This retrospective clinical study analyzed 227 stroke patients treated with various therapies to evaluate the effectiveness of cerebral antiedema agents. The therapies included dexamethasone alone, dexamethasone plus mannitol infusions, and no antiedema therapy. The study found no significant difference in the 10-day survival rate between the treatment groups. The only significant finding was that patients who became comatose within 24 hours of onset had a poorer prognosis than non-comatose patients. The study concludes that cerebral edema may not be as relevant to short-term survival as previously thought, and antiedema therapy does not significantly change mean life expectancy in unselected stroke patients.
1) A prospective study of 344 cardiac arrest survivors in the Netherlands found that 62 (18%) reported having a near-death experience (NDE).
2) Occurrence of NDE was not associated with duration of cardiac arrest, unconsciousness, medication, or pre-arrest fear of death. Factors affecting frequency included age, multiple resuscitations, previous NDE, and memory problems after prolonged CPR.
3) Depth of NDE was affected by sex, location of resuscitation, and pre-arrest fear, with significantly more patients who reported deep NDE dying within 30 days of CPR compared to those without NDE.
This editorial discusses cardiovascular risk in patients with HIV infection. It summarizes several studies that have shown increased cardiovascular risk in HIV patients, especially those receiving protease inhibitors as part of HAART treatment. However, the studies have limitations like low event rates, short exposure durations, and retrospective designs. The editorial evaluates a new study that provides more complete data on imaging, metabolic factors, and their association with cardiovascular risk. A key finding is that HIV patients meeting criteria for metabolic syndrome had increased markers of insulin resistance and cardiovascular risk. Larger, prospective studies are still needed to better understand cardiovascular risk in HIV patients and the effects of antiretroviral therapy, aging, and other risk factors.
Prehospital induced hypothermia post cardiac arrest jun 2010[1]Robert Cole
The document discusses the benefits of induced hypothermia for patients who regain spontaneous circulation after cardiac arrest. Two landmark studies from 2002 showed that cooling patients to 32-34°C for 12-24 hours improved both survival rates and neurological outcomes compared to normothermia. The studies found that induced hypothermia reduced mortality by around 30% and doubled the number of patients with good neurological recoveries. Subsequently, international resuscitation guidelines recommended induced hypothermia for comatose cardiac arrest patients whose initial rhythm was ventricular fibrillation. The document explores the theoretical mechanisms by which mild hypothermia may protect the brain, such as reducing cerebral metabolism and modulating apoptotic and excitotoxic pathways after global ischemia.
1. A review of studies found the lowest risk of stroke and death for patients with atrial fibrillation occurred with INRs between 2.0-2.5.
2. Analysis of over 21,000 Swedish patients found U-shaped relationships between INR and risk of death or brain diseases, with minimum risks at INR 2.24 and 2.38 respectively.
3. Reanalysis of a previous study suggested the risk of intracranial hemorrhage may increase substantially when INR is raised from 2.5 to 4.
This study investigated the risks of stroke, bleeding, and thromboembolism in patients with atrial fibrillation and chronic kidney disease. The study used Danish national registries to identify over 132,000 patients hospitalized for atrial fibrillation between 1997-2008. Patients with non-end stage chronic kidney disease had a 49% higher risk of stroke or thromboembolism compared to those without renal disease. Patients requiring dialysis had an 83% higher risk. Warfarin reduced these risks for both groups of patients with chronic kidney disease but increased bleeding risk. Thus, chronic kidney disease increases the risks of stroke and bleeding in atrial fibrillation patients, and warfarin decreases stroke risk but increases
1) A prospective study of 344 cardiac arrest survivors in the Netherlands found that 62 (18%) reported having a near-death experience (NDE).
2) Occurrence of NDE was not associated with duration of cardiac arrest, unconsciousness, medication, or pre-arrest fear of death. Factors affecting frequency included age, multiple resuscitations, previous NDE, and memory problems after prolonged CPR.
3) Depth of NDE was affected by sex, location of resuscitation, and pre-arrest fear, with significantly more patients who reported deep NDE dying within 30 days of CPR compared to those without NDE.
This editorial discusses cardiovascular risk in patients with HIV infection. It summarizes several studies that have shown increased cardiovascular risk in HIV patients, especially those receiving protease inhibitors as part of HAART treatment. However, the studies have limitations like low event rates, short exposure durations, and retrospective designs. The editorial evaluates a new study that provides more complete data on imaging, metabolic factors, and their association with cardiovascular risk. A key finding is that HIV patients meeting criteria for metabolic syndrome had increased markers of insulin resistance and cardiovascular risk. Larger, prospective studies are still needed to better understand cardiovascular risk in HIV patients and the effects of antiretroviral therapy, aging, and other risk factors.
Prehospital induced hypothermia post cardiac arrest jun 2010[1]Robert Cole
The document discusses the benefits of induced hypothermia for patients who regain spontaneous circulation after cardiac arrest. Two landmark studies from 2002 showed that cooling patients to 32-34°C for 12-24 hours improved both survival rates and neurological outcomes compared to normothermia. The studies found that induced hypothermia reduced mortality by around 30% and doubled the number of patients with good neurological recoveries. Subsequently, international resuscitation guidelines recommended induced hypothermia for comatose cardiac arrest patients whose initial rhythm was ventricular fibrillation. The document explores the theoretical mechanisms by which mild hypothermia may protect the brain, such as reducing cerebral metabolism and modulating apoptotic and excitotoxic pathways after global ischemia.
1. A review of studies found the lowest risk of stroke and death for patients with atrial fibrillation occurred with INRs between 2.0-2.5.
2. Analysis of over 21,000 Swedish patients found U-shaped relationships between INR and risk of death or brain diseases, with minimum risks at INR 2.24 and 2.38 respectively.
3. Reanalysis of a previous study suggested the risk of intracranial hemorrhage may increase substantially when INR is raised from 2.5 to 4.
This study investigated the risks of stroke, bleeding, and thromboembolism in patients with atrial fibrillation and chronic kidney disease. The study used Danish national registries to identify over 132,000 patients hospitalized for atrial fibrillation between 1997-2008. Patients with non-end stage chronic kidney disease had a 49% higher risk of stroke or thromboembolism compared to those without renal disease. Patients requiring dialysis had an 83% higher risk. Warfarin reduced these risks for both groups of patients with chronic kidney disease but increased bleeding risk. Thus, chronic kidney disease increases the risks of stroke and bleeding in atrial fibrillation patients, and warfarin decreases stroke risk but increases
1) The document discusses a prospective study on near-death experiences (NDEs) in 344 cardiac arrest survivors in the Netherlands. The study found that 18% reported some recollection of the period of unconsciousness during cardiac arrest, with 12% reporting a core NDE experience.
