated with acute awakening in comatose patients. These findings suggest objective parameters to guide prognosis and treatment in patients with acute onset of coma.
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Affiliation(s)
- Robert G Kowalski
- Neurosciences Critical Care Division, Departments of Neurology, Neurosurgery, and Anesthesiology-Critical Care Medicine
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Perez-Barcena J, Llompart-Pou JA, O'Phelan KH. Intracranial Pressure Monitoring and Management of Intracranial Hypertension. Crit Care Clin 2014; 30:735-50. [DOI: 10.1016/j.ccc.2014.06.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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25
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Kim JE, Ko SB, Kang HS, Seo DH, Park SQ, Sheen SH, Park HS, Kang SD, Kim JM, Oh CW, Hong KS, Yu KH, Heo JH, Kwon SU, Bae HJ, Lee BC, Yoon BW, Park IS, Rha JH. Clinical practice guidelines for the medical and surgical management of primary intracerebral hemorrhage in Korea. J Korean Neurosurg Soc 2014; 56:175-87. [PMID: 25368758 PMCID: PMC4217052 DOI: 10.3340/jkns.2014.56.3.175] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 07/15/2014] [Accepted: 09/06/2014] [Indexed: 12/03/2022] Open
Abstract
The purpose of this clinical practice guideline (CPG) is to provide current and comprehensive recommendations for the medical and surgical management of primary intracerebral hemorrhage (ICH). Since the release of the first Korean CPGs for stroke, evidence has been accumulated in the management of ICH, such as intracranial pressure control and minimally invasive surgery, and it needs to be reflected in the updated version. The Quality Control Committee at the Korean Society of cerebrovascular Surgeons and the Writing Group at the Clinical Research Center for Stroke (CRCS) systematically reviewed relevant literature and major published guidelines between June 2007 and June 2013. Based on the published evidence, recommendations were synthesized, and the level of evidence and the grade of the recommendation were determined using the methods adapted from CRCS. A draft guideline was scrutinized by expert peer reviewers and also discussed at an expert consensus meeting until final agreement was achieved. CPGs based on scientific evidence are presented for the medical and surgical management of patients presenting with primary ICH. This CPG describes the current pertinent recommendations and suggests Korean recommendations for the medical and surgical management of a patient with primary ICH.
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Affiliation(s)
- Jeong Eun Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sang-Bae Ko
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Dae-Hee Seo
- Department of Neurosurgery, Good Morning Hospital, Pyeongtaek, Korea
| | - Sukh-Que Park
- Department of Neurosurgery, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Seung Hun Sheen
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Hyun Sun Park
- Department of Neurosurgery, Inha University College of Medicine, Incheon, Korea
| | - Sung Don Kang
- Department of Neurosurgery, Wonkwang University School of Medicine, Iksan, Korea
| | - Jae Min Kim
- Department of Neurosurgery, Hanyang University College of Medicine, Guri, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Keun-Sik Hong
- Department of Neurology, Inje University College of Medicine, Goyang, Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University College of Medicine, Anyang, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Sun-Uck Kwon
- Department of Neurology, University of Ulsan College of Medicine, Seoul, Koera
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym University College of Medicine, Anyang, Korea
| | - Byung-Woo Yoon
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea
| | - In Sung Park
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Incheon, Korea
| | - Joung-Ho Rha
- Department of Neurology, Inha University College of Medicine, Incheon, Korea
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26
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Sadaka F, Kasal J, Lakshmanan R, Palagiri A. Placement of intracranial pressure monitors by neurointensivists: case series and a systematic review. Brain Inj 2013; 27:600-4. [PMID: 23473439 DOI: 10.3109/02699052.2013.772238] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PRIMARY OBJECTIVE Placement of an intracranial pressure (ICP) monitor to guide the management of patients with severe traumatic brain injury (TBI) has been historically performed by neurosurgeons. It is hypothesized that ICP monitors can be placed by non-surgeon neurointensivists, with placement success and complication rates comparable to neurosurgeons. RESEARCH DESIGN Retrospective review and systematic review of the literature. METHODS AND PROCEDURES This study reviewed the medical records of patients with TBI who required insertion of parenchymal ICP monitors performed by four neurointensivists in a large level I trauma centre. Patient data recorded were age, gender, CT findings, ICP monitor placement, location and length of placement, complications related to the ICP monitor and patient outcomes. MAIN OUTCOMES AND RESULTS Thirty-eight (38) monitors (Camino) were placed. Patients' average age was 43.0 years (SD = 21.6); 76% were males. The location of monitor was right frontal in 89% and left frontal in 11%. Mean ICP was 24 (SD = 15), duration of ICP monitor was 4.9 days (SD = 3.6). All monitors were placed successfully. There were no major technical complications, no episodes of major catheter-induced intracranial haemorrhage and no infectious complications. These findings were comparable to published outcomes from neurosurgeon placements. CONCLUSIONS It is believed that insertion of ICP monitors by neurointensivists is safe and may aid in providing prompt monitoring of patients with severe TBI.
