Observations on recent research in neurocritical care
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8/4/04
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Neurocritical Care Copyright © 2004 Humana Press Inc. All rights of any nature whatsoever are reserved. ISSN 1541-6933/04/3:403
Spanning the Globe Observations on Recent Research in Neurocritical Care Christopher Commichau Bourekas EC, Slivka AP, Shah R, Tarr RW, Sunshine J, Suarez JI. Intraarterial thrombolysis therapy within 3 hours of the onset of stroke. Neurosurgery 2004;54:39–46.
over 60%, a figure most would consider a bit high. The threshold for considering a patient as having failed weaning and the threshold for shunt placement was low. There was not a standard time at which weaning was initiated. Certainly, decreased length of stay (an attractive prospect for many) can be achieved through rapid weaning but this is likely at the expense of higher shunt rates with what long-term implications? There must be a happy medium.
Should we be satisfied with intravenous thrombolysis for acute stroke? For selected patients, many believe that intra-arterial thrombolysis may offer an attractive and effective alternative. Kudos to the authors for tackling this question. Fifty percent of patients treated with intraarterial thrombolysis within 3 hours of onset achieved an outcome of minimal to no deficit, in comparison to 39% in the NINDS rt-PA trial. Patients treated with intra-arterial thrombolysis had a higher symptomatic hemorrhage rate but mortality rates were similar to those treated with intravenous thrombolysis. Furthermore, recanalization rates seen in IA thrombolysis can be doubled those seen in intravenous treatment groups. There now appears to be the impetus to perform the randomized, sufficiently powered study to compare these treatments and further maximize acute stroke outcomes.
Uhl E, Kreth FW, Elias B, Goldammer A, Hempelmann RG, Liefner M, Nowak G, Oertal M, Schmieder K, Schneider GH. Outcome and prognostic factors of hemicraniectomy for space occupying cerebral infarction. J Neurol Neurosurg Psychiatry 2004;75:270–274. This article examines data from eight German centers performing hemicraniectomy for middle cerebral artery (MCA) infarction. Medical management of mass effect was considered first line therapy. Hemicraniectomy was performed for clinical deterioration as evidenced by a median drop in GCS of three points and preoperative pupillary abnormalities in 40% prior to surgery. Intracranial pressure was not measured routinely. In retrospective analysis, age over 50 years and involvement of more that one vascular distribution remained significant predictors of poor outcome. Thirty-five percent of those under age 50 years achieved good outcome. Proponents of hemicraniectomy would argue against its use as a salvage procedure after medical failure and would emphasize attention to factors such as fever burden, hyperglycemia and cerebral perfusion as critical in outcomes.
Klimo P, Jr, Kestle JRW, MacDonald JD, Schmidt RH. Marked reduction of cerebral vasospasm with lumbar drainage of cerebrospinal fluid after subarachnoid hemorrhage. J Neurosurg 2004;100: 215–224. Effective
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