2) The study could not find any physiological, pharmacological, psychological, or demographic factors that explained why some patients experienced consciousness during clinical death while most did not.
3) The findings challenge assumptions that consciousness is localized in the brain, as complex experiences were reported when brain function had ceased during cardiac arrest. The results push the boundaries of understanding about consciousness and its relationship to the brain.
Targeted temperature management in traumatic brain injuryDhaval Shukla
The document summarizes research on targeted temperature management in severe traumatic brain injury. It discusses several key studies that have evaluated inducing hypothermia or maintaining normothermia/fever control in brain injury patients. The NABIS:H II and Eurotherm3235 trials found no clinical benefit to early, short-term hypothermia induction. The Brain-Hypothermia trial found no difference between prolonged mild hypothermia and fever control. Ongoing trials are further evaluating the potential roles of hypothermia and tight fever control. Current guidelines recommend maintaining normothermia and preventing fever after brain injury.
Okyanos Heart Institute provides cardiac stem cell therapy to treat coronary artery disease using a patient's own adult stem cells. The therapy involves extracting stem cells from fat tissue, processing them, and injecting them into the heart via catheter. Clinical trials show the therapy improves oxygen consumption, exercise capacity, and reduces damage from heart attacks. Dr. Howard Walpole leads the institute and has extensive experience in cardiology and healthcare leadership. The typical treatment involves evaluations, the stem cell procedure and recovery over a 5 day stay.
This clinical study examined whether decompressive craniectomy (DC) reduces cumulative ischemic burden and therapeutic intensity levels in severe traumatic brain injury (TBI) patients with elevated intracranial pressure (ICP). The study found that performing DC on 10 severe TBI patients with elevated ICP reduced ICP immediately and lowered therapeutic intensity levels within 12 hours after surgery. DC also significantly reduced the duration and severity of cumulative ischemic burden in these patients. Overall mortality was lower than predicted, suggesting DC may help reduce secondary brain injury from elevated ICP in severe TBI.
Persistent monocytosis and CAL in Kawasaki disease, Ho-Chang Kuo, MD (郭和昌醫師 川崎症)Ho-Chang Kuo (郭和昌 醫師)
This study investigated whether changes in complete blood counts (CBC), differential counts (DC), and C-reactive protein (CRP) levels before and after intravenous immunoglobulin (IVIG) therapy were correlated with the development of coronary artery lesions (CALs) in 147 patients with Kawasaki disease. The study found that persistent monocytosis after IVIG treatment was the only factor significantly correlated with CAL formation. Specifically, 29% of patients developed CALs, and multivariate analysis showed those with ongoing monocytosis following IVIG had a higher risk of CALs. This suggests monitoring monocyte levels could help predict and prevent CAL complications in Kawasaki disease.
This letter discusses the findings of the LateTIME trial, which found no benefit of intracoronary delivery of bone marrow mononuclear cells (BMCs) 2-3 weeks after myocardial infarction. The letter raises several points for further consideration:
1) Patient selection may have been too broad, including those with non-anterior wall MIs and moderate, not just severe, left ventricular dysfunction.
2) The mean number of BMCs delivered may have been too low to produce benefits seen in prior studies.
3) Characteristics of myocardial damage seen on MRI, such as infarct size, could help identify subgroups more likely to benefit from cell therapies and were not reported.
Dialysis is not indicated immediately after administration of nonionic contra...AngeLica Abad
This study examined whether immediate dialysis is necessary after administering nonionic contrast agents to patients with end-stage renal disease undergoing hemodialysis. The researchers studied 10 patients receiving hemodialysis who underwent 11 radiographic procedures with nonionic contrast. No significant changes in blood pressure, ECG results, or lab tests occurred after contrast administration, and no patients required emergent dialysis. The study concludes that nonionic contrast can be safely administered to these patients, and immediate post-procedure dialysis is unwarranted as a routine practice.
This document provides an overview and summary of a presentation on assessing pain, sedation, and delirium in intensive care unit patients. It discusses:
- The importance of using validated scales like the Richmond Agitation-Sedation Scale (RASS) and Sedation-Agitation Scale (SAS) to accurately assess sedation levels in patients receiving sedatives.
- The challenges of assessing delirium given confounding factors like a patient's sedation level, wakefulness, and other psychiatric diagnoses. Scales like the Confusion Assessment Method for the ICU (CAM-ICU) are used but their accuracy depends on a patient's sedation.
- How pharmacokinetic factors like drug-
This randomized, double-blind, placebo-controlled trial evaluated the effects of transendocardial delivery of autologous bone marrow mononuclear cells (BMCs) in 92 patients with chronic heart failure. The primary objectives were to determine if BMC administration improved left ventricular end-systolic volume (LVESV), maximal oxygen consumption, or reversibility of perfusion defects on single-photon emission computed tomography (SPECT) compared to placebo at 6 months. Results showed no statistically significant differences between the BMC and placebo groups in changes in LVESV, maximal oxygen consumption, or reversible defect size by SPECT. There were also no differences in any secondary outcomes, including echocardiographic or clinical measures. Thus, tran
This study followed up patients from the previous ENIGMA trial to evaluate long-term cardiovascular risks associated with nitrous oxide anesthesia. The researchers reviewed patient records and interviewed surviving patients with a median follow-up time of 3.5 years. They found that nitrous oxide was associated with a 59% increased odds of myocardial infarction but did not significantly increase the risk of death or stroke. The exact relationship between nitrous oxide and serious long-term outcomes requires confirmation in a larger randomized controlled trial.
Management of headaches - an evidence based approach. Presented by Dr. George Koshy Vilanilam M.B.B.S as a part of research topic presentation for clinical rotation, July 2017
This study tested whether treating anemia in patients with type 2 diabetes and chronic kidney disease using darbepoetin alfa would reduce rates of death and cardiovascular events compared to a placebo. Over 4,000 patients were randomized to receive darbepoetin alfa or placebo, with the goal of maintaining a hemoglobin level of 13.0 g/dL in the treatment group. The study found no significant difference in rates of death, cardiovascular events, or end-stage renal disease between the groups. However, there was an increase in stroke risk observed with darbepoetin alfa treatment.
1) The study retrospectively reviewed 57 cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) treated at a hospital in Indonesia from 2009-2013.
2) All cases were treated with systemic corticosteroids alone, with dosages varying based on the severity of SJS or TEN.
3) Outcomes were generally positive, with 87.7% of patients improving, though the mortality rate was higher for TEN (36.4%) than SJS (7.7%). The most common causes were drug reactions like paracetamol.
