Showing papers in "Neurocritical Care in 2012"

Guidelines for the Evaluation and Management of Status Epilepticus

Abstract: Status epilepticus (SE) treatment strategies vary substantially from one institution to another due to the lack of data to support one treatment over another. To provide guidance for the acute treatment of SE in critically ill patients, the Neurocritical Care Society organized a writing committee to evaluate the literature and develop an evidence-based and expert consensus practice guideline. Literature searches were conducted using PubMed and studies meeting the criteria established by the writing committee were evaluated. Recommendations were developed based on the literature using standardized assessment methods from the American Heart Association and Grading of Recommendations Assessment, Develop- ment, and Evaluation systems, as well as expert opinion when sufficient data were lacking.

Critical thresholds for cerebrovascular reactivity after traumatic brain injury.

Abstract: Pressure-reactivity index (PRx) is a useful tool in brain monitoring of trauma patients, but the question remains about its critical values. Using our TBI database, we identified the thresholds for PRx and other monitored parameters that maximize the statistical difference between death/survival and favorable/unfavorable outcomes. We also investigated how these thresholds depend on clinical factors such as age, gender and initial GCS. A total of 459 patients from our database were eligible. Tables of 2 × 2 format were created grouping patients according to survival/death or favorable/unfavorable outcomes and varying thresholds for PRx, ICP and CPP. Pearson’s chi square was calculated, and the thresholds returning the highest score were assumed to have the best discriminative value. The same procedure was repeated after division according to clinical factors. In all patients, we found that PRx had different thresholds for survival (0.25) and for favorable outcome (0.05). Thresholds of 70 mmHg for CPP and 22 mmHg for ICP were identified for both survival and favorable outcomes. The ICP threshold for favorable outcome was lower (18 mmHg) in females and patients older than 55 years. In logistic regression models, independent variables associating with mortality and unfavorable outcome were age, GCS, ICP and PRx. The prognostic role of PRx is confirmed but with a lower threshold of 0.05 for favorable outcome than for survival (0.25). Results for ICP are in line with current guidelines. However, the lower value in elderly and in females suggests increased vulnerability to intracranial hypertension in these groups.

Frequency and Timing of Nonconvulsive Status Epilepticus in Comatose Post-Cardiac Arrest Subjects Treated with Hypothermia

Abstract: Background Therapeutic hypothermia (TH) improves outcomes in comatose patients resuscitated from cardiac arrest. However, nonconvulsive status epilepticus (NCSE) may cause persistent coma. The frequency and timing of NCSE after cardiac arrest is unknown.

Transcranial Doppler Pulsatility Index: What it is and What it Isn’t

Abstract: Background Transcranial Doppler (TCD) pulsatility index (PI) has traditionally been interpreted as a descriptor of distal cerebrovascular resistance (CVR). We sought to evaluate the relationship between PI and CVR in situations, where CVR increases (mild hypocapnia) and decreases (plateau waves of intracranial pressure—ICP).

Decompressive Hemicraniectomy in Malignant Middle Cerebral Artery Infarct: A Randomized Controlled Trial Enrolling Patients up to 80 Years Old

Abstract: Decompressive hemicraniectomy (DHC) has proven efficacious for the treatment of malignant middle cerebral artery infarction (mMCAI) only in patients less than 60 years. This study aimed to assess the effectiveness of DHC in patients up to 80. This is a prospective, randomized, controlled trail comparing the outcomes with or without DHC in patients aged 18–80 with mMCAI (ChiCTR–TRC–11001757). The primary outcome measure was the modified Rankin Scale (mRS) scores at 6 months. The secondary outcome measures included the 6- and 12-month mortality and the mRS scores after 1 year. The prognosis of patients was evaluated independently by two blinded investigators. In addition, subgroup analyses were done for those above 60 years of age. All analyses were by intention-to-treat. A significant reduction in the poor outcome (mRS > 4) following DHC was reached after 36 patients had completed the follow-up period of 6 months. The trial was then terminated when 47 participants (24 in the surgical group vs. 23 in the medical group) had been recruited. The final analysis, based on the outcome data of the 47 patients, showed that DHC significantly reduced mortality at 6 and 12 months (12.5 vs. 60.9 %, P = 0.001 and 16.7 vs. 69.6 %, P 4 after surgery (33.3 vs. 82.6 %, P = 0.001 and 25.0 vs. 87.0 %, P < 0.001, respectively). Similar results were present in the subgroup analyses of elderly participants For patients up to 80 years who suffered mMCAI, DHC within 48 h of stroke onset not only is a life-saving treatment, but also increases the possibility of surviving without severe disability (mRS = 5).

