Tag Archives: Neurology

Efficacy of Combined Intravenous Thrombolysis and Thrombectomy

Mechanical thrombectomy (MT) improves clinical outcomes in patients with acute ischemic stroke (AIS) caused by a large vessel occlusion. However, it is not known whether intravenous thrombolysis (IVT) is of added benefit in patients undergoing MT. Coutinho et al set out to address this unknown.

The results indicate that treatment of patients experiencing AIS due to a large vessel occlusion with IVT before MT does not appear to provide a clinical benefit over MT alone.

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Preventing Early Seizures in Children with TBI

Traumatic brain injury (TBI) is a leading cause of death and disability in children. Early posttraumatic seizures can exacerbate some of the metabolic and physiologic derangements seen with TBI. In a prospective observational study by Chung and O’Brien, the authors sought to evaluate the prevalence of early seizures after levetiracetam prophylaxis in children with moderate to severe TBI.

They found that early clinical posttraumatic seizures occurred frequently in children with moderate to severe TBI despite seizure prophylaxis with levetiracetam.

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What Is the Incidence of Subclinical and Clinical Seizures in Pediatric TBI?

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children. The primary medical management of TBI relies on minimization of secondary injury. Posttraumatic seizures are relatively common and can cause secondary injury or worsen other sources of secondary injury. O’Neill et al sought to determine the incidence of seizures in children with TBI using a protocol for early continuous electroencephalography monitoring.

This study affirmed that posttraumatic seizures are relatively common in pediatric patients with TBI.

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Study Questions the Efficacy of Therapeutic Hypothermia

Therapeutic hypothermia is recommended for comatose adults after witnessed out-of-hospital cardiac arrest, but there have been recent questions about its effectiveness and data about this intervention in children are limited. Moler et al recruited children older than two days and younger than 18 years of age who remained unconscious after having an out-of-hospital cardiac arrest with return of spontaneous circulation. The authors then randomized these patients into either a therapeutic hypothermia arm or a therapeutic normothermia arm. The primary outcome was survival at 12 months with a good neurobehavioral outcome.

In comatose children who survived out-of-hospital cardiac arrest, therapeutic hypothermia, as compared with therapeutic normothermia, did not confer a significant benefit in survival with a good functional outcome at one year.

With this study’s findings, a general lack of clarity about the efficacy of therapeutic hypothermia in general has materialized. Previously, Nielsen et al described the lack of benefit in mortality or neurologic outcomes in adult cardiac arrest patients who underwent therapeutic hypothermia compared to those patients in the therapeutic normothermia arm. Further studies will be needed to definitively judge this therapy’s overall usefulness in both the adult and pediatric population.

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Impact of ICH Duration and Intensity on TBI Patients

Traumatic brain injury (TBI) is a major cause of permanent disability and death in young patients. Monitoring and manipulation of intracranial pressure (ICP) has been a cornerstone in the management of these patients. Güiza et al sought to determine if the cumulative ICP burden was associated with outcomes in adult and pediatric TBI patients.

The authors showed that the ICP burden, defined by intensity and duration of intracranial hypertension, was associated with outcomes in both patient groups. They also found that children cannot tolerate high ICPs for the same amount of time as adults.

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Vasospasm in Pediatric Traumatic Brain Injury

Pediatric traumatic brain injury (TBI) is a major cause of death and disability. While the damage caused by the primary injury may not be alterable by treatment, the effects of the secondary injury—subsequent metabolic, humoral and cellular derangements—can be modified. By ensuring good hemodynamics, gas exchange and intracranial pressure control, physicians can improve outcomes. However, the appearance of vasospasm and subsequent ischemia has been demonstrated in up to 45% of adults with TBI (depending on the criteria used to define vasospasm) and has been associated with worse outcomes. In a recent study, O’Brien et al sought to evaluate the prevalence, time to onset and duration of vasospasm in children with moderate to severe TBI. For their single center, prospective, observational study, the authors enrolled 69 children with TBI (35 subjects had moderate TBI and 34 had severe TBI).

They found that vasospasm occurs in a sizeable number of children with moderate and severe TBI. However, while the authors recommend “aggressive screening” for posttraumatic vasospasm in these patients, appropriate therapies have not been described in any studies. Clearly, future studies should be done to measure long-term outcomes and responses to specific therapies.

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