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Affiliation(s)
- Farid Sadaka
- Mercy Hospital St Louis, St Louis University, St Lousi, MO, USA.
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27
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Seder DB, Riker RR, Jagoda A, Smith WS, Weingart SD. Emergency neurological life support: airway, ventilation, and sedation. Neurocrit Care 2013; 17 Suppl 1:S4-20. [PMID: 22972019 DOI: 10.1007/s12028-012-9753-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Airway management is central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Therefore, airway, ventilation, and sedation were chosen as an Emergency Neurological Life Support (ENLS) protocol. Reviewed topics include airway management; the decision to intubate; when and how to intubate with attention to cardiovascular status; mechanical ventilation settings; and the use of sedation, including how to select sedative agents based on the patient's neurological status.
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Affiliation(s)
- David B Seder
- Department of Critical Care Services, Maine Medical Center, Tufts University School of Medicine, Boston, MA, USA.
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28
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Gürer B, Kertmen H, Yilmaz ER, Sekerci Z. The surgical outcome of traumatic extra-axial hematomas causing brain herniation in children. Pediatr Neurosurg 2013; 49:215-22. [PMID: 25073982 DOI: 10.1159/000363193] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 04/20/2014] [Indexed: 11/19/2022]
Abstract
AIM The aim of this study was to assess the surgical outcome and prognostic importance of clinical and radiological data from children operated on under emergency conditions due to an extra-axial hematoma causing brain herniation. METHODS This retrospective study included 25 children operated on due to herniated traumatic extra-axial hematomas from January 2000 to December 2010. RESULTS Of those 25 children, 17 (68%) were diagnosed with subdural hematoma (SDH), 7 (28%) with epidural hematoma (EDH) and only 1 patient (4%) suffered from both SDH and EDH. Overall mortality from a herniated extra-axial hematoma was 44%. The mortality rate for herniated SDH patients was 52.9%, and only 1 patient died from a herniated EDH (14.2%). Low Glasgow coma scale scores at admission, high postoperative intracranial pressure (ICP) values, longer intervals from trauma to surgery, longer durations of brain herniation, the presence of intraoperative brain swelling, larger and thicker hematomas and more displacement of the midline structures and obliteration of the basal cisterns were all correlated with mortality and an unfavorable outcome. CONCLUSIONS Brain herniation is a serious consequence of traumatic extra-axial hematomas in children, and approximately one third of these patients have the potential for a favorable outcome. We recommend postoperative ICP monitoring to predict outcome and early decompressive surgery when possible for promising results.
