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Chapter 14

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Introduction

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A 34-year-old right-handed woman with history of smoking presented with a sudden onset of severe occipital headache followed by loss of consciousness that started while cleaning her bathroom. In the emergency department, she was found to be arousable to deep stimulation, her pupils were very sluggish and almost nonreactive at 3-mm diameter, and she was withdrawing to painful stimulation bilaterally. When her mental status further declined, she was intubated for airway protection. Head computerized tomographic (CT) scanning (Figure 14-1) revealed subarachnoid hemorrhage (SAH) with thick blood filling the basal cisterns, hydrocephalus, and bilateral intraventricular hemorrhage (IVH). CT angiography revealed an aneurysm of the anterior communicating artery (ACoM). She was transferred to the nearest tertiary medical care center.

Cerebral angiography revealed an 8 cm × 4 cm ACoM aneurysm which was coiled on SAH day 1 (Figure 14-2). Additionally, angiography revealed severe, bilateral anterior cerebral artery vasospasm, which improved after treatment with 12 mg of intra-arterial (IA) verapamil. The postprocedural CT scan revealed global cerebral edema and worsening hydrocephalus. An external ventricular drainage catheter was placed. Postoperatively, the patient was found to be in coma with intact brainstem reflexes, bilateral posturing to painful stimulation, and bilateral positive Babinski signs. At that time, the treating physicians decided to place a multimodality neuromonitoring bundle through a right frontal burr hole consisting of a parenchymal intracranial pressure (ICP) monitor, a brain tissue oxygenation probe, and a microdialysis catheter.

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Figure 14-1.

Selected cuts of the admission head computed tomography without contrast demonstrating diffuse filling of the basal cisterns (left image) and signs of diffuse global edema (right image).

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Figure 14-2.

A. Cerebral angiography demonstrating an 8 cm × 4 cm anterior communicating artery aneurysm and severe vasospasm. B. The patient underwent coil embolization of the aneurysm.

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What is the purpose of invasive neuromonitoring in comatose patients?

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One of the most important goals of neurologic critical care is to detect secondary brain injury at a time when permanent damage can still be prevented. The clinical examination remains the gold standard for the assessment of patients with neurologic disease despite great advances in neuroimaging and other diagnostic tools. Furthermore, in medical intensive care unit (ICU) patients, daily interruption of sedation has been shown to decrease the duration of mechanical ventilation, shorten hospital stay, and, in combination with spontaneous breathing trials, lead to improved outcome.1,2 There is some evidence suggesting that daily interruption of sedation is safe even in patients with brain injury,3 but this remains controversial.4 Clearly, there are a number of patients with acute brain injury in whom interruption of sedation is contraindicated such as those with ongoing status epilepticus, severe ICP crises, or respiratory failure requiring sedation. ...

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