Are there predictive pupillometry markers in determining external ventricular device (EVD) weaning failure or success in subarachnoid hemorrhage patients?

Pupillometers objectively measure constriction (i.e., parasympathetic pathwy) and dilation (i.e., sympathetic pathway) velocities of the pupillary reflex. These pathways may be affected by increases in ventricular size due to changes in cerebrospinal fluid (CSF) volume, such as during external ventricular device (EVD) weaning in aneurysmal subarachnoid hemorrhage (aSAH) patients. This pilot study evaluated if changes in pupillary responses could be predictive of EVD weaning failure in aSAH patients. Additionally, we analyzed ventricular size and pupillary reactions in these two groups.Includes bibliographical reference

Imaging modalities in acute ischemic stroke

As "time is brain", acute ischemic stroke is considered a medical emergency. With the introduction of thrombolytic therapy and availability of modern neuroimaging modalities, timely diagnosis of an ischemic lesion, exclusion of intracerebral hemorrhage, assessing the degree of brain injury, and evaluation of cerebral vasculature is necessary in acute stroke management. In this review we will highlight the importance of available imaging modalities used to assess patients with acute ischemic stroke.Includes bibliographical reference

Acute ischemic stroke management review for the hospitalist

The treatment of acute ischemic stroke is dependent on timely recognition. After ensuring airway, respiratory and circulatory stability, NIHSS should be performed and urgent CT scan obtained. If no exclusions exist, recombinant tissue plasminogen activator (rtPA) should be administered as soon as possible. Select patients may be eligible for mechanical thrombectomy. Stroke patients shouldbe admitted to a dedicated stroke service to determine stroke mechanism, manage risk factors, and initiate preventive therapies.Includes bibliographical reference

Feasibility of performing apnea test in a brain dead patient on veno-venous extracorporeal membrane oxygenation (ECMO)

Extracorporeal membrane oxygenation (ECMO) is being increasingly used to provide support in patients with refractory cardiopulmonary distress syndromes. Neurological sequelae, either from the ECMO or the hypoxic/hypotensive event leading to ECMO, are common. We present a patient requiring veno-venous (V-V) ECMO for an acute respiratory distress syndrome (ARDS) following cardiopulmonary arrest who suffered an irreversible brain injury. Eventually she required an evaluation for death by neurological criteria while on V-V ECMO making apnea testing challenging. We report the ability to safely perform apnea testing in a patient with a devastating brain injury requiring V-V ECMO.Includes bibliographical reference

Prolonged duration of apnea test during brain death examination in a case of intraparenchymal hemorrhage

Objective: Apnea test is required as part of the brain death examination. The duration of the apnea test is variable but typically requires 8–10 min. Prolonged apnea tests have been reported in the setting of hypothermia. Here, we describe a case of prolonged duration of apnea test secondary to a phenomenon called cardiac ventilation. Methods: The patient presented in coma with brainstem areflexia after having an intracerebral hemorrhage resulting in subfalcine, central, uncal, and tonsillar herniations. Confounding variables were excluded. Brain death testing was performed, and she was found to have brainstem areflexia. Pre-requisites for apnea test were then met. Results: Apnea testing, however, was prolonged at 110 min. When reconnected to ventilator, it was noted that she had small (30–35 cc) tidal volumes at a rate of her heart rate without respiratory effort. Ancillary testing with four-vessel cerebral angiogram confirmed cerebral circulatory arrest. Conclusions: To our knowledge, this is the longest reported case of apnea testing during brain death testing. Variables known to cause a delay in the rise of carbon dioxide (PaCO 2 ) levels were excluded. We suspect the hyperdynamic cardiac state caused cardiac ventilations resulting in slow increase in carbon dioxide levels

Seizure prophylaxis in the neuroscience intensive care unit

Abstract Background Seizures are a considerable complication in critically ill patients. Their incidence is significantly high in neurosciences intensive care unit patients. Seizure prophylaxis with anti-epileptic drugs is a common practice in neurosciences intensive care unit. However, its utility in patients without clinical seizure, with an underlying neurological injury, is somewhat controversial. Body In this article, we have reviewed the evidence for seizure prophylaxis in commonly encountered neurological conditions in neurosciences intensive care unit and discussed the possible prognostic role of continuous electroencephalography monitoring in detecting early seizures in critically ill patients. Conclusion Based on the current evidence and guidelines, we have proposed a presumptive protocol for seizure prophylaxis in neurosciences intensive care unit. Patients with severe traumatic brain injury and possible subarachnoid hemorrhage seem to benefit with a short course of anti-epileptic drug. In patients with other neurological illnesses, the use of continuous electroencephalography would make sense rather than indiscriminately administering anti-epileptic drug

White Matter Changes in Corpus Callosum in a Patient with Idiopathic Normal Pressure Hydrocephalus

Idiopathic normal pressure hydrocephalus (INPH) is characterized by the clinical triad of gait and cognitive dysfunction and urinary incontinence. Ventriculoperitoneal (VP) shunting is often required for treatment. Review of literature shows few case reports discussing benign magnetic resonance imaging (MRI) T2 hyperintense changes in the corpus callosum of NPH patients after shunting due to mechanical compression of the middle and posterior regions of the body against falx cerebri leading to ischemic demyelination. These changes can be a delayed phenomenon and may interfere with clinical evaluation and may lead to unnecessary procedures and investigations. We present a patient with NPH who was admitted to the neurocritical care unit in coma with quetiapine and trazodone overdose. Diffuse changes in the body of the corpus callosum were seen on MRI suspicious for acute vasogenic edema due to drug overdose. However, it was later determined to be due to the VP shunting for the NPH. We report this case to raise the awareness of neuroimaging changes in patients with NPH who have VP shunting

Successful Extubation Using Heliox BiPAP in Two Patients with Postextubation Stridor

Postextubation stridor is associated with significant morbidity. It commonly results in extubation failure after established medical treatment fails, such as nebulized epinephrine and/or intravenous steroids. The role of heliox (i.e., combination of helium and oxygen) in managing patients with postextubation stridor has not been fully established. We report two cases of postextubation stridor successfully treated with heliox delivered with bilevel positive airway pressure (BiPAP) after failure of standard medical therapy

A new strategy in neurocritical care nurse continuing stroke education: A hybrid simulation pilot study

Introduction: High-fidelity simulation is frequently utilized in medical education. Its use in the neurosciences is limited by the inherent limitations of the manikin to simulate neurological changes. We report here the use of a hybrid simulation – a combination of lecture and high-fidelity manikin – in the education of neurosciences nurses, involved in care of neurocritical care patients. Methods: Neurosciences nurses from at the University of Missouri, Columbia, MO, USA, which is an academic, tertiary-care medical center participated in the simulation during Spring of 2016. The simulation involved a patient presenting with acute intracerebral hemorrhage (ICH) who neurologically deteriorated to brain death. Pre- and post-simulation questionnaires were administered using a questionnaire with five-point Liker scale. Results: Seventy-two responses were returned. The majority had 0-5 years of nursing experience with 83.8% having prior critical care experience. Pre-simulation, the majority of nurses (85.7%) agreed or strongly agreed with managing patients with ICH. When the responses of “agree” were compared to “strongly agree”, a significant improvement (p<0.001) in all responses except confidence in speaking with other healthcare providers was found. Conclusion: Nurses reported significant improvement in understanding and managing patients with acute ICH and neurological deterioration after participating in a neurocritical care hybrid simulation. This study shows the benefit of using hybrid simulation in the education of neurocritical care nurses