Therapeutic Hypothermia: The pharmacologic inhibition of thermoregulationtgraphos
Therapeutic hypothermia involves reducing a patient's core body temperature to 32-34°C following cardiac arrest to protect brain function. The body's natural defenses of vasoconstriction and shivering counter therapeutic cooling efforts. Neuromuscular blockers are commonly used to prevent shivering but have disadvantages. Alternative pharmacological agents that widen the body's interthreshold temperature range, like merperidine and buspirone, effectively reduce the shivering threshold with fewer risks than neuromuscular blockers. Studies show these agents can have additive or synergistic effects in preventing shivering during therapeutic hypothermia.
To describe the frequency, type, and clinical course
of hearing loss in Wegener’s granulomatosis and assess hearing
loss as an indicator of disease activity.
Bansal 2011 chronic fatigue syndrome, the immune system and viral infectiondegarden
This document summarizes research on the relationship between chronic fatigue syndrome (CFS) and the immune system. It finds that CFS is a heterogeneous disorder often associated with viral infection or stress. While the cause is unclear, CFS appears to involve slight increases in inflammatory markers and impaired natural killer cell and T cell function. Some evidence also suggests viral persistence due to inadequate containment of viral replication. The document hypothesizes that viral impairment of T cell memory may explain symptoms and that immunomodulatory therapies could provide benefit.
Delirium in ICU: Nomenclature and DiagnosisSimone Piva
The document discusses delirium screening tools used in the intensive care unit (ICU). It notes that the Confusion Assessment Method for the ICU (CAM-ICU) involves a one-minute assessment while the Intensive Care Delirium Screening Checklist (ICDSC) evaluates patients over 8-24 hours. The longer assessment period of the ICDSC may increase the detection of delirium fluctuations but also potentially false positives if symptoms were present in the past 24 hours but not currently. The CAM-ICU uses specifically defined measures requiring patient interaction while the ICDSC relies on observation, with each tool having potential advantages and disadvantages depending on patient factors.
This case report describes a 5-year-old boy with nephrotic syndrome who presented with sudden loss of vision. His blood pressure was elevated and imaging showed abnormalities in the parietal lobe white matter. After his blood pressure was normalized, his vision returned within 48 hours and follow-up imaging showed resolution of the abnormalities, leading to a diagnosis of posterior reversible encephalopathy syndrome (PRES). PRES is characterized by neurological symptoms including visual disturbances that are reversible if blood pressure is controlled. The report discusses the clinical features and imaging findings of PRES.
Stroke prevention a reality in this millenniumwebzforu
The document discusses strategies for stroke prevention. It finds that ACE inhibitors such as perindopril are effective for secondary stroke prevention, reducing risks by 28% overall and up to 50% for hemorrhagic stroke. All stroke patients, whether hypertensive or normotensive, should receive an ACE inhibitor. Statins also benefit stroke prevention and survival, especially for patients with known coronary artery disease or high-risk hypertension, even with normal LDL cholesterol levels.
This document summarizes research on therapeutic hypothermia for comatose cardiac arrest patients. It discusses the pathophysiology of the post-cardiac arrest syndrome in multiple phases. It also reviews studies showing improved outcomes with therapeutic hypothermia, describing techniques for induction and maintenance of targeted temperature management. The document considers optimal temperature, duration and rate of cooling, as well as important aspects of care during and after rewarming.
This study examined the effects of mannitol and hypertonic saline (HTS) on brain tissue oxygen tension (PbtO2) in 12 patients with severe traumatic brain injury (TBI) and refractory intracranial hypertension. The researchers found that while mannitol did not significantly affect PbtO2 levels, HTS treatment was associated with a significant increase in PbtO2 over time. HTS was also associated with lower intracranial pressure and higher cerebral perfusion pressure and cardiac output compared to mannitol. The results suggest that HTS may be a better option than mannitol for improving brain oxygenation in patients with severe TBI and elevated intracranial pressure refract
Mannitol is an osmotic diuretic that is freely filtered by the glomerulus but not reabsorbed by renal tubules. It works by increasing the osmolarity of renal tubular fluid and drawing fluid from intracellular to extracellular spaces. Main uses include prophylaxis of acute renal failure, treatment of acute oliguria and increased intracranial pressure. While it reduces ICP, mannitol provides limited benefit for oxygenation compared to hypertonic saline and risks cardiac failure and electrolyte imbalance with higher doses.
1) The document discusses a prospective study on near-death experiences (NDEs) in 344 cardiac arrest survivors in the Netherlands. The study found that 18% reported some recollection of the period of unconsciousness during cardiac arrest, with 12% reporting a core NDE experience.
2) The study could not find any physiological, pharmacological, psychological, or demographic factors that explained why some patients experienced consciousness during clinical death while most did not.
3) The findings challenge assumptions that consciousness is localized in the brain, as complex experiences were reported when brain function had ceased during cardiac arrest. The results push the boundaries of understanding about consciousness and its relationship to the brain.
Targeted temperature management in traumatic brain injuryDhaval Shukla
The document summarizes research on targeted temperature management in severe traumatic brain injury. It discusses several key studies that have evaluated inducing hypothermia or maintaining normothermia/fever control in brain injury patients. The NABIS:H II and Eurotherm3235 trials found no clinical benefit to early, short-term hypothermia induction. The Brain-Hypothermia trial found no difference between prolonged mild hypothermia and fever control. Ongoing trials are further evaluating the potential roles of hypothermia and tight fever control. Current guidelines recommend maintaining normothermia and preventing fever after brain injury.
Okyanos Heart Institute provides cardiac stem cell therapy to treat coronary artery disease using a patient's own adult stem cells. The therapy involves extracting stem cells from fat tissue, processing them, and injecting them into the heart via catheter. Clinical trials show the therapy improves oxygen consumption, exercise capacity, and reduces damage from heart attacks. Dr. Howard Walpole leads the institute and has extensive experience in cardiology and healthcare leadership. The typical treatment involves evaluations, the stem cell procedure and recovery over a 5 day stay.
This clinical study examined whether decompressive craniectomy (DC) reduces cumulative ischemic burden and therapeutic intensity levels in severe traumatic brain injury (TBI) patients with elevated intracranial pressure (ICP). The study found that performing DC on 10 severe TBI patients with elevated ICP reduced ICP immediately and lowered therapeutic intensity levels within 12 hours after surgery. DC also significantly reduced the duration and severity of cumulative ischemic burden in these patients. Overall mortality was lower than predicted, suggesting DC may help reduce secondary brain injury from elevated ICP in severe TBI.
Persistent monocytosis and CAL in Kawasaki disease, Ho-Chang Kuo, MD (郭和昌醫師 川崎症)Ho-Chang Kuo (郭和昌 醫師)
This study investigated whether changes in complete blood counts (CBC), differential counts (DC), and C-reactive protein (CRP) levels before and after intravenous immunoglobulin (IVIG) therapy were correlated with the development of coronary artery lesions (CALs) in 147 patients with Kawasaki disease. The study found that persistent monocytosis after IVIG treatment was the only factor significantly correlated with CAL formation. Specifically, 29% of patients developed CALs, and multivariate analysis showed those with ongoing monocytosis following IVIG had a higher risk of CALs. This suggests monitoring monocyte levels could help predict and prevent CAL complications in Kawasaki disease.