Brain Tissue Oxygen-Based Therapy and Outcome After Severe Traumatic Brain Injury: A Systematic Literature Review

Abstract: Observational clinical studies demonstrate that brain hypoxia is associated with poor outcome after severe traumatic brain injury (TBI). In this study, available medical literature was reviewed to examine whether brain tissue oxygen (PbtO2)-based therapy is associated with improved patient outcome after severe TBI. Clinical studies published between 1993 and 2010 that compared PbtO2-based therapy combined with intracranial and cerebral perfusion pressure (ICP/CPP)-based therapy to ICP/CPP-based therapy alone were identified from electronic databases, Index Medicus, bibliographies of pertinent articles, and expert consultation. For analysis, each selected paper had to have adequate data to determine odds ratios (ORs) and confidence intervals (CIs) of outcome described by the Glasgow outcome score (GOS). Seven studies that compared ICP/CPP and PbtO2- to ICP/CPP-based therapy were identified. There were no randomized studies and no comparison studies in children. Four studies, published in 2003, 2009, and 2010 that included 491 evaluable patients were used in the final analysis. Among patients who received PbtO2-based therapy, 121(38.8%) had unfavorable and 191 (61.2%) had a favorable outcome. Among the patients who received ICP/CPP-based therapy 104 (58.1%) had unfavorable and 75 (41.9%) had a favorable outcome. Overall PbtO2-based therapy was associated with favorable outcome (OR 2.1; 95% CI 1.4–3.1). Summary results suggest that combined ICP/CPP- and PbtO2-based therapy is associated with better outcome after severe TBI than ICP/CPP-based therapy alone. Cross-organizational practice variances cannot be controlled for in this type of review and so we cannot answer whether PbtO2-based therapy improves outcome. However, the potentially large incremental value of PbtO2-based therapy provides justification for a randomized clinical trial.

Emergency Neurological Life Support: Intracranial Hypertension and Herniation

Abstract: Sustained intracranial hypertension and acute brain herniation are "brain codes," signifying catastrophic neurological events that require immediate recognition and treatment to prevent irreversible injury and death. As in cardiac arrest, a brain code mandates the organized implementation of a stepwise management algorithm. The goal of this emergency neurological life support protocol is to implement an evidence-based, standardized approach to the evaluation and management of patients with intracranial hypertension and/or herniation.

Early Platelet Transfusion Improves Platelet Activity and May Improve Outcomes After Intracerebral Hemorrhage

