Simulation-based training in brain death determination.

Background: Despite straightforward guidelines on brain death determination by the American Academy of Neurology (AAN), substantial practice variability exists internationally, between states, and among institutions. We created a simulation-based training course on proper determination based on the AAN practice parameters to address and assess knowledge and practice gaps at our institution.

Methods: Our intervention consisted of a didactic course and a simulation exercise, and was bookended by before and after multiple-choice tests.

Neuroprognostication of hypoxic-ischaemic coma in the therapeutic hypothermia era.

Neurological prognostication after cardiac arrest has always been challenging, and has become even more so since the advent of therapeutic hypothermia (TH) in the early 2000s. Studies in this field are prone to substantial biases--most importantly, the self-fulfilling prophecy of early withdrawal of life-sustaining therapies--and physicians must be aware of these limitations when evaluating individual patients. TH mandates sedation and prolongs drug metabolism, and delayed neuronal recovery is possible after cardiac arrest with or without hypothermia treatment; thus, the clinician must allow an adequate observation period to assess for delayed recovery.

Neurocritical care clinicians' perceptions of nurse practitioners and physician assistants in the intensive care unit.

Background: The contributions and perceptions of staff regarding nurse practitioners (NPs) and physician assistants (PAs) in neuroscience intensive care units (ICUs) throughout the country are not well known. The objectives of this study were to determine the impact of neuroscience NPs and PAs and assess demographics of ICUs.

Methods: All members of the Neurocritical Care Society were asked to complete a survey to obtain their perception regarding the addition of NPs and PAs to the ICU team.

Recommendations for the management of cerebral and cerebellar infarction with swelling: a statement for healthcare professionals from the American Heart Association/American Stroke Association.

Background And Purpose: There are uncertainties surrounding the optimal management of patients with brain swelling after an ischemic stroke. Guidelines are needed on how to manage this major complication, how to provide the best comprehensive neurological and medical care, and how to best inform families facing complex decisions on surgical intervention in deteriorating patients. This scientific statement addresses the early approach to the patient with a swollen ischemic stroke in a cerebral or cerebellar hemisphere.

How to assess prognosis after cardiac arrest and therapeutic hypothermia.

The prognosis of patients who are admitted in a comatose state following successful resuscitation after cardiac arrest remains uncertain. Although the introduction of therapeutic hypothermia (TH) and improvements in post-resuscitation care have significantly increased the number of patients who are discharged home with minimal brain damage, short-term assessment of neurological outcome remains a challenge. The need for early and accurate prognostic predictors is crucial, especially since sedation and TH may alter the neurological examination and delay the recovery of motor response for several days.

Cryptogenic stroke-the appropriate diagnostic evaluation.

Ischemic strokes are a significant cause of morbidity and mortality in the United States. They may be due to large artery atherosclerosis, small vessel occlusion, cardioembolism, or other less common mechanisms such as toxins, hypercoagulable disorders, and vasospasm. Each mechanism carries its own risk of recurrence and prognosis.

Traumatic carotid artery dissection during acrobatic flight associated with -G(z) acceleration.

Background: A 38-yr-old man developed the acute onset of expressive aphasia and right hemiparesis during the performance of an advanced aerobatic flight maneuver.

Case Report: Magnetic resonance imaging (MRI) demonstrated patchy infarction in the territory of the left middle cerebral artery. Magnetic resonance, angiography (MRA) revealed a dissection of the left internal carotid artery.

Quality of evidence in studies evaluating neuroimaging for neurologic prognostication in adult patients resuscitated from cardiac arrest.

Aim: Neuroimaging has been proposed as a predictor of neurologic outcome in comatose survivors of cardiac arrest. We reviewed the quality and level of evidence of the current neuroimaging literature for predicting neurologic outcome in cardiac arrest patients treated with or without therapeutic hypothermia (TH).

Data Sources: Medline, EMBASE, and Cochrane Databases were searched using the terms "cardiac arrest," "cardiopulmonary resuscitation," "brain hypoxia," "brain anoxia," "brain hypoxia-ischaemia," "neuroimaging," and "prognosis.

Clinical examination for prognostication in comatose cardiac arrest patients.

Objective: To build new algorithms for prognostication of comatose cardiac arrest patients using clinical examination, and investigate whether therapeutic hypothermia influences the value of the clinical examination.

Methods: From 2000 to 2007, 500 consecutive patients in non-traumatic coma were prospectively enrolled, 200 of whom were post-cardiac arrest. Outcome was determined by modified Rankin Scale (mRS) score at 6 months, with mRS≤3 indicating good outcome.

End-of-life and brain death in acute coma and disorders of consciousness.