This letter discusses the findings of the LateTIME trial, which found no benefit of intracoronary delivery of bone marrow mononuclear cells (BMCs) 2-3 weeks after myocardial infarction. The letter raises several points for further consideration:
1) Patient selection may have been too broad, including those with non-anterior wall MIs and moderate, not just severe, left ventricular dysfunction.
2) The mean number of BMCs delivered may have been too low to produce benefits seen in prior studies.
3) Characteristics of myocardial damage seen on MRI, such as infarct size, could help identify subgroups more likely to benefit from cell therapies and were not reported.
Dialysis is not indicated immediately after administration of nonionic contra...AngeLica Abad
This study examined whether immediate dialysis is necessary after administering nonionic contrast agents to patients with end-stage renal disease undergoing hemodialysis. The researchers studied 10 patients receiving hemodialysis who underwent 11 radiographic procedures with nonionic contrast. No significant changes in blood pressure, ECG results, or lab tests occurred after contrast administration, and no patients required emergent dialysis. The study concludes that nonionic contrast can be safely administered to these patients, and immediate post-procedure dialysis is unwarranted as a routine practice.
This document provides an overview and summary of a presentation on assessing pain, sedation, and delirium in intensive care unit patients. It discusses:
- The importance of using validated scales like the Richmond Agitation-Sedation Scale (RASS) and Sedation-Agitation Scale (SAS) to accurately assess sedation levels in patients receiving sedatives.
- The challenges of assessing delirium given confounding factors like a patient's sedation level, wakefulness, and other psychiatric diagnoses. Scales like the Confusion Assessment Method for the ICU (CAM-ICU) are used but their accuracy depends on a patient's sedation.
- How pharmacokinetic factors like drug-
This randomized, double-blind, placebo-controlled trial evaluated the effects of transendocardial delivery of autologous bone marrow mononuclear cells (BMCs) in 92 patients with chronic heart failure. The primary objectives were to determine if BMC administration improved left ventricular end-systolic volume (LVESV), maximal oxygen consumption, or reversibility of perfusion defects on single-photon emission computed tomography (SPECT) compared to placebo at 6 months. Results showed no statistically significant differences between the BMC and placebo groups in changes in LVESV, maximal oxygen consumption, or reversible defect size by SPECT. There were also no differences in any secondary outcomes, including echocardiographic or clinical measures. Thus, tran
This study followed up patients from the previous ENIGMA trial to evaluate long-term cardiovascular risks associated with nitrous oxide anesthesia. The researchers reviewed patient records and interviewed surviving patients with a median follow-up time of 3.5 years. They found that nitrous oxide was associated with a 59% increased odds of myocardial infarction but did not significantly increase the risk of death or stroke. The exact relationship between nitrous oxide and serious long-term outcomes requires confirmation in a larger randomized controlled trial.
Management of headaches - an evidence based approach. Presented by Dr. George Koshy Vilanilam M.B.B.S as a part of research topic presentation for clinical rotation, July 2017
This study tested whether treating anemia in patients with type 2 diabetes and chronic kidney disease using darbepoetin alfa would reduce rates of death and cardiovascular events compared to a placebo. Over 4,000 patients were randomized to receive darbepoetin alfa or placebo, with the goal of maintaining a hemoglobin level of 13.0 g/dL in the treatment group. The study found no significant difference in rates of death, cardiovascular events, or end-stage renal disease between the groups. However, there was an increase in stroke risk observed with darbepoetin alfa treatment.
1) The study retrospectively reviewed 57 cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) treated at a hospital in Indonesia from 2009-2013.
2) All cases were treated with systemic corticosteroids alone, with dosages varying based on the severity of SJS or TEN.
3) Outcomes were generally positive, with 87.7% of patients improving, though the mortality rate was higher for TEN (36.4%) than SJS (7.7%). The most common causes were drug reactions like paracetamol.
Therapeutic Hypothermia: The pharmacologic inhibition of thermoregulationtgraphos
Therapeutic hypothermia involves reducing a patient's core body temperature to 32-34°C following cardiac arrest to protect brain function. The body's natural defenses of vasoconstriction and shivering counter therapeutic cooling efforts. Neuromuscular blockers are commonly used to prevent shivering but have disadvantages. Alternative pharmacological agents that widen the body's interthreshold temperature range, like merperidine and buspirone, effectively reduce the shivering threshold with fewer risks than neuromuscular blockers. Studies show these agents can have additive or synergistic effects in preventing shivering during therapeutic hypothermia.
To describe the frequency, type, and clinical course
of hearing loss in Wegener’s granulomatosis and assess hearing
loss as an indicator of disease activity.
Bansal 2011 chronic fatigue syndrome, the immune system and viral infectiondegarden
This document summarizes research on the relationship between chronic fatigue syndrome (CFS) and the immune system. It finds that CFS is a heterogeneous disorder often associated with viral infection or stress. While the cause is unclear, CFS appears to involve slight increases in inflammatory markers and impaired natural killer cell and T cell function. Some evidence also suggests viral persistence due to inadequate containment of viral replication. The document hypothesizes that viral impairment of T cell memory may explain symptoms and that immunomodulatory therapies could provide benefit.
Delirium in ICU: Nomenclature and DiagnosisSimone Piva
The document discusses delirium screening tools used in the intensive care unit (ICU). It notes that the Confusion Assessment Method for the ICU (CAM-ICU) involves a one-minute assessment while the Intensive Care Delirium Screening Checklist (ICDSC) evaluates patients over 8-24 hours. The longer assessment period of the ICDSC may increase the detection of delirium fluctuations but also potentially false positives if symptoms were present in the past 24 hours but not currently. The CAM-ICU uses specifically defined measures requiring patient interaction while the ICDSC relies on observation, with each tool having potential advantages and disadvantages depending on patient factors.
This case report describes a 5-year-old boy with nephrotic syndrome who presented with sudden loss of vision. His blood pressure was elevated and imaging showed abnormalities in the parietal lobe white matter. After his blood pressure was normalized, his vision returned within 48 hours and follow-up imaging showed resolution of the abnormalities, leading to a diagnosis of posterior reversible encephalopathy syndrome (PRES). PRES is characterized by neurological symptoms including visual disturbances that are reversible if blood pressure is controlled. The report discusses the clinical features and imaging findings of PRES.