Abstract: In patients with acute intracerebral hemorrhage (ICH), reduced platelet activity on admission predicts hemorrhage growth and poor outcomes. We tested the hypotheses that platelet transfusion improves measured platelet activity. Further, we hypothesized that earlier treatment in patients at high risk for hemorrhage growth and poor outcome would reduce follow-up hemorrhage size and poor clinical outcomes. We prospectively identified consecutive patients with ICH who had reduced platelet activity on admission and received a platelet transfusion. We defined high-risk patients as per a previous publication, reduced platelet activity, or known anti-platelet therapy (APT) and the diagnostic CT within 12 h of symptom onset. Platelet activity was measured with the VerifyNow-ASA (Accumetrics, CA), ICH volumes on CT with computerized quantitative techniques, and functional outcomes with the modified Rankin Scale (mRS) at 3 months. Forty-five patients received a platelet transfusion with an increase in platelet activity from 472 ± 50 (consistent with an aspirin effect) to 561 ± 92 aspirin reaction units (consistent with no aspirin effect, P 12 h, was associated with smaller follow-up hemorrhage size (8.4 [3–17.4] vs. 13.8 [12.3–62.5] ml, P = 0.04) and increased odds of independence (mRS < 4) at 3 months (11 of 20 vs. 0 of 7, P = 0.01). There were similar results for patients with known APT. In patients at high risk for hemorrhage growth and poor outcome, early platelet transfusion improved platelet activity assay results and was associated with smaller final hemorrhage size and more independence at 3 months.

Early cerebral metabolic crisis after TBI influences outcome despite adequate hemodynamic resuscitation.

Abstract: Optimal resuscitation after traumatic brain injury (TBI) remains uncertain. We hypothesize that cerebral metabolic crisis is frequent despite adequate resuscitation of the TBI patient and that metabolic crisis negatively influences outcome. We assessed the effectiveness of a standardized trauma resuscitation protocol in 89 patients with moderate to severe TBI, and determined the frequency of adequate resuscitation. Prospective hourly values of heart rate, blood pressure, pulse oximetry, intracranial pressure (ICP), respiratory rate, jugular venous oximetry, and brain extracellular values of glucose, lactate, pyruvate, glycerol, and glutamate were obtained. The incidence during the initial 72 h after injury of low brain glucose 25, and metabolic crisis, defined as the simultaneous occurrence of both low glucose and high LPR, were determined for the group. 5 patients were inadequately resuscitated and eight patients had intractable ICP. In patients with successful resuscitation and controlled ICP (n = 76), within 72 h of trauma, 76 % had low glucose, 93 % had elevated LPR, and 74 % were in metabolic crisis. The duration of metabolic crisis was longer in those patients with unfavorable (GOSe ≤ 6) versus favorable (GOSe ≥ 7) outcome at 6 months (P = 0.011). In four multivariate models the burden of metabolic crisis was a powerful independent predictor of poor outcome. Metabolic crisis occurs frequently after TBI despite adequate resuscitation and controlled ICP, and is a strong independent predictor of poor outcome at 6 months.

Cerebral infarction in adults with bacterial meningitis.

Abstract: To evaluate clinical features and prognostic factors of cerebral infarctions in adults with community-acquired bacterial meningitis. An observational cross-sectional study, including 696 patients of whom 174 had cerebral infarction, from a prospective nationwide cohort of community-acquired bacterial meningitis (period, 1998–2002), confirmed by culture of cerebral spinal fluid (CSF) in patients aged over 16 years. Two investigators independently determined the presence of infarction. Cerebral infarction occurred in 174 episodes (25%), with a high inter-rater agreement for determining the presence of cerebral infarction (kappa 0.95). Cerebral infarctions occurred in 128 of 352 patients (36%) with pneumococcal meningitis, in 22 of 257 (9%) with meningococcal meningitis and in 24 of 87 patients (28%) with meningitis caused by other bacteria. Patients with infarctions were older (P < 0.001) and often presented with predisposing conditions, such as otitis and/or sinusitis (P = 0.001) or an immunocompromised state (P = 0.003) compared to those without infarction. Patients with infarctions presented with lower scores on the Glasgow Coma Scale (P < 0.001), lower CSF white cell counts (P = 0.001), and higher serum erythrocyte sedimentation rate (ESR) (P < 0.001). Unfavorable outcome occurred in 108 (62%) patients with infarctions. In a multivariate analysis, infarction was related with unfavorable outcome (odds ratio 3.37; 95% confidence interval 2.19–5.21; P < 0.001). We identified lower CSF white cell counts and high ESR to be independent risk factors for cerebral infarction. Cerebral infarction is a common and severe complication in adults with community-acquired bacterial meningitis. Preventing cerebral infarctions will be important in reducing the high morbidity and mortality rate in adults with community-acquired bacterial meningitis.