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Affiliation(s)
- Bora Gürer
- Neurosurgery Clinic, Fatih Sultan Mehmet Education and Research Hospital, Ministry of Health, Istanbul, Turkey
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Ziai WC, Chandolu S, Geocadin RG. Cerebral herniation associated with central venous catheter insertion: risk assessment. J Crit Care 2012; 28:189-95. [PMID: 23159141 DOI: 10.1016/j.jcrc.2012.09.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 09/18/2012] [Accepted: 09/19/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE Central venous catheters (CVCs) are often necessary to treat acute brain-injured patients. Four cases of cerebral herniation immediately following central venous catheterization were the impetus for an investigation of clinical and radiologic parameters associated with this complication. MATERIALS AND METHODS This is a case series of 4 consecutive patients who experienced clinical cerebral herniation immediately following CVC placement in Trendelenburg or supine position. Clinical and computed tomography imaging findings were reviewed. RESULTS All 4 patients developed new-onset clinical signs of cerebral herniation (unilateral or fixed dilated pupil and Glasgow Coma Scale [GCS], 3) within 30 minutes of the procedure. All had radiographic signs of Sylvian fissure and/or basal cistern effacement on the preceding computed tomographic scan secondary to unilateral or bilateral mass lesions. Preprocedure GCS was 8 or more in all cases. Herniation was medically reversed in 3 of 4 patients, and 1 patient died of progressive brainstem ischemia. CONCLUSIONS Trendelenburg and even flat position during CVC placement can increase intracranial pressure leading to cerebral herniation in patients with significant intracranial mass effect. Careful review of neuroimaging for signs of impending herniation before inserting CVCs and choosing an alternative treatment plan in these cases may avoid this potentially underreported complication.
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Affiliation(s)
- Wendy C Ziai
- Department of Neurology, Division of Neurosciences Critical Care, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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Rincon F, Mayer SA. Intracerebral hemorrhage: clinical overview and pathophysiologic concepts. Transl Stroke Res 2012; 3:10-24. [PMID: 24323860 DOI: 10.1007/s12975-012-0175-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Revised: 04/09/2012] [Accepted: 04/11/2012] [Indexed: 10/28/2022]
Abstract
Intracerebral hemorrhage is by far the most destructive form of stroke. Apart from the management in a specialized stroke or neurological intensive care unit (NICU), no specific therapies have been shown to consistently improve outcomes after ICH. Current guidelines endorse early aggressive optimization of physiologic derangements with ventilatory support when indicated, blood pressure control, reversal of any preexisting coagulopathy, intracranial pressure monitoring for certain cases, osmotherapy, temperature modulation, seizure prophylaxis, treatment of hyerglycemia, and nutritional support in the stroke unit or NICU. Ventriculostomy is the cornerstone of therapy for control of intracranial pressure patients with intraventricular hemorrhage. Surgical hematoma evacuation does not improve outcome for more patients, but is a reasonable option for patients with early worsening due to mass effect due to large cerebellar or lobar hemorrhages. Promising experimental treatments currently include ultra-early hemostatic therapy, intraventricular clot lysis with thrombolytics, pioglitazone, temperature modulation, and deferoxamine to reduce iron-mediated perihematomal inflammation and tissue injury.
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Affiliation(s)
- Fred Rincon
- Department of Neurology and Neurosurgery, Division of Critical Care and Neurotrauma, Thomas Jefferson University, Philadelphia, PA, USA
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31
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Sadaka F, Veremakis C. Therapeutic hypothermia for the management of intracranial hypertension in severe traumatic brain injury: a systematic review. Brain Inj 2012; 26:899-908. [PMID: 22448655 DOI: 10.3109/02699052.2012.661120] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major source of death and severe disability worldwide. Raised Intracranial pressure (ICP) is an important predictor of mortality in patients with severe TBI and aggressive treatment of elevated ICP has been shown to reduce mortality and improve outcome. The acute post-injury period in TBI is characterized by several pathophysiologic processes that start in the minutes to hours following injury. All of these processes are temperature-dependent; they are all aggravated by fever and inhibited by hypothermia. METHODS This study reviewed the current clinical evidence in support of the use of therapeutic hypothermia (TH) for the treatment of intracranial hypertension (ICH) in patients with severe TBI. RESULTS This study identified a total of 18 studies involving hypothermia for control of ICP; 13 were randomized controlled trials (RCT) and five were observational studies. TH (32-34°C) was effective in controlling ICH in all studies. In the 13 RCT, ICP in the TH group was always significantly lower than ICP in the normothermia group. In the five observational studies, ICP during TH was always significantly lower than prior to inducing TH. CONCLUSIONS Pending results from large multi-centre studies evaluating the effect of TH on ICH and outcome, TH should be included as a therapeutic option to control ICP in patients with severe TBI.