Stroke prevention a reality in this millenniumwebzforu
The document discusses strategies for stroke prevention. It finds that ACE inhibitors such as perindopril are effective for secondary stroke prevention, reducing risks by 28% overall and up to 50% for hemorrhagic stroke. All stroke patients, whether hypertensive or normotensive, should receive an ACE inhibitor. Statins also benefit stroke prevention and survival, especially for patients with known coronary artery disease or high-risk hypertension, even with normal LDL cholesterol levels.
This document summarizes research on therapeutic hypothermia for comatose cardiac arrest patients. It discusses the pathophysiology of the post-cardiac arrest syndrome in multiple phases. It also reviews studies showing improved outcomes with therapeutic hypothermia, describing techniques for induction and maintenance of targeted temperature management. The document considers optimal temperature, duration and rate of cooling, as well as important aspects of care during and after rewarming.
This study examined the effects of mannitol and hypertonic saline (HTS) on brain tissue oxygen tension (PbtO2) in 12 patients with severe traumatic brain injury (TBI) and refractory intracranial hypertension. The researchers found that while mannitol did not significantly affect PbtO2 levels, HTS treatment was associated with a significant increase in PbtO2 over time. HTS was also associated with lower intracranial pressure and higher cerebral perfusion pressure and cardiac output compared to mannitol. The results suggest that HTS may be a better option than mannitol for improving brain oxygenation in patients with severe TBI and elevated intracranial pressure refract
Mannitol is an osmotic diuretic that is freely filtered by the glomerulus but not reabsorbed by renal tubules. It works by increasing the osmolarity of renal tubular fluid and drawing fluid from intracellular to extracellular spaces. Main uses include prophylaxis of acute renal failure, treatment of acute oliguria and increased intracranial pressure. While it reduces ICP, mannitol provides limited benefit for oxygenation compared to hypertonic saline and risks cardiac failure and electrolyte imbalance with higher doses.
CEREBRAL EDEMA AND ITS MANAGEMENTdema measuresRajesh Kabilan
This document discusses various anti-edema measures for managing cerebral edema. It describes monitoring intracranial pressure (ICP) and guidelines for ICP monitoring in traumatic brain injury (TBI) patients. It outlines general measures like head positioning and specific measures like controlled hyperventilation, osmotherapy using mannitol or hypertonic saline, and other therapies to lower ICP and reduce cerebral edema.
Intracranial hemorrhage (ICH) in newborns ranges from 2-30% depending on gestational age and type of hemorrhage. Diagnosis is based on clinical suspicion and confirmed via CT or MRI. The presence and severity of brain injury best predicts outcomes. ICH results from ruptured veins and occurs more often in preterm infants, while trauma often causes ICH in full-term infants. Management depends on the type and severity of hemorrhage, but often involves stabilization, treatment of seizures, and monitoring for complications. Prognosis relates to other factors in addition to the hemorrhage.
This document discusses different types of cerebral edema including cytotoxic, vasogenic, hydrostatic, osmotic, and hydrocephalic edema. It provides details on the causes, mechanisms, and management of each type. The key management strategies for cerebral edema discussed are head elevation, oxygenation, fluid management, seizure prophylaxis, fever control, nutrition, hyperventilation, osmotherapy using mannitol, and other adjunctive therapies.
Cerebral edema and intracranial hypertension after traumatic brain injury can be managed through various interventions to control increased intracranial pressure. These include cerebral resuscitation, intracranial pressure monitoring, hyperosmolar therapy with mannitol or hypertonic saline, mild hyperventilation, CSF drainage, temperature control, surgical decompression, and in refractory cases high-dose barbiturates or calcium channel blockers. Nutritional support and anti-seizure prophylaxis may also be considered as part of the management approach.
Intracerebral hemorrhage is more common in Asian countries and incidence increases with age. It has a high mortality rate, especially when located in the brainstem. Clinical presentation includes altered mental status, headache, nausea and focal neurological deficits depending on the location of bleeding in the brain. CT scan is used to diagnose and determine the size and location of hemorrhage. Treatment focuses on controlling blood pressure, reducing ICP and treating the underlying cause.
This document discusses intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). ICH can be caused by hypertension, cerebral amyloid angiopathy, aneurysms, or bleeding disorders. Common symptoms include sudden headache, weakness on one side of the body, and altered mental status. Treatment focuses on controlling blood pressure, reducing pressure in the brain, and potentially surgically evacuating large bleeds. SAH most often results from aneurysms and presents with a sudden, severe headache. Angiography is used to locate the source of bleeding, and aneurysms are often clipped surgically to prevent rebleeding.
This document summarizes different types of intracranial hemorrhages. It classifies hemorrhages based on location as either intra-axial within the brain parenchyma, or extra-axial outside the brain. Common intra-axial hemorrhages include those in the basal ganglia, thalamus, cerebellum, and pons caused by hypertension. Extra-axial hemorrhages include epidural, subdural, and subarachnoid hemorrhages. Clinical features, management, and prognosis are described for different hemorrhage types. Surgical evacuation or medical management are used depending on location and size of the bleed.
This document summarizes the management and complications of stroke. It discusses the medical management of acute ischemic stroke, which falls into six categories: medical support, IV thrombolysis, endovascular techniques, antithrombotic treatment, neuroprotection, and stroke centers and rehabilitation. It also outlines common complications of stroke seen in studies such as falls, urinary tract infections, chest infections, pressure sores, and depression. Serious complications discussed include various types of pneumonia, heart failure, gastrointestinal bleeding, cardiac arrest, and deep venous thrombosis.
Did you know that the right kind of salt actually HELPS your heart? How about that blood pressure drugs slow down the heart which decreases oxygen to the brain. Does that sound like a good idea to you? Did you also know that cholesterol is critical for hormone production in the body? It's time for some common sense! You are built to be healthy!
Critical Synopsis in Brain Death Determination: A Case Report of Brain DeathJaveriana Cali
This document presents a case report of a 47-year-old woman who was admitted to the emergency room in a deep coma state and acute renal failure following a urinary infection. She had a history of stage 4 lung cancer. After being in cardiopulmonary arrest for an hour, she remained comatose without brainstem or respiratory function. Tests showed the absence of brainstem reflexes and respiratory drive without ventilation. She met the clinical criteria for brain death. The document then discusses brain death, including its epidemiology, treatment, controversies, and clinical and instrumental criteria for determination according to medical standards.
1) Intracerebral hemorrhage is now understood as a dynamic process that evolves over days rather than a single event. Recent studies have provided insights into hematoma expansion, edema formation, and optimal blood pressure control.
2) Ongoing clinical trials are exploring intensive blood pressure control, induced hypothermia, hypertonic saline use, and other therapies to reduce hematoma growth and edema, with the goal of improving outcomes.
