Showing papers by "Rishi Gupta published in 2004"

Hemicraniectomy for Massive Middle Cerebral Artery Territory Infarction: A Systematic Review

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 ≤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.

Bispectral Index monitoring correlates with sedation scales in brain-injured patients

Abstract: Objective: Monitoring critically ill, brain-injured patients with a decreased level of consciousness is challenging. Our goal is to determine in this population the correlation between the Bispectral Index (BIS) and three commonly used sedation agitation scales: the Richmond Agitation-Sedation Scale (RASS), the Sedation-Agitation Scale (SAS) and the Glasgow Coma Scale (GCS) scores. Design: Prospective, single-blinded observational study. Setting: Eight-bed neurology-neurosurgery intensive care unit at the Cleveland Clinic Foundation. Patients: Thirty critically ill patients admitted to the neurointensive care unit with primary brain injury and a decreased level of consciousness. Measurements and Main Results: Patients were prospectively evaluated for level of consciousness using the RASS, SAS, and GCS every hour and simultaneously were monitored continuously with a BIS monitor for 6 hrs. A Spearman's correlation coefficient was used to correlate the BIS scores with clinical scales. In 15 patients monitored with the newer BIS XP version, the BIS values correlated significantly with the RASS (R 2 =.810; p <.0001), SAS (R 2 =.725; p <.0001), and GCS (R 2 =.655; p <.0001). In 15 patients monitored with the older BIS 2.1.1 software, the correlation was as follows: for RASS, R 2 =.30 (p <.008), for SAS: R 2 =.376 (p <.001), and for GCS: R 2 =.274 (p <.015). This correlation was maintained in patients who received sedative medications. Conclusions: A statistically significant correlation existed between BIS values and the RASS, SAS, and GCS scores in critically ill brain-injured patients, with and without sedation. The newer BIS XP software package may be a useful adjunctive tool in objective assessment of level of consciousness in brain-injured patients.

Reversible leukoencephalopathy associated with cerebral amyloid angiopathy

Abstract: The authors describe three patients with reversible leukoencephalopathy associated with cerebral amyloid angiopathy (CAA). Rapid progression of neurologic symptoms was followed by dramatic clinical and radiographic improvement. Pathologically, CAA was associated with varying degrees of inflammation ranging from none to transmural granulomatous infiltration. In the appropriate clinical context, the MRI finding of lobar white matter edema with evidence of prior hemosiderin deposition may indicate the presence of a reversible CAA leukoencephalopathy.

Intracranial Revascularization Therapy: Angioplasty and Stenting.

Abstract: Depending on the population studied, intracranial atherosclerosis accounts for 10% to 29% of ischemic brain events. A significant number of patients with intracranial atherosclerosis continue to suffer from repeated strokes or transient ischemic attacks despite optimal medical management. In selected patients, intracranial angioplasty with or without stenting is a promising treatment option. Patient selection, careful periprocedural medical management, and a highly skilled neuroendovascular interventionalist are required in order to perform the procedure with an acceptable risk.