Increased Rate of Aspiration Pneumonia and Poor Discharge Outcome Among Acute Ischemic Stroke Patients Following Intubation for Endovascular Treatment

Abstract: Background An increased risk of aspiration pneumonia among acute ischemic stroke patients following intubation for endovascular treatment may explain the higher rates of poor outcomes among patients requiring general anesthesia compared with those performed under local sedation. Methods Rates of aspiration pneumonia and its contribution to poor outcome at discharge (modified Rankin score C3), and in-hospital mortality were analyzed among endovascularly treated acute ischemic stroke patients at two university-affiliated comprehensive stroke centers. Logistic regression model was used to assess the contribution of intubation and aspiration pneumonia on poor outcome after adjusting for potential confounders. Results There were 136 acute ischemic stroke patients who received endovascular treatment: 83 patients received local sedation without intubation and 53 patients were intubated. The rates of aspiration pneumonia were 12 (14%) in endovascularly treated patients not intubated, and 12 (23%) in endovascularly treated intubated patients. Rates of poor outcomes were 46 (55%) in the non-intubated endovascularly treated patients, and 44 (83%) in intubated endovascularly treated patients. After adjusting for age, gender, National Institutes of Health Stroke Scale (NIHSS) score strata, poor outcome at discharge (OR 2.9, 95% CI 1.2‐7.4) (P = 0.0243) and in-hospital mortality (OR 4.5, 95% CI 1.5‐12.5) (P = 0. 0.0046) were significantly higher among intubated patients. After adjusting for pneumonia, the effect of intubation on poor

Continuous monitoring of cerebrovascular reactivity using pulse waveform of intracranial pressure.

Abstract: Guidelines for the management of traumatic brain injury (TBI) call for the development of accurate methods for assessment of the relationship between cerebral perfusion pressure (CPP) and cerebral autoregulation and to determine the influence of quantitative indices of pressure autoregulation on outcome. We investigated the relationship between slow fluctuations of arterial blood pressure (ABP) and intracranial pressure (ICP) pulse amplitude (an index called PAx) using a moving correlation technique to reflect the state of cerebral vasoreactivity and compared it to the index of pressure reactivity (PRx) as a moving correlation coefficient between averaged values of ABP and ICP. A retrospective analysis of prospective 327 TBI patients (admitted on neurocritical care unit of a university hospital in the period 2003–2009) with continuous ABP and ICP monitoring. PAx was worse in patients who died compared to those who survived (−0.04 ± 0.15 vs. −0.16 ± 0.15, χ2 = 28, p < 0.001). In contrast to PRx, PAx was able to differentiate between fatal and non-fatal outcome in a group of 120 patients with ICP levels below 15 mmHg (−0.04 ± 0.16 vs. −0.14 ± 0.16, χ2 = 6, p = 0.01). PAx is a new modified index of cerebrovascular reactivity which performs equally well as established PRx in long-term monitoring in severe TBI patients, but importantly is potentially more robust at lower values of ICP. In view of establishing an autoregulation-oriented CPP therapy, continuous determination of PAx is feasible but its value has to be evaluated in a prospective controlled trail.

Milrinone and Homeostasis to Treat Cerebral Vasospasm Associated with Subarachnoid Hemorrhage: The Montreal Neurological Hospital Protocol

Abstract: Introduction For the treatment of cerebral vasospasm, current therapies have focused on increasing blood flow through blood pressure augmentation, hypervolemia, the use of intra-arterial vasodilators, and angioplasty of proximal cerebral vessels. Through a large case series, we present our experience of treating cerebral vasospasm with a protocol based on maintenance of homeostasis (correction of electrolyte and glucose disturbances, prevention and treatment of hyperthermia, replacement of fluid losses), and the use of intravenous milrinone to improve microcirculation (the Montreal Neurological Hospital protocol). Our objective is to describe the use milrinone in our practice and the neurological outcomes associated with this approach.

