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Two patients with large bilateral subdural haematomas with patterns of non-enhanced brain computed tomography (CT) falsely suggesting coexistent subarachnoid haemorrhage are presented. The CT images showed marked effacement of the [...]

INTRODUCTION: Patients in the intensive care unit develop generalized weakness due to a number of factors. Neuromuscular weakness is a common cause of failure to wean from the ventilator and decreased limb movements. A rational approach to evaluation of weakness will help to identify most of the common causes of neuromuscular weakness in the intensive care unit. AIMS: This review provides an analysis of neuromuscular weakness and a practical algorithm to assist in diagnostic evaluation. CONCLUSIONS: The most common acquired causes of weakness in the critically ill patient in the intensive care unit are critical illness polyneuropathy and critical illness myopathy. In the intensive care unit setting, electrophysiological studies, biopsies, and imaging studies are often necessary to complement the clinical impression. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To review journalists' preferences and accuracy in reporting comatose states. METHODS: Using the Lexis-Nexis database, we selected newspaper headlines from January 1, 2001, through December 31, 2005, that included the words coma, comatose, unconsciousness, vegetative state, awakening, and brain dead. RESULTS: We identified 340 stories by headlines. The median age of persons in coma was 26 years. Coma cases in men were twice as common as those in women. In 71% of coma cases, the cause of coma was associated with motor vehicle crashes or violence. Persistent vegetative state was reported in 25 articles (7%), frequently when a family or physician conflict emerged. In 33 stories (10%), coma was medically induced but not mentioned in the headline. Three 'miracle' recoveries involved resumption of speech in patients in a minimally conscious state. CONCLUSION: Few news reports had gross inaccuracies or misrepresentations; however, definitional difficulties of unconscious states with the reporters remain. The reporting of coma may be biased toward violence and trauma. Medically induced coma was present in 1 of 10 reports but rarely mentioned in the headline. [ABSTRACT FROM AUTHOR]

A prolonged state of impaired consciousness is a devastating consequence of severe structural brain injury but fortunately is uncommon. Patients may be diagnosed as being in a persistent vegetative state, having akinetic mutism, or being in a minimally conscious state. These conditions can be distinguished from each other by a comprehensive clinical neurologic examination. Recovery is determined by age, cause, and time in such state. For patients diagnosed as being in a permanent (irreversible) vegetative state, hope for a clinically meaningful recovery is unrealistic after 1 year. Prolonged survival is possible only with meticulous care and aggressive medical intervention to prevent and treat systemic complications. [ABSTRACT FROM AUTHOR]

Aneurysmal subarachnoid hemorrhage (SAH) is often a neurologic catastrophe. Diagnosing SAH can be challenging, and treatment is complex, sophisticated, multidisciplinary, and rarely routine. This review emphasizes treatment in the intensive care unit, surgical and endovascular therapeutic options, and the current state of treatment of major complications such as cerebral vasospasm, acute hydrocephalus, and rebleeding. Outcome assessment in survivors of SAH and controversies in screening of family members are discussed. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To identify predictive factors for postoperative coma or stupor and to examine the value of neuroimaging techniques in elucidating structural brain damage. PATIENTS AND METHODS: We performed a case-control study of surgical patients admitted to a Mayo Clinic-affiliated hospital. We studied preoperative comorbidity, intraoperative hypotension, and postoperative data in patients with postoperative stupor or coma and compared the characteristics with control patients (surgical intensive care unit patients with neurologic consultations for other reasons). RESULTS: A total of 35 patients with stupor or coma after surgery and 31 control patients participated in this study. Comatose patients were older (P=.004) and had significantly more presurgical comorbidity (P<.001), cardiovascular surgical procedures (P<.001), and intraoperative hypotension (P=.03). Adjusted for age and comorbidity, intraoperative hypotension remained statistically significant but not after adjusting for cardiovascular surgery. Of the 34 computed tomograms obtained, 41% showed abnormal results; of the 12 magnetic resonance images obtained, 58% showed abnormal results. Both showed primarily infarctions. In 4 patients with normal computed tomographic results, magnetic resonance imaging showed multiple territorial infarctions. CONCLUSION: Prior comorbidity, older age, intraoperative hypotension, and cardiovascular surgery may predispose patients to postoperative coma. Widespread structural ischemic brain damage was often documented by neuroimaging. Metabolic causes for coma were uncommon. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Devastating stroke can produce irreversible brain damage of massive proportions. In those patients, continuation of aggressive medical or surgical care may be futile and may unnecessarily prolong the suffering of families. Therefore, it is essential for clinicians to be aware of key clinical and radiologic features predictive of poor outcome. There has not been a critical review of the data used to make decisions of withdrawal of care in patients with severe strokes. DATA SOURCE: Literature review. DATA SYNTHESIS: Although in many instances the studies that validate these prognosticators represent class III or class IV evidence, there are several clinico-radiologic profiles that have consistently been predictive of mortality or dependency after cerebrovascular catastrophes. CONCLUSIONS: Inconclusiveness remains in the determination of futility of care after major stroke. However, predictors of dismal outcome after several types of stroke have been identified and are relevant information in regard to withdrawal of care. [ABSTRACT FROM AUTHOR]