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Affiliation(s)
- Farid Sadaka
- St. John's Mercy Medical Center, St Louis University, St Louis, MO, USA.
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32
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Beyond herniation. Clin Neurol Neurosurg 2012; 114:1177-80. [PMID: 22418050 DOI: 10.1016/j.clineuro.2012.02.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Revised: 02/15/2012] [Accepted: 02/18/2012] [Indexed: 11/22/2022]
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Treatment of Elevated Intracranial Pressure with Hyperosmolar Therapy in Patients with Renal Failure. Neurocrit Care 2012; 17:388-94. [DOI: 10.1007/s12028-012-9676-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Qureshi AI, Palesch YY. Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) II: design, methods, and rationale. Neurocrit Care 2011; 15:559-76. [PMID: 21626077 PMCID: PMC3340125 DOI: 10.1007/s12028-011-9538-3] [Citation(s) in RCA: 158] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The December 2003 report from the National Institute of Neurological Disorders and Stroke (NINDS) Workshop on priorities for clinical research in intracerebral hemorrhage (ICH) recommended clinical trials for evaluation of blood pressure management in acute ICH as a leading priority. The Special Writing Group of the Stroke Council of the American Heart Association in 1999 and 2007 emphasized the need for clinical trials to ensure evidence-based treatment of acute hypertensive response in ICH. To address important gaps in knowledge, we conducted a pilot study funded by the NINDS, Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) I Trial, during 2004-2008 to determine the appropriate level of systolic blood pressure (SBP) reduction. We now have initiated a multi-center, randomized Phase III trial, the ATACH II Trial, to definitively determine the efficacy of early, intensive, antihypertensive treatment using intravenous (IV) nicardipine initiated within 3 h of onset of ICH and continued for the next 24 h in subjects with spontaneous supratentorial ICH. The primary hypothesis of this large (N = 1,280), streamlined, and focused trial is that SBP reduction to ≤140 mm Hg reduces the likelihood of death or disability at 3 months after ICH, defined by modified Rankin scale score of 4-6, by at least 10% absolute compared to standard SBP reduction to ≤180 mm Hg. The ATACH II trial is a natural extension of numerous case series, the subsequent ATACH I pilot trial, and a preliminary, randomized, and controlled trial in this patient population funded by the Australian National Health and Medical Research Council. Both trials recently confirmed the safety and tolerability of both the regimen and goals of antihypertensive treatment in acutely hypertensive patients with ICH, as proposed in the present trial. The underlying mechanism for this expected beneficial effect of intensive treatment is presumably mediated through reduction of the rate and magnitude of hematoma expansion observed in approximately 73% of the patients with acute ICH. The Australian trial provided preliminary evidence of attenuation of hematoma expansion with intensive SBP reduction. The ATACH II trial will have important public health implications by providing evidence of, or lack thereof, regarding the efficacy and safety of acute antihypertensive treatment in subjects with ICH. This treatment represents a strategy that can be made widely available without the need for specialized equipment and personnel, and therefore, can make a major impact upon clinical practice for treating patients with ICH.
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Affiliation(s)
- A I Qureshi
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, MN, USA.