Impact of a Neurointensivist on Outcomes in Critically Ill Stroke Patients

Abstract: Current guidelines for management of critically ill stroke patients suggest that treatment in a neurocritical care unit (NCCU) and/or by a neurointensivist (NI) may be beneficial, but the contribution of each to outcome is unknown. The relative impact of a NCCU versus NI on short- and long-term outcomes in patients with acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and aneurysmal subarachnoid hemorrhage (SAH) was assessed. 2,096 stroke patients admitted to a NCCU or nonneuro ICU at a tertiary stroke center were analyzed before the appointment of a NI, during the NI’s tenure, and after the NI departed and was not replaced. Data included admission ICU type, availability of a NI, age, NIHSS, ICH score, and 3 and 12 month outcome. For AIS, compared to the time interval with a NI, departure of the NI predicted a worse rate of return to pre-stroke function at 3 months. For ICH, NCCU treatment predicted shorter ICU and hospital LOS but had no effect on short- or long-term outcomes. No effect of a NI was seen. For SAH, availability of an NI (but not an NCCU) predicted improved outcomes but longer ICU LOS. Disposition and in-hospital mortality improved when a NI was present, but continued improvement did not occur after the NI’s departure. Presence of an NI was associated with improved clinical outcomes. This effect was more evident in patients with SAH. Patients with ICH tend to have poor outcomes regardless of the presence of a NCCU or a NI.

Brain Resuscitation in the Drowning Victim

Abstract: Drowning is a leading cause of accidental death. Survivors may sustain severe neurologic morbidity. There is negligible research specific to brain injury in drowning making current clinical management non-specific to this disorder. This review represents an evidence-based consensus effort to provide recommendations for management and investigation of the drowning victim. Epidemiology, brain-oriented prehospital and intensive care, therapeutic hypothermia, neuroimaging/monitoring, biomarkers, and neuroresuscitative pharmacology are addressed. When cardiac arrest is present, chest compressions with rescue breathing are recommended due to the asphyxial insult. In the comatose patient with restoration of spontaneous circulation, hypoxemia and hyperoxemia should be avoided, hyperthermia treated, and induced hypothermia (32–34 °C) considered. Arterial hypotension/hypertension should be recognized and treated. Prevent hypoglycemia and treat hyperglycemia. Treat clinical seizures and consider treating non-convulsive status epilepticus. Serial neurologic examinations should be provided. Brain imaging and serial biomarker measurement may aid prognostication. Continuous electroencephalography and N20 somatosensory evoked potential monitoring may be considered. Serial biomarker measurement (e.g., neuron specific enolase) may aid prognostication. There is insufficient evidence to recommend use of any specific brain-oriented neuroresuscitative pharmacologic therapy other than that required to restore and maintain normal physiology. Following initial stabilization, victims should be transferred to centers with expertise in age-specific post-resuscitation neurocritical care. Care should be documented, reviewed, and quality improvement assessment performed. Preclinical research should focus on models of asphyxial cardiac arrest. Clinical research should focus on improved cardiopulmonary resuscitation, re-oxygenation/reperfusion strategies, therapeutic hypothermia, neuroprotection, neurorehabilitation, and consideration of drowning in advances made in treatment of other central nervous system disorders.

Monitoring cerebral autoregulation after head injury. Which component of transcranial Doppler flow velocity is optimal

Abstract: Background Cerebral autoregulation assessed using transcranial Doppler (TCD) mean flow velocity (FV) in response to various physiological challenges is predictive of outcome after traumatic brain injury (TBI). Systolic and diastolic FV have been explored in other diseases. This study aims to evaluate the systolic, mean and diastolic FV for monitoring autoregulation and predicting outcome after TBI.