3) For anticoagulant-related hemorrhages, rapidly reversing coagulopathy through agents like prothrombin complex concentrates or recombinant factor VIIa may help limit expansion and improve prognosis over traditional fresh frozen plasma therapy alone.
Therapeutic hypothermia a physiological analysis of a new potential for post...Pedram Rahmanian
Therapeutic hypothermia (TH) involves lowering a patient's body temperature after cardiac arrest to improve outcomes. The document analyzes why TH increases survival rates for out-of-hospital cardiac arrest caused by ventricular fibrillation. It discusses the history of TH, major clinical trials showing improved survival and neurological function with TH, and the physiology of how hypothermia reduces reperfusion injury after cardiac arrest. The author concludes that TH should be implemented as part of standard post-cardiac arrest care due to the compelling evidence that it improves both survival and reduces disability.
This document summarizes a study examining medical and neurological complications in 279 patients with acute ischemic stroke. The study found that 95% of patients experienced at least one complication. The most common serious medical complication was pneumonia (5%) and the most common serious neurological complication was new or extended cerebral infarction (5%). Medical complications contributed to 51% of deaths within 3 months. Patients with serious medical complications had significantly worse outcomes on functional scales even after accounting for baseline differences.
The document describes a classification system called TOAST (Trial of Org 10172 in Acute Stroke Treatment) for categorizing subtypes of acute ischemic stroke. The 5 subtypes are: 1) large artery atherosclerosis, 2) cardioembolism, 3) small vessel occlusion, 4) stroke of other determined etiology, and 5) stroke of undetermined etiology. The classification system was tested by two neurologists on 20 patients and found to have good interobserver agreement, with the physicians disagreeing on only one patient. The TOAST system categorizes stroke subtype based on clinical features and results of diagnostic tests, and can be applied both initially and after further evaluation, making it useful for clinical trials.
Unanswered questions in thrombolytic therapy for acute ischemic stroke. 2013Javier Pacheco Paternina
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This document reviews neurological complications that can occur after acute ischemic stroke, including brain edema, hemorrhagic transformation, seizures, recurrent stroke, and delirium. Brain edema, which involves swelling of brain tissue, is a leading cause of death within the first week after stroke. Malignant middle cerebral artery infarction involves complete infarction of the middle cerebral artery territory and rapidly developing brain swelling, which can cause herniation of brain tissue and is fatal in 40-80% of cases if left untreated. There is a lack of evidence-based guidelines for the prevention and management of many neurological complications after acute ischemic stroke.
An ischemic stroke occurs when a blood vessel supplying the brain becomes blocked, cutting off blood flow and oxygen to brain cells. A hemorrhagic stroke occurs when a blood vessel in the brain bursts, leaking blood into tissues. Stroke is a leading cause of death and disability in the US. Research supported by NIH aims to improve prevention, diagnosis, treatment and rehabilitation of stroke through studies of risk factors, brain imaging, new acute treatments, and methods to enhance recovery.
This document provides an overview of cerebrovascular accidents or strokes. It defines a stroke as the sudden death of brain cells due to lack of oxygen from a blocked or ruptured artery in the brain. Risk factors include hypertension, heart disease, smoking, obesity, and age. Strokes are classified as ischemic or hemorrhagic and treatment involves medications to break up clots, surgery, and rehabilitation to regain functions. Nursing care focuses on airway maintenance, communication, mobilization, and psychological support during recovery.
This document provides guidelines for hemodynamic support of sepsis in adult patients. It was developed by an international task force convened by the Society of Critical Care Medicine. The task force reviewed literature and drew on member expertise to develop consensus recommendations. Therapies for septic shock should aim to restore tissue perfusion and normalize cellular metabolism. Goals include maintaining blood pressure and organ function while identifying and treating infection. Therapies include fluid resuscitation, vasopressors, and inotropes, titrated based on parameters of global and regional perfusion.
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The document summarizes guidelines from the Brain Trauma Foundation (BTF) for the management of severe traumatic brain injury (TBI). The BTF released the 4th edition of these guidelines in 2016 to provide evidence-based recommendations for treating severe TBIs. The guidelines provide recommendations on various treatment strategies, such as decompressive craniectomy, hypothermia, hyperosmolar therapy, cerebrospinal fluid drainage, ventilation, anesthetics/sedatives, and monitoring thresholds. Each recommendation is assigned a level depending on the quality of evidence.
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This study compared outcomes of early mobilization (out of bed after 52 hours) versus delayed mobilization (out of bed after 7 days) in 50 patients with ischemic stroke. There were fewer severe complications in the early mobilization group (2 patients, 8%) compared to the delayed group (8 patients, 47%). However, there were no differences in total complications or 3-month clinical outcomes between the groups. Cerebral blood flow measurements also did not differ between groups. The results suggest early mobilization reduces severe complications without increasing risk and supports larger trials to further evaluate optimal mobilization timing.
This study compared outcomes of early mobilization (out of bed after 52 hours) versus delayed mobilization (out of bed after 7 days) in 50 patients with ischemic stroke. There were fewer severe complications in the early mobilization group (2 patients, 8%) compared to the delayed group (8 patients, 47%). However, there were no differences in total complications or 3-month clinical outcomes between the groups. Cerebral blood flow measurements also did not differ between groups. The results suggest early mobilization reduces severe complications without increasing risk and supports larger trials to further evaluate optimal mobilization timing.
Long-term cognitive impairment after critical illness (CIACI) is frequently reported in up to 66% of patients three months after intensive care hospitalization. The condition has overlapping neurological changes with stroke, traumatic brain injury, and neurodegenerative disorders. Risk factors for CIACI include depression, biomarkers for Alzheimer's disease, delirium duration during hospitalization, and exposure to certain drugs. Current strategies to prevent or treat CIACI focus on reducing delirium and agitation, as well as physical and cognitive rehabilitation. Neurotrophic factors may play a role in neurogenesis, blood-brain barrier integrity, and neuronal repair, suggesting they could be a potential target for novel CIACI treatments.
1) The VISSIT trial compared outcomes of 112 patients with symptomatic intracranial stenosis randomized to balloon-expandable stent plus medical therapy or medical therapy alone. At 1 year, the stent group had a higher risk of stroke or TIA compared to the medical therapy group.
2) The CADISS trial randomized 250 patients with carotid or vertebral artery dissection to antiplatelet drugs or anticoagulant drugs for 3 months. Both groups had low risks of stroke, with no significant difference between treatments.
3) The ATTEST trial compared tenecteplase to alteplase in 104 patients with acute ischemic stroke within 4.5 hours of onset. There were no significant differences in pen
2. Stroke
JULY-AUGUST 1975
VOL. 6 NO. 4
A Journal of Cerebral Circulation
Therapy Against Brain Swelling
in Stroke Patients
A RETROSPECTIVE CLINICAL STUDY O N 227 PATIENTS
BY LIVIA CANDELISE, M.D., ALVARO COLOMBO, M.D., AND
HANS SPINNLER, M.D.