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35
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Tao T, Wang T, Zhang JH, Qin X. Characteristics of pulse pressure parameters in acute intracerebral hemorrhage patients. ACTA NEUROCHIRURGICA. SUPPLEMENT 2011; 111:349-52. [PMID: 21725780 DOI: 10.1007/978-3-7091-0693-8_58] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
We explored the features of changes in pulse pressure (PP) in patients with intracerebral hemorrhage (ICH). Two hundred one patients with ICH were admitted to our hospital from January 2008 to August 2009. Meanwhile, another 201 people matching in age and gender with these patients were assigned as controls. Blood Pressures (BP) were collected within the first 24 h after admission. PP was calculated from the BP readings. The mean of PPs was compared via T-test. The distributed frequency of the PP level was analyzed using the chi-square test. PPs in the ICH group were higher than those of the controls (P<0.001). Chi-square test showed a significant difference in distribution ratios of PP (P<0.01) between the ICH and control group. The largest PP range in the ICH group was from 80 to 99 mmHg, which accounted for 33.3%; PP of the control group was from 40 to 49 mmHg (30.3%). The PP level in the 40-89-year-old case group was higher than that in the 40-89-year-old control group. PP increased with age. Our investigation indicates that higher PP is correlated with acute ICH and that PP is important in predicting the risk of ICH.
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Affiliation(s)
- Tao Tao
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
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Abstract
BACKGROUND Intracerebral hemorrhage (ICH) care can vary among centers and previous studies have demonstrated differences in ICH outcome based on variations in patient care in various settings. The purpose of this paper is to present the design of an evidence-based dataset of elements of a new ICH specific intensity of care quality metrics. METHODS The articles were identified based on personal knowledge of the subject supplemented by data derived from multi-center randomized trials, and selected non-randomized or observational clinical studies. The information was identified with multiple searches on MEDLINE from 1986 through 2009. The current guidelines from American Heart Association (AHA)/American Stroke Association (ASA) Stroke Council and The European Stroke Initiative (EUSI) Writing Committee for management of ICH were reviewed extensively for identifying quality indicators and available scientific evidence. For certain elements where stroke-specific data was not available, data derived from other disease process with direct relevance was used. RESULTS A total of 26 quality indicators related to 18 facets of care with thresholds for quality response were identified. A pilot study was performed to asses and score 1300 (26 indicator per patientX25 patientsX2 raters) quality indicators. The minimum proportion of patients meeting quality parameter ranged from 44% to 100% depending upon the variable. The lowest performance scores were observed in the early intubation and mechanical ventilation, treatment of significant intracranial mass effect or transtentorial herniation, and timely acquisition of neuroimaging. The highest performance scores were seen in treatment of any seizure within 2 weeks of admission, status epilepticus, and prevention of gastric ulcer. CONCLUSIONS The next step in development of a new ICH specific intensity of care quality metrics is validation and refinement of the quality indicators and thresholds presented in the current report. Future activities may include selection and validation based on consensus of experts and application of the system to a large series of patients with ICH and assessment of relationship of components in isolation and as a group to outcome after severity adjustment.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Research Center, University of Minnesota, 12-100 PWB, 516 Delaware St. SE, Minneapolis, MN 55455, USA.
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Abstract
Cancer patients frequently develop brain metastases. Symptomatic treatments are important to stabilize these patients before an oncological procedure (usually radiotherapy, sometimes surgery or chemotherapy) can be started. These symptomatic treatments mainly rely on steroids to reduce the peritumoral edema; anti-epileptic drugs for patients who previously had seizures, and low-molecular-weight heparin for patients at risk of thrombo-embolic events.
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Bailon O, Kallel A, Chouahnia K, Billot S, Ferrari D, Carpentier AF. [Management of brain metastases from non-small cell lung carcinoma]. Rev Neurol (Paris) 2011; 167:579-91. [PMID: 21546046 DOI: 10.1016/j.neurol.2011.01.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Revised: 01/03/2011] [Accepted: 01/17/2011] [Indexed: 01/08/2023]
Abstract
INTRODUCTION In France, approximately 30,000 new patients per year develop brain metastases (BM), most of them resulting from a lung cancer. STATE OF THE ART Surgery and radiosurgery of all the BM must be considered when possible. In other cases, whole brain radiotherapy remains the standard of care. PERSPECTIVES The role of chemotherapy, poorly investigated so far, should be revisited. CONCLUSION This review focused on BM secondary to a non-small cell lung carcinoma.