Continuous video EEG for patients with acute encephalopathy in a pediatric intensive care unit.

Abstract: Objectives In this study, we aimed to determine the incidence of electrographic seizures among patients in a pediatric intensive care unit (PICU) presenting with acute encephalopathy. Risk factors and duration of continuous EEG monitoring needed to capture electrographic seizures were also assessed.

CTA spot sign predicts hematoma expansion in patients with delayed presentation after intracerebral hemorrhage.

Abstract: Background Hematoma expansion after acute intracerebral hemorrhage occurs most frequently in patients presenting within 3 h of symptom onset. However, the majority of patients present outside this window or with an unknown onset time. We investigated the prevalence of hematoma expansion in these patients and assessed the accuracy of the CT angiography (CTA) spot sign for identifying risk of hematoma expansion.

The FOUR Score Predicts Outcome in Patients After Traumatic Brain Injury

Abstract: Background The most widely used and most studied coma score to date is the Glasgow Coma Scale (GCS), which is used worldwide to assess level of consciousness and predict outcome after traumatic brain injury (TBI). Our aim was to determine whether the Full Outline of UnResponsiveness (FOUR) score is an accurate predictor of outcome in TBI patients and to compare its performance to GCS.

Emergency Neurological Life Support: Intracerebral Hemorrhage

Abstract: Intracerebral hemorrhage (ICH) is a subset of stroke resulting from bleeding within the brain parenchyma of the brain. It is potentially lethal, and survival depends on ensuring an adequate airway, reversal of coagulopathy, and proper diagnosis. ICH was chosen as an emergency neurological life support (ENLS) protocol because intervention within the first critical hour may improve outcome, and it is helpful to have a protocol to drive care quickly and efficiently.

Early ketamine to treat refractory status epilepticus.

Abstract: Management of refractory status epilepticus (SE) involves administration of intravenous γ-aminobutyric acid (GABAA) receptor agonists, such as benzodiazepines, barbiturates, or propofol. Animal models suggest that reductions in synaptic GABAA receptors may cause these drugs to become less effective as the duration of SE increases. This may explain the large doses that are commonly required to control seizures, which in turn contributes to a high incidence of complications, including hypotension and the need for vasopressors. In contrast, expression of excitatory N-methyl-d-aspartate (NMDA) receptors increases with prolonged SE and their stimulation by glutamate may propagate seizure activity. Ketamine is a NMDA-receptor antagonist that is considered promising as treatment for refractory SE. Compared with other anaesthetic drugs, ketamine produces less hypotension. This report describes a patient who developed worsening hypotension with escalating doses of midazolam and propofol in the context of non-convulsive SE. He was therefore treated with ketamine within hours of being diagnosed. Ketamine was immediately efficacious at reducing the frequency, amplitude, and duration of seizures. The dose was rapidly titrated upwards using quantitative continuous EEG monitoring, until seizures were completely abolished. SE did not recur with weaning of sedatives and he went on to have an excellent recovery. A small number of previous reports have found ketamine to abort late SE. In most cases, ketamine was administered several days into the course, and outcomes were poor even though seizures were controlled. Larger series and phase I clinical trial(s) of ketamine for treatment of refractory SE seem warranted.

Hyperosmolar Therapy for Intracranial Hypertension

Abstract: The use of hyperosmolar agents for intracranial hypertension was introduced in the early 20th century and remains a mainstay of therapy for patients with cerebral edema Both animal and human studies have demonstrated the efficacy of two hyperosmolar agents, mannitol and hypertonic saline, in reducing intracranial pressure via volume redistribution, plasma expansion, rheologic modifications, and anti-inflammatory effects However, because of physician and institutional variation in therapeutic practices, lack of standardized protocols for initiation and administration of therapy, patient heterogeneity, and a paucity of randomized controlled trials have yielded little class I evidence on which clinical decisions can be based, most current evidence regarding the use of hyperosmolar therapy is derived from retrospective analyses (class III) and case series (class IV) In this review, we summarize the available evidence regarding the use of hyperosmolar therapy with mannitol or hypertonic saline for the medical management of intracranial hypertension and present a comprehensive discussion of the evidence associated with various theoretical and practical concerns related to initiation, dosage, and monitoring of therapy

Angiogram-negative subarachnoid hemorrhage: relationship between bleeding pattern and clinical outcome.