Objectives: To describe the clinical characteristics of acute stroke attributable to trauma and to analyze the mechanisms and effect of stroke on outcome in patients with polytrauma.Patients and Methods: We retrospectively reviewed the medical records of patients with polytrauma complicated by stroke at the Mayo Clinic in Rochester, Minn. The diagnosis of stroke was matched with trauma for the period between January 1, 1985, and December 31, 2001. Polytrauma was defined as at least 2 injuries that involve at least 1 vital organ (eg, lung or liver) and necessitate patient admission to a trauma intensive care unit.Results: We identified 14 patients with polytrauma who had experienced a stroke (13 ischemic and 1 hemorrhagic). Craniocervical artery dissection was the most common mechanism (7 patients), and skull or facial fractures were a possible marker for this (5 of 7 patients). There were frequent delays in identifying stroke, with limb fracture on the side of the paresis (5 of 6 patients) being a possible factor. Four patients died of postischemic brain swelling, and 5 had major neurologic impairment.Conclusions: Stroke after polytrauma is due to various mechanisms, is frequently difficult to recognize early, and profoundly affects patient outcome. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To characterize the phenomenon of complete bilateral ptosis associated with massive infarction of the right cerebral hemisphere, particularly with respect to its time course and relationship to herniation syndromes. PATIENTS AND METHODS: In May through July 2002, consecutive patients admitted to the neurology/neurosurgery intensive care unit at the Mayo Clinic in Rochester, Minn, with massive infarction of the right cerebral hemisphere, and later, complete bilateral ptosis, underwent serial neurologic examinations and neuroimaging. RESULTS: Six patients with massive infarction of the right cerebral hemisphere developed complete bilateral ptosis. All had normal eyelid opening at initial examination and later developed ptosis, which clearly preceded signs of herniation. Three patients died after herniation syndromes developed. In the 3 survivors, improvement in ptosis closely followed resolution of midbrain distortion seen on computed tomographic scans. CONCLUSION: The precise anatomical explanation for complete bilateral ptosis is unclear, but upper brainstem involvement seems most likely. Complete bilateral ptosis is a valuable clinical sign in patients with a massive hemispheric infarction that precedes herniation and could provide an opportunity for early intervention. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To establish the rate of successful cardiopulmonary resuscitation (CPR) and to study outcome predictors in patients who experienced in-hospital cardiac arrest after being admitted to the neurologic-neurosurgical intensive care unit (ICU) with a primary neurologic diagnosis. PATIENTS AND METHODS: We identified patients admitted to the neurologic-neurosurgical ICU between 1994 and 2001 who experienced in-hospital cardiac arrest and received CPR. Functional outcome was assessed using the modified Rankin scale. RESULTS: During the study period, 38 consecutive patients experienced in-hospital cardiac arrest and received CPR. The median age of the patients was 65 years (range, 16-81 years), and the mean interval from admission to CPR was 12 days (range, 3 hours to 47 days). Acute intracranial disease was present in 32 patients (84%). Twenty-one patients (55%) were in the ICU at the time of the cardiac arrest; cardiac arrests in the wards occurred at a mean interval of 9 days (range, 1-45 days) after ICU discharge. Cardiopulmonary resuscitation achieved return of spontaneous circulation in 23 patients (61%). Seven patients (18%) were discharged from the hospital, 5 of whom later achieved a modified Rankin scale score of 2 or lower. Cardiac arrest after a deteriorating clinical course resulted in uniformly fatal outcomes. Duration of CPR shorter than 5 minutes and CPR in the ICU were associated with survival and good functional recovery. CONCLUSIONS: Cardiopulmonary resuscitation is a worthwhile procedure in severely ill neurologic-neurosurgical patients, regardless of the patient's age. However, the outcome after CPR appears much worse in patients with a prior deteriorating clinical course. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine the Incidence of cardiac troponin T (cTnT) elevation, electrocardiographic (ECG) changes, and arrhythmias in supratentorial intracerebral hemorrhage (ICH) and their association with early mortality. PATIENTS AND METHODS: Patients with supratentorial ICHs admitted to Mayo Clinic, Rochester, Minn, from March 1998 to October 2003 were studied. We excluded moribund patients with ICHs who died within 12 hours of hospital admission. Cardiac troponin T levels measured on admission and day 2 were determined by a third-generation enzyme-linked immunosorbent assay. Continuous ECG monitoring was performed In all patients. Computed tomographic scans were graded and correlated with abnormal cardiac variables. RESULTS: Peak levels of cTnT were elevated at 0.035 to 1.2 microg/L (mean +/- SD, 0.27 +/- 0.38 microg/L) in 10 (20%) of 49 patients and were not associated with changes in creatine kinase MB fraction or ECG results. The cTnT levels did not correlate with location or side of hemorrhage or mortality at 30 days. Seventy (64%) of 110 patients displayed ECG abnormalities. The ECG changes did not correlate with the location or side of ICH, hydrocephalus, midline shift, or extension to the ventricles. CONCLUSION: The cTnT elevations in survivors of acute ICH are frequent but without confirmatory ECG changes that suggest mild myocardial injury. One-month mortality is not influenced by such cTnT elevations. In addition, ECG abnormalities are common but likely benign in patients with supratentorial ICH who survive the initial insult. [ABSTRACT FROM AUTHOR]