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Affiliation(s)
- O Bailon
- Service de neurologie, hôpital Avicenne, AP-HP, 125, route de Stalingrad, 93000 Bobigny, France
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Hinson HE, Stein D, Sheth KN. Hypertonic saline and mannitol therapy in critical care neurology. J Intensive Care Med 2011; 28:3-11. [PMID: 21436162 DOI: 10.1177/0885066611400688] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Osmotic agents play a vital role in the reduction of elevated intracranial pressure and treatment of cerebral edema in Neurologic critical care. Both mannitol and hypertonic saline reduce cerebral edema in many clinical syndromes, yet there is controversy over agent selection, timing, and dosing regimens. Despite the lack of randomized, controlled trials, our knowledge base on the appropriate clinical use of osmotic agents continues to expand. This review will summarize the evidence for the use of mannitol and hypertonic saline in a variety of disease states causing cerebral edema, as well as outlining monitoring and safety considerations.
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Affiliation(s)
- Holly E Hinson
- Neurosciences Critical Care, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Should ancillary brain blood flow analyses play a larger role in the neurological determination of death? Can J Anaesth 2010; 57:927-35. [DOI: 10.1007/s12630-010-9359-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Accepted: 07/06/2010] [Indexed: 10/19/2022] Open
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Qureshi AI, Palesch YY, Martin R, Novitzke J, Cruz-Flores S, Ehtisham A, Ezzeddine MA, Goldstein JN, Hussein HM, Suri MFK, Tariq N. Effect of systolic blood pressure reduction on hematoma expansion, perihematomal edema, and 3-month outcome among patients with intracerebral hemorrhage: results from the antihypertensive treatment of acute cerebral hemorrhage study. ACTA ACUST UNITED AC 2010; 67:570-6. [PMID: 20457956 DOI: 10.1001/archneurol.2010.61] [Citation(s) in RCA: 160] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Evidence indicates that systolic blood pressure (SBP) reduction may reduce hematoma expansion in patients with intracerebral hemorrhage (ICH) who are initially seen with acute hypertensive response. OBJECTIVE To explore the relationship between different variables of SBP reduction and hematoma expansion, perihematomal edema, and 3-month outcome among patients with ICH. DESIGN Post hoc analysis of a traditional phase 1 dose-escalation multicenter prospective study. SETTING Emergency departments and intensive care units. PATIENTS Patients having ICH with an elevated SBP of at least 170 mm Hg who were seen within 6 hours of symptom onset. INTERVENTION Systolic blood pressure reduction using intravenous nicardipine hydrochloride targeting 3 tiers of sequentially escalating SBP reduction goals (170-199, 140-169, or 110-139 mm Hg). MAIN OUTCOME MEASURES We evaluated the effect of SBP reduction (relative to initial SBP) on the following: hematoma expansion (defined as an increased intraparenchymal hemorrhage volume >33% on 24-hour vs baseline computed tomographic [CT] images), higher perihematomal edema ratio (defined as a >40% increased ratio of edema volume to hematoma volume on 24-hour vs baseline CT images), and poor 3-month outcome (defined as a modified Rankin scale score of 4-6). RESULTS Sixty patients (mean [SD] age, 62.0 [15.1] years; 34 men) were recruited (18, 20, and 22 patients in each of the 3 SBP reduction goal tiers). The median area under the curve (AUC) (calculated as the area between the hourly SBP measurements over 24 hours and the baseline SBP) was 1360 (minimum, 3643; maximum, 45) U. Comparing patients having less vs more aggressive SBP reduction based on 24-hour AUC analysis, frequencies were 32% vs 17% for hematoma expansion, 61% vs 40% for higher perihematomal edema ratio, and 46% vs 38% for poor 3-month outcome (P > .05 for all). The median SBP reductions were 54 mm Hg at 6 hours and 62 mm Hg at 6 hours from treatment initiation. Comparing patients having equal to or less vs more than the median SBP reduction at 2 hours, frequencies were 21% vs 31% for hematoma expansion, 42% vs 57% for higher perihematomal edema ratio, and 35% vs 48% for poor 3-month outcome (P > .05 for all). CONCLUSIONS We found no significant relationship between SBP reduction and any of the outcomes measured herein; however, the Antihypertensive Treatment of Acute Cerebral Hemorrhage study was primarily a safety study and was not powered for such end points. The consistent favorable direction of these associations supports further studies with an adequately powered randomized controlled design to evaluate the efficacy of aggressive pharmacologic SBP reduction.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, MN 55455, USA.