Abstract: Angiogram-negative subarachnoid hemorrhage (anSAH) accounts for 15% of spontaneous SAH. Recent studies suggest the outcome and diagnostic yield in anSAH differ based on initial bleeding pattern. We present a single-center experience in managing patients with SAH and negative initial digital-subtracted angiogram (DSA). Records of all patients with anSAH were reviewed. Bleeding pattern was determined from computed tomography (CT) and was categorized as perimesencephalic (PMN), diffuse, cortical, or xanthochromia (blood not detectable by CT). Diagnostic yield, in-hospital complications, and outcome parameters were analyzed. Of 352 patients admitted with spontaneous SAH from 2003 to 2008, 68 (19.3%) had negative initial DSA. Mean age was 59.5 ± 14, and 33 were female. By CT, 27 (39.7%) patients exhibited PMN SAH, 33 (48.5%) diffuse SAH, 6 (8.8%) cortical SAH, and 2 (2.9%) xanthochromia only. Sixty-one patients had good Hunt and Hess (H/H) grades (I–III) and seven had poor grades (IV–V). Additional diagnostic studies included repeat angiogram (54), brain and C-spine magnetic resonance imaging (20), and repeat CTA (15). A structural bleeding cause was determined in six (8.8%) patients, 4 of which had diffuse SAH and 2 cortical SAH. Among these, two aneurysms (2.9%) were detected and surgically clipped, and both had diffuse SAH. Twenty-nine patients (42.6%) experienced medical complications, with infection (18), cardiovascular problems (12), and vasospasm (10) being the most frequent events. Additional surgeries included 13 ventriculoperitoneal shunts, 4 tracheostomies, and 9 gastric tube placements. Favorable outcome (mRS = 0–2) was recorded in 49 (72.1%) patients and unfavorable (3–6) in 19 (17.49%), with 1 (1.2%) in-hospital death. Multivariable logistic regression revealed older age and diffuse bleeding pattern were significant predictors of unfavorable outcome. The overall incidence of true aneurysms in patients with angiogram-negative SAH is low (2.9%). Initial bleeding pattern strongly correlates with diagnostic yield and clinical outcome. Diffuse bleeding pattern is associated with significantly higher diagnostic yield, more in-hospital complications, and worse clinical outcome. Patients with initial imaging characteristics other than diffuse pattern SAH developed few disease related complications, with the majority of in-hospital adverse events treatment related.

Emergency Neurological Life Support: Airway, Ventilation, and Sedation

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.

Emergency Neurological Life Support: Traumatic Spine Injury

Abstract: Traumatic spine injuries (TSIs) carry significantly high risks of morbidity, mortality, and exorbitant health care costs from associated medical needs following injury. For these reasons, TSI was chosen as an ENLS protocol. This article offers a comprehensive review on the management of spinal column injuries using the best available evidence. Though the review focuses primarily on cervical spinal column injuries, thoracolumbar injuries are briefly discussed as well. The initial emergency department clinical evaluation of possible spinal fractures and cord injuries, along with the definitive early management of confirmed injuries, are also covered.

Increased CSF concentrations of myelin basic protein after TBI in infants and children: absence of significant effect of therapeutic hypothermia.

Abstract: Background The objectives of this study were to determine effects of severe traumatic brain injury (TBI) on cerebrospinal fluid (CSF) concentrations of myelin basic protein (MBP) and to assess relationships between clinical variables and CSF MBP concentrations.