Intracerebral hemorrhage (ICH) accounts for approximately 10% of all strokes and causes high morbidity and mortality. Rupture of the small perforating vessels of the cerebral arteries is caused by chronic hypertension, which induces pathologic changes in the small vessels and accounts for most cases of ICH; however, amyloid angiopathy and other secondary causes are being seen more frequently with the increasing age of the population. Recent computed tomographic studies have revealed that ICH is a dynamic process with up to one third of initial hemorrhages expanding within the first several hours of ictus. Secondary injury is believed to result from the development of cerebral edema and the release of specific neurotoxins associated with the breakdown products of hemoglobin. Treatment is primarily supportive. Surgical evacuation is the treatment of choice for patients with neurologic deterioration from infratentorial hematomas. Randomized trials comparing surgical evacuation to medical management have shown no benefit of surgical removal of supratentorial hemorrhages. New strategies focusing on early hemostasis, improved critical care management, and less invasive surgical techniques for clot evacuation are promising to decrease secondary neurologic injury. We review the pathophysiology of ICH, its medical management, and new treatment strategies for improving patient outcome. [ABSTRACT FROM AUTHOR]

The treatment of acute ischemic stroke has evolved from observation and the passage of time dictating outcome to an approach that emphasizes time from ictus, rapid response, and a dedicated treatment team. We review the treatment of acute ischemic stroke from the prehospital setting, to the emergency department, to the inpatient hospital setting. We discuss the importance of prehospital assessment and treatment, including the use of elements of the neurologic examination, recognition of symptoms that can mimic those of acute ischemic stroke, and rapid transport of patients who are potential candidates for thrombolytic therapy to hospitals with that capability. Coordinated management of acute ischemic stroke in the emergency department is critical as well, beginning with non-contrast-enhanced computed tomography of the brain. The advantages of a multidisciplinary dedicated stroke team are discussed, as are thrombolytic therapy and other inpatient treatment options. Finally, we cover evolving management strategies, treatments, and tools that could improve patient outcomes. [ABSTRACT FROM AUTHOR]

We treated a patient who developed transient multifocal encephalopathy with extrapyramidal symptoms (oromandibular dystonia, oculogyric crisis, and limb dystonia) in temporal proximity to ondansetron administration on emergence from general anesthesia. No other medications known to cause extrapyramidal reactions were administered. Although these symptoms resolved fully, the presentation was dramatic and resembled the symptoms of structural brain injury. Ondansetron is used frequently as an antiemetic agent in many clinical settings and is not limited to surgical patients. Therefore, the entire medical community should be cognizant of this potential adverse reaction. [ABSTRACT FROM AUTHOR]

Exchanges in medical practice are necessary for training. The use of movies for promoting medical practice was introduced in the late 19th century. The authors analyzed an unidentified movie titled Trepanation for Rolandic Zone Tumor (Trépanation pour tumeur de la zone rolandique) stored at the Établissement de Communication et de Production Audiovisuelle de la Défense of the French Ministry of Armed Forces. This silent black-and-white movie, lasting 15 minutes and depicting the removal of a meningioma, did not contain information or a legend. The surgical tools used were those developed by Thierry de Martel. The furniture and interior design shown in the film corresponded with the Vercingétorix Clinic that this surgeon had acquired in Paris. A publication from 1922 contained 14 pictures taken from the movie presented in this paper and referred to a movie directed in 1911 by Thierry de Martel. This is strong circumstantial evidence that the film was directed and the surgery was performed by Thierry de Martel at the Vercingétorix Clinic in Paris, France, in 1911 while using the technology of the Gaumont company. This is a contemporary testimony to what surgical practice was over a century ago, and it illustrates how movies were, and remain, a unique way to learn and teach medicine.