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Abstract
The diagnosis and management of patients with persistent vegetative (PVS) and minimally conscious (MCS) states entail powerful medical, ethical and legal debates. The recent description of the MCS highlights the crucial role of unexpected and well-documented recoveries of cognitive functions. Functional neuroimaging has provided new insights for assessing neuropathology and cerebral activity in these patients, providing information on the presence, degree, and location of any residual brain function in patients with PVS or MCS. We present a review on this topic, emphasizing the clinical and neuroimaging assessment of these states, with some of our recent results in this area. We conclude that the development of rehabilitation techniques for patients with PVS and others suffering long-lasting effects of brain injury is a crucial challenge for actual and future generations of neuroscientists.
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Vascular Diseases. Neurosurgery 2010. [DOI: 10.1007/978-3-540-79565-0_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Evaluation and Management of Moderate to Severe Pediatric Head Trauma. J Emerg Med 2009; 37:63-8. [DOI: 10.1016/j.jemermed.2009.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2008] [Revised: 01/30/2009] [Accepted: 02/05/2009] [Indexed: 11/21/2022]
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Abstract
Intracerebral haemorrhage is an important public health problem leading to high rates of death and disability in adults. Although the number of hospital admissions for intracerebral haemorrhage has increased worldwide in the past 10 years, mortality has not fallen. Results of clinical trials and observational studies suggest that coordinated primary and specialty care is associated with lower mortality than is typical community practice. Development of treatment goals for critical care, and new sequences of care and specialty practice can improve outcome after intracerebral haemorrhage. Specific treatment approaches include early diagnosis and haemostasis, aggressive management of blood pressure, open surgical and minimally invasive surgical techniques to remove clot, techniques to remove intraventricular blood, and management of intracranial pressure. These approaches improve clinical management of patients with intracerebral haemorrhage and promise to reduce mortality and increase functional survival.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Research Center, Department of Neurology and Neurosurgery, University of Minnesota, MN, Minnesota 55455, USA.
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Hanley DF. Intraventricular hemorrhage: severity factor and treatment target in spontaneous intracerebral hemorrhage. Stroke 2009; 40:1533-8. [PMID: 19246695 DOI: 10.1161/strokeaha.108.535419] [Citation(s) in RCA: 174] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND PURPOSE This review focuses on the emerging principles of intracerebral hemorrhage (ICH) management, emphasizing the natural history and treatment of intraventricular hemorrhage. The translational and clinical findings from recent randomized clinical trials are defined and discussed. Summary of Review- Brain hemorrhage is the most severe of the major stroke subtypes. Extension of the hemorrhage into the ventricles (a 40% occurrence) can happen early or late in the sequence of events. Epidemiological data demonstrate the amount of blood in the ventricles relates directly to the degree of injury and likelihood of survival. Secondary tissue injury processes related to intraventricular bleeding can be reversed by removal of clot in animals. Specific benefits of removal include limitation of inflammation, edema, and cell death, as well as restoration of cerebral spinal fluid flow, intracranial pressure homeostasis, improved consciousness, and shortening of intensive care unit stay. Limited clinical knowledge exists about the benefits of intraventricular hemorrhage (IVH) removal in humans, because organized attempts to remove blood have not been undertaken in large clinical trials on a generalized scale. New tools to evaluate the volume and location of IVH and to test the benefits/risks of removal have been used in the clinical domain. Initial efforts are encouraging that increased survival and functional improvement can be achieved. Little controversy exists regarding the need to scientifically investigate treatment of this severity factor. CONCLUSIONS Animal models demonstrate clot removal can improve the acute and long-term consequences of intraventricular extension from intracerebral hemorrhage by using minimally invasive techniques coupled to recombinant tissue plasminogen activator-mediated clot lysis. The most recent human clinical trials show that severity of initial injury and the long-term consequences of blood extending into the ventricles are clearly related to the amount of bleeding into the ventricular system. The failure of the last 2 pivotal brain hemorrhage randomized control trials may well relate to the consequences of intraventricular bleeding. Small proof of concept studies, meta-analyses, and preliminary pharmacokinetics studies support the idea of positive shifts in mortality and morbidity, if this 1 critical disease severity factor, IVH, is properly addressed. Understanding clinical methods for the removal of IVH is required if survival and long-term functional outcome of brain hemorrhage is to improve worldwide.