Abstract: • The effectiveness of cerebral antiedema agents in stroke has been questioned. Animal and
Therapy clinical work is inconclusive about steroids and osmotic drugs. A retrospective study of a con-
Against
Brain tinuous series of 227 stroke patients treated in the acute stage (some with dexamethasone alone,
Swelling in some with dexamethasone plus hyperosmotic mannitol infusions, and some without antiedema
Stroke therapy) showed no significant difference in the ten-day survival rate. On this criterion, there is
Patients no ground for the systematic use of such agents against this type of brain swelling.
Additional Key Words cerebrovascular disease mannitol dexamethasone
D A retrospective study was undertaken to evaluate against the unselective use of steroids in acute stroke
the short-term value of antiedema therapy in stroke patients,1418 although some suggest that the treatment
patients. Brain swelling is one of the major conse- is useful.1922 With regard to osmotic drugs, urea was
quences of a stroke, coming three or four days after triedfirst,23then mannitol,2426 andfinallyglycerol.27-28
the actual infarction. It may result in cingulate and Here again, the findings are inconclusive. Now, con-
central tentorial or uncal herniations, possibly leading current treatment with dexamethasone and osmotic
during the acute stage to rostro-caudal deterioration drugs has been proposed.29
of consciousness and ultimately to death. 1 ' 2
Moreover, edema around the ischemic area may Methods
worsen the neurological deficit.3-4 Drug therapy for
PATIENTS
stroke-induced brain swelling is based on the assump-
tion that such edema is one of the crucial mechanisms The 227 patients with cerebral infarction were admitted to
of neurological worsening and death in the acute stage the neurological wards of the Clinic for Nervous and Mental
Diseases of the University of Milan (Italy) from 1965 to
of a stroke. 1974. No a priori selection of the patients, other than that
Steroids and hyperosmotic infusions are used to determined by the criteria below, has been made.
control brain swelling of varying etiology and they are The patients constitute a continuous series, encom-
claimed to do this by different mechanisms: delayed passing three different therapeutic periods (admittedly, with
intracellular fluid accumulation in the case of the some overlapping at the interposed borderlines), namely
former, and immediate extracellular fluid accumula- that of a more or less defined vasodilator drug therapy, that
tion in the case of the latter. Experimental studies on of steroids, and that of steroids plus mannitol treatment.
steroids in ischemic brain damage are inconclusive: in- During all of these periods, comparable supportive, nursing,
effective according to several studies,5"11 effective ac- physiotherapeutic, dietary and general medical care was
cording to other studies.12'13 Many clinical reports are provided. None of the patients who entered the study
received intensive care or neurosurgery.
Cerebrovascular disease samples are made up of
From the Clinic for Nervous and Mental Diseases, University of
heterogeneous subdivisions. The criteria used for inclusion
Milan, Milan, Italy. in this study were: (1) clinical evidence of a completed stroke
Reprint requests to C. L. Clinica delle Malattie Nervose e to one hemisphere, occurring up to 24 hours before admis-
Mentali dell Universita di Milano, Via Francesco Sforza, 35-20122, sion, (2) treatment starting within 24 hours following the
Milan, Italy. stroke, and (3) evidence (from history) that this was the first
Stroke, Vol. 6. July-August 1975 353
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3. CANDELISE, COLOMBO, SPiNNLER
major cerebrovascular event for this patient. Some patients The frequencies within each cell of the four-
were excluded because (1) the etiology was an intracranial dimension contingency table are given in table 1.
aneurysm or an arteriovenous malformation, (2) clouding of Table 2 shows the outcome of non-parametric
consciousness or death was not definitely related to cerebral analysis.
disease, and (3) the treatment used could not be classified ac- The only comparison of statistical significance
cording to our criteria. Twenty-four percent of the original
group of patients had to be excluded. was the interaction between presence and absence of
The patients treated with antiedema medication coma and survival rate. This means that the patients
received drugs according to the following schedules: who become comatose within the first 24 hours of
1. Dexamethasone. Mean dosages were 8 mg t.i.d. onset have a significantly poorer life expectancy (67%
(range, 4 to 16 mg). The drug was supplied in 250 ml of dead) than noncomatose patients (24% dead).
Ringer's solution or 5% glucose solution t.i.d. intravenously
during the first seven days. In a small number of patients the
same dosages of steroid were given intramuscularly.
2. Dexamethasone plus mannitol. The concurrent Discussion
treatment always started from the beginning of the therapy. The negative outcome of our comparisons, which
Infusions of 250 ml of 20% mannitol plus dexamethasone (as precludes any hard inferences, may be due to the
above) were administered t.i.d. for the first three or four roughness of the ten-day survival as a criterion of
days. On the following days, the patient received the same effectiveness. And yet, our sample was large enough to
therapy as before. elicit some evidence of a relationship between treat-
ment and survival, if there was one. Cerebral edema
STATISTICAL PROCEDURES
following a stroke may not be as relevant to short-
The principal items considered were: age, patients surviving term survival expectancy as is generally thought; alter-
at the tenth day following the stroke, presence or absence of
a coma (provided the coma had been noted within the first natively, it may not respond to the type of antiedema
24 hours of the cerebral event), and the pharmacological therapy we used. The first possibility is supported by
treatment. Coma was defined as impaired consciousness at Shaw's findings,1 which by no means bear out the
or below the diencephalic level.30 predominance of stroke-induced brain swelling in the
The patients were divided into three groups according death mechanism, since for only a half of his patients
to therapy: no antiedema therapy (64 patients), dex- death could be traced back to edema. Intracranial
amethasone therapy (88 patients), and dexamethasone plus pressure studies in massive hemorrhage32 likewise fail
mannitol therapy (75 patients). to find it of key importance. Further, only 21% of
Four crossed criteria were used to classify the patients Plum's33 106 hemispheric infarct patients showed a
of each group: (1) survival rate at the tenth day following the rapidly rostro-caudal deterioration of coma suggest-
stroke, (2) presence or absence of a coma, (3) age, as below ing a clearcut supratentorial growing edema, while
or above 65 years, and (4) the three treatments listed
previously. only 13% of Ng's 2 353 stroke patients had severe brain
The result was a four-dimension contingency table.31 swelling.