Emergency Neurological Life Support: Status Epilepticus

Abstract: Patients with prolonged or rapidly recurring convulsions lasting more than 5 min are in status epilepticus (SE) and require immediate resuscitation. Although there are relatively few randomized clinical trials, available evidence and experience suggest that early and aggressive treatment of SE improves patient outcomes, for which reason it was chosen as an Emergency Neurologic Life Support protocol. The current approach to the emergency treatment of SE emphasizes rapid initiation of adequate doses of first line therapy, as well as accelerated second line anticonvulsant drugs and induced coma when these fail, coupled with admission to a unit capable of neurologic critical care and electroencephalography monitoring. This protocol not only will focus on the initial treatment of SE but also review subsequent steps in the protocol once the patient is hospitalized.

Treatment of Intracerebral Hemorrhage with Tranexamic Acid After Thrombolysis with Tissue Plasminogen Activator

Abstract: Thrombolytic treatment with intravenous tissue plasminogen activator (iv tPA) is the only FDA-approved therapy for acute ischemic stroke. There are risks associated with thrombolytics, including intracranial and extracranial hemorrhage and hypersensitivity reactions. Established treatment for post-tPA hemorrhage includes administration of blood products including cryoprecipitate, fresh frozen plasma, and platelets which have poorly established efficacy. Tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA) have been studied as hemostatic therapies in post-operative hemorrhage, menorrhagia, intracranial hemorrhage (ICH), subarachnoid hemorrhage, and trauma patients. There is no reported literature on the use of TXA to reverse thrombolytic therapy with tPA. This is a case report of a Jehovah’s Witness patient who was unwilling to receive blood products after developing symptomatic ICH following iv tPA. He consequently received TXA for reversal of thrombolytic therapy. The patient received a total of 1.675 g of iv TXA within 3 h of finishing the iv tPA. Repeat brain imaging with computed tomography and magnetic resonance imaging revealed no further expansion of hemorrhages. TXA is an inexpensive medication which competitively inhibits the activation of plasminogen and can be given to reverse thrombolysis in the setting of hemorrhage after iv thrombolytic therapy.

Predictive Biomarkers of Recovery in Traumatic Brain Injury

Abstract: Recent advances in medicine, intensive care and diagnostic imaging modalities have led to a pronounced reduction in deaths and disability resulting from traumatic brain injury. However, there are not sufficient findings to evaluate and quantify the severity of the initial and secondary processes destructive and therefore there are not effective therapeutic measures to effectively predict the outcome. For this reason, in recent decades, researchers and clinicians have focused on specific markers of cellular brain injury to improve the diagnosis and the evaluation of outcome. Many proteins synthesized in the astroglia cells or in the neurons, such as neuron-specific enolase, S100 calcium binding protein B, myelin basic protein, creatine kinase brain isoenzyme, glial fibrilary acidic protein, plasma desoxyribonucleic acid, brain-derived neurotrophic factor, and ubiquitin carboxy-terminal hydrolase-L1, have been proposed as potential markers for cell damage in central nervous system. Usually, the levels of these proteins increase following brain injury and are found in increasing concentrations in the cerebrospinal fluid depending on the injury magnitude, and can also be found in blood stream because of a compromised blood–brain barrier. In this review, we examine the various factors that must be taken into account in the search for a reliable non-invasive biomarkers in traumatic brain injury and their role in the diagnosis and outcome evaluation.

Clinical MRI interpretation for outcome prediction in cardiac arrest.

Abstract: Background In clinical practice, magnetic resonance imaging (MRI) is commonly used to assess the severity of a cardiac arrest patient’s cerebral injury, utilizing treating neurologists’ imaging interpretation. We sought to determine whether clinical interpretation of diffusion-weighted imaging (DWI) helps to determine poor outcome in comatose cardiac arrest patients.