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Affiliation(s)
- Daniel F Hanley
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, CRB-II, Baltimore, MD 21231, USA.
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Cronin CA, Weisman CJ, Llinas RH. Stroke treatment: beyond the three-hour window and in the pregnant patient. Ann N Y Acad Sci 2008; 1142:159-78. [PMID: 18990126 DOI: 10.1196/annals.1444.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
For acute stroke patients who arrive at the hospital within 3 h of symptom onset, the focus of care involves screening for eligibility to receive intravenous tissue plasminogen activator. The publication of the National Institute of Neurological Disorders and Stroke recombinant tissue-type plasminogen activator (tPA, or alteplase) study in 1995 (Marler, J.R. 1995, New England Journal of Medicine333: 1581-1587) spurred protocol changes, which continue to evolve, throughout the health care system in an effort to streamline the patient through the Emergency Medical System. The need to expedite patient evaluation involving emergency department, laboratory, radiology, and clinical neurology testing is clear and has been a focus of many stroke centers. For some patients, intravenous thrombolysis within 3 h has a dramatic effect on outcome. However, that is not the only course of action for acute stroke patients. This article will review some of the effective treatments for stroke patients beyond the first 3 h of their care.
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Affiliation(s)
- C A Cronin
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland 21224, USA
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Rincon F, Mayer SA. Clinical review: Critical care management of spontaneous intracerebral hemorrhage. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:237. [PMID: 19108704 PMCID: PMC2646334 DOI: 10.1186/cc7092] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Intracerebral hemorrhage is by far the most destructive form of stroke. The clinical presentation is characterized by a rapidly deteriorating neurological exam coupled with signs and symptoms of elevated intracranial pressure. The diagnosis is easily established by the use of computed tomography or magnetic resonance imaging. Ventilatory support, blood pressure control, reversal of any preexisting coagulopathy, intracranial pressure monitoring, osmotherapy, fever control, seizure prophylaxis, treatment of hyerglycemia, and nutritional supplementation are the cornerstones of supportive care in the intensive care unit. Dexamethasone and other glucocorticoids should be avoided. Ventricular drainage should be performed urgently in all stuporous or comatose patients with intraventricular blood and acute hydrocephalus. Emergent surgical evacuation or hemicraniectomy should be considered for patients with large (>3 cm) cerebellar hemorrhages, and in those with large lobar hemorrhages, significant mass effect, and a deteriorating neurological exam. Apart from management in a specialized stroke or neurological intensive care unit, no specific medical therapies have been shown to consistently improve outcome after intracerebral hemorrhage.
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Affiliation(s)
- Fred Rincon
- Department of Medicine, Cooper University Hospital, The Robert Wood Johnson Medical School University of Medicine and Dentistry of New Jersey, Camden, NJ 08501, USA
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Affiliation(s)
- Adnan I. Qureshi
- From the Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis
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