Consulting neurologists are often asked to evaluate patients in acute nontraumatic coma. The authors review prognostication of functional outcomes, determining brain death, and managing end-of-life care. Prognostication of outcome after cardiac arrest in comatose patients is a frequently encountered scenario with high-stakes implications.

Enrollment of Research Subjects through Telemedicine Networks in a Multicenter Acute Intracerebral Hemorrhage Clinical Trial: Design and Methods.

Background: Enrollment of subjects in acute stroke trials is often hindered by narrow timeframes, because a large proportion of patients arrive via transfers from outside facilities rather than primary arrival at the enrolling hospital.

Rationale: Telemedicine networks have been increasingly utilized for provision of care for acute stroke patients at facilities outside of major academic centers. Treatment decisions made through Telemedicine networks in patients with acute ischemic stroke have been shown to be safe, reliable, and effective.

Assessment of brain death in the neurocritical care unit.

This article reviews current guidelines for death by neurologic criteria and addresses topics relevant to the determination of brain death in the intensive care unit. The history of brain death as a concept leads into a discussion of the evolution of practice parameters, focusing on the most recent 2010 update from the American Academy of Neurology and the practice variability that exists worldwide. Proper transition from brain death determination to possible organ donation is reviewed.

Disconnection of the ascending arousal system in traumatic coma.

Traumatic coma is associated with disruption of axonal pathways throughout the brain, but the specific pathways involved in humans are incompletely understood. In this study, we used high angular resolution diffusion imaging to map the connectivity of axonal pathways that mediate the 2 critical components of consciousness-arousal and awareness-in the postmortem brain of a 62-year-old woman with acute traumatic coma and in 2 control brains. High angular resolution diffusion imaging tractography guided tissue sampling in the neuropathologic analysis.

Hippocampal magnetic resonance imaging abnormalities in cardiac arrest are associated with poor outcome.

Background: The role of neuroimaging in assessing prognosis in comatose cardiac survivors appears promising, but little is known regarding the import of particular spatial patterns. We report a specific spatial imaging abnormality on magnetic resonance imaging (MRI) that portends a poor prognosis: bilateral hippocampal hyperintensities on diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) sequences.

Methods: Eighty sequential comatose cardiac arrest patients underwent MRI scans.

Neuroanatomic connectivity of the human ascending arousal system critical to consciousness and its disorders.

The ascending reticular activating system (ARAS) mediates arousal, an essential component of human consciousness. Lesions of the ARAS cause coma, the most severe disorder of consciousness. Because of current methodological limitations, including of postmortem tissue analysis, the neuroanatomic connectivity of the human ARAS is poorly understood.

Clinical MRI interpretation for outcome prediction in cardiac arrest.

Background: In clinical practice, magnetic resonance imaging (MRI) is commonly used to assess the severity of a cardiac arrest patient's cerebral injury, utilizing treating neurologists' imaging interpretation. We sought to determine whether clinical interpretation of diffusion-weighted imaging (DWI) helps to determine poor outcome in comatose cardiac arrest patients.

Methods: We analyzed 80 consecutive MRIs from patients in coma following cardiac arrest.

Plantar flexion with noxious dorsal foot stimulation in brain death.

Background: Plantar flexion with plantar stimulation has been well described in brain death, and is compatible with brain death. However, plantar flexion with stimulation to the dorsal surface of the foot has not been reported previously in brain dead patients.

Methods: Case report with Technetium-99 m hexamethylpropyleneamine oxime brain scan and video.

Comparative sensitivity of computed tomography vs. magnetic resonance imaging for detecting acute posterior fossa infarct.

Background: Posterior fossa strokes, particularly those related to basilar occlusion, pose a high risk for progression and poor neurological outcomes. The clinical history and examination are often not adequately sensitive or specific for detection.

Study Objectives: Because this population stands to benefit from acute interventions such as intravenous and intra-arterial tissue plasminogen activator, mechanical thrombectomy, and intensive monitoring for neurologic deterioration, this study examined the sensitivity of non-contrast head computed tomography (NCCT) for diagnosing posterior fossa strokes in the emergency department.

Brain natriuretic peptide predicts functional outcome in ischemic stroke.

Background And Purpose: Elevated serum levels of brain natriuretic peptide (BNP) have been associated with cardioembolic stroke and increased poststroke mortality. We sought to determine whether BNP levels were associated with functional outcome after ischemic stroke.

Methods: We measured BNP in consecutive patients aged ≥ 18 years admitted to our stroke unit between 2002 to 2005.

Clinical examination for outcome prediction in nontraumatic coma.

Objectives: Determine the utility of the neurologic examination in comatose patients from nontraumatic causes in the modern era.

Design: Prospective observational study.

Setting: Single academic medical center.