The second possibility corresponds with some
Results clinical evidence which suggests that edema, mainly
Of the 227 patients, 46% were women. The average due to chronic focal lesions and certainly not prevail-
age of all patients was 56.7 years. Twenty-six percent ing in ischemic brain damage, responds to steroids.34
had diabetes and 9% had chronic atrial fibrillation Otherwise, mannitol works only on the swelling that
with mitral valve disease. None of these concomitant develops in a nonischemically damaged part of the
variables had a significantly different distribution at brain.35
the chi-square analysis. Even if nearly all cerebral lesions, both acute and
TABLE 1
Distribution of 227 Stroke Patients According to a Four-Dimension Contingency Table
With coma (82) Without coma (1 45)
Therapy Age Survivor* Dead Total Survivors Dead Total
10 13 23 3 26
CO CN
None (64) <65
>65 4 6 14 5 19
Total 5 14 19 37 8 45
Dexamethasone (88) <65 5 9 14 25 5 30
>65 4 12 16 21 7 28
Total 9 21 30 46 12 58
Dexamethasone
plus mannitol (75) <65 5 5 10 15 4 19
>65 8 15 23 12 11 23
Total 13 20 33 27 15 42
354 Stroke, Vol. 6, Jvly-Auguit 1975
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4. THERAPY AGAINST BRAIN SWELLING IN STROKE PATIENTS
TABLE 2 vasculature obstruction produced by ischemia. J Neurosurg
30:50-54, 1969
Four-Dimension Chi-Square Analysis of the Frequencies
Given in Table 1 7. Kahn K, Pranzarone GF, Newman T: Dexamethasone treat-
ment of experimental cerebral infarction, (abstract)
Interaction! D.F. Chi-square Neurology 22:406-407, 1972
Therapy X survival X age 2 0.799 ns 8. Siegel BA, Studer RB, Potchen EJ: Effect of dexamethasone
X coma on triethyl tin induced brain edema and the early edema in
Therapy X survival X coma 2 3.605 ns cerebral ischemia. In Reulen HJ, Schurmann K (eds): Ste-
Therapy X survival X age 2 0.733 ns roids and Brain Edema. Berlin, Springer-Verlag, p 113-121,
Therapy X survival 2 1.419 ns 1972
Survival X coma 1 31.633 < 0.005 9. Donley RF, Sundt TM: The effect of dexamethasone on the
Survival X age 1 2.762 ns edema of focal cerebral ischemia. Stroke 4:148-155 (Mar-
Apr) 1973
10. Brunson B, Robertson JT, Morgan H, et al: Evaluation of
treatment methods of cerebral infarction edema. Stroke
chronic, cause some degree of swelling, it is probably 4:461-464 (May-June) 1973
an oversimplification to classify them all by the type of 11. tee MC, Mastri AR, Waltz AG, et al: Ineffectiveness of dex-
the prevailing edema and the expected phar- amethasone for treatment of experimental cerebral infarc-
macological responsiveness to the two main classes of tion. Stroke 5:216-218 (Mar-Apr) 1974
12. Bartko D, Reulen HJ, Koch H, et al: Effect of dexamethasone
antiedemic drugs.
on the early edema following occlusion of the middle
Our feeling, supported only by scattered single cerebral artery in cats. In Reulen HJ, Schurmann K (eds):
observations, is that at least for some young patients Steroids and Brain Edema. Berlin, Springer-Verlag, p 127-
(e.g., those with internal carotid occlusion or with 137, 1972
massive embolic infarction) there is often clearcut 13. Harrison MJG, Russell RWR: Effect of dexamethasone on ex-
response to mannitol plus dexamethasone treatment, perimental cerebral infarction in the gerbil. J Neurol
both in terms of level of consciousness and survival. Neurosurg Psychiat 35:520-521, 1972
Nevertheless, we think that brain swelling is not 14. Dyken M, White PT: Evaluation of cortisone in the treatment
systematically the leading factor in the acute of cerebral infarction. JAMA 162:1531-1534, 1956
prognosis of the stroke patient and therefore the an- 15. Hetzel BS, tander H, Robson HN: Immediate treatment of
apoplexy, (correspondence) Brit Med J 1:1122, 1957
tiedema therapy cannot dramatically change the mean
16. Candelise t, Spinnler H: Dexamethasone and stroke,
life expectancy in a sample of unselected stroke (correspondence) Med J Aust 5:335 (Aug) 1972
patients. 17. Tellez H, Bauer RB: Dexamethasone as treatment in
Therefore, the wise course would seem to be to cerebrovascular disease. A controlled study in intracerebral
give antiedema therapy only to selected stroke hemorrhage. Stroke 4:541-546 (July-Aug) 1973
patients, i.e., those in whom acute cerebral edema is 18. Bauer RB, Tellez H: Dexamethasone as treatment in
likely to develop. Rapid worsening of consciousness cerebrovascular disease. A controlled study in acute cerebral
and neurological deficits soon after stroke seem to be infarction. Stroke 4:547-555 (July-Aug) 1973
the most reliable clinical signs of developing edema. 19. Russek HI, Russek AS, Zohman BL: Cortisone in immediate
Continuous monitoring for midline shift and for in- therapy of apoplectic stroke. JAMA 159:102-105, 1955
20. Roberts HJ: Supportive adrenocortical steroid therapy in
tracranial hypertension and serial EMI scanning will
acute and subacute cerebrovascular accidents, with par-
possibly further help to single out the patients for an- ticular reference to brain stem involvement. J Amer Geriat
tiedema treatment. Soc 6:686-702, 1958
21. Rubenstein MK: The influence of adrenocortical steroids on
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CORRECTION
An error appeared in the abstract in STROKE 6:237 (Mar- baboons the effect of blood pressure and arterial Pco2 on
Apr) 1975. local cerebral blood volume was examined. The following
equation of the regression plane relating local cerebral blood
volume (LCBV), Paco2 and mean arterial blood pressure
Measurement of Local Cerebral Blood Volume in (MABP) was obtained:
Three Dimensions in Man — Kuhl DE, Reivich M, Nyary
LCBV = 2.88 + 0.049 Paco 2 - 0.013 MABP
I, Alavi A (Cerebrovascular Research Center, Hospital of
the University of Pennsylvania, Philadelphia, Pennsylvania Local cerebral blood volume was measured in a series of
19104) eight patients and values ranged from 1.80 to 4.13 ml/100
A method has been developed for the measurement of gm depending on the location within the cross-section. The
local cerebral blood volume in man with three-dimensional higher blood volumes coincided with cortical regions. In one
resolution. Transverse section imaging with an improved patient abnormal vascularization in association with a
data processing technique enables a linear relationship to be tumor was clearly identified in the LCBV scan. In another,
obtained between the counts at any point in the scan and the the reduction in LCBV caused by edema surrounding a
radioactivity in the scanned object. This makes it possible to small glioma was demonstrated in the LCBV scan which
make absolute measurements of the concentration within also showed improved regional circulation after steroid
the brain localized in three dimensions. In a series of five therapy.
356 Stroke. Vol. 6, July-August 1975
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