1,721,010 research outputs found
Clinical Course after End-of-Life Decisions on a Neurosurgical Ward: Much to Learn and Improve
No full textAbstract Background End-of-life (EoL) decisions are routine in neurosurgical care due to frequent devastating and life-threatening diagnoses. Advance directives, discussions with patients' relatives, and evaluation of the alleged will of the patient play an increasing important role in clinical decision-making. Institutional standards, ethical values, different ethnical backgrounds, and individual physician's experiences influence clinical judgments and decisions. We hypothesize that the implementation of palliative care in neurosurgical wards needs optimization. The aim of this study is to identify possible sources of error and to share our experiences. Methods This is a retrospective observational analysis. One hundred and sixty-eight patients who died on a regular neurosurgical ward between 2014 and 2019 were included. Medical reports were analyzed in detail. A differentiation between consistent and nonconsistent palliation was made, with consistent palliative care consisting of discontinuation of medication that was no longer indicated, administration of medication for symptom control, and consequent discontinuation of nutrition and fluid substitution that went beyond satisfying hunger or thirst. Results EoL decisions were made in 127 (84.1%) of all 168 cases; 100 patients were included in our analysis. Of these patients, only 24 had an advance directive, and the relatives were included in the communication about the therapy goals in 71 cases. Discontinuation of medication that is not for symptom control was performed in 63 patients, food withdrawal in 66 patients, and fluid substitution that went beyond the quenching of thirst was withdrawn in 27 patients. Thus, consistent palliative care was realized in 25% of all patients. The mean duration from the EoL decision until death was 2.1 days (range: 0–20 days). If a consistent palliative care was carried out, patients survived significantly shorter (nonconsistent palliative care: 2.4 days; range: 0–10 days vs. consistent palliative care: 1.2 days; range: 0–4 days; p = 0.008). Conclusions The therapy goal should be thoroughly considered and determined at an early stage. If an EoL decision is reached, consistent palliative care should be carried out in order to limit suffering of moribund patients
Safety aspects of opioid-naïve patients with high-grade glioma treated with D,L-Methadone: an observational case series
No full textMessung des zerebralen Sauerstoffpartialdrucks (ptiO2)
No full textDie Sauerstoffgewebspartialdruckmessung dient der Vermeidung ischämischer Organschäden. Ihre Implementierung ist relativ einfach, die Interpretation der erhobenen Werte erfordert allerdings Erfahrung und Kenntnisse (patho)physiologischer Zusammenhänge. Indikationen für die Messung des zerebralen Sauerstoffgewebspartialdrucks sind schwere Schädel-Hirn-Traumata und hochgradige Subarachnoidalblutungen, für diese Krankheitsbilder konnten positive Auswirkungen auf den klinischen Behandlungsverlauf gezeigt werden. Die zerebrale Sauerstoffgewebspartialdruckmessung erfolgt sollwertorientiert (goal-targeted therapy)
Surgical timing and indications for decompressive craniectomy in malignant stroke: results from a single-center retrospective analysis
Full text linkAbstract Purpose Acute ischemic stroke induces rapid neuronal death and time is a key factor in its treatment. Despite timely recanalization, malignant cerebral infarction can ensue, requiring decompressive surgery (DC). The ideal timing of surgery is still a matter of debate; in this study, we attempt to establish the ideal time to perform surgery in this population. Methods We conducted a retrospective study of patients undergoing DC for stroke at our department. The indication for DC was based on drop in level of consciousness and standard imaging parameters. Patients were stratified according to the timing of DC in four groups: (a) “ultra-early” ≤12 h, (b) “early” >12≤24 h, (c) “timely” >24≤48 h, and (d) “late” >48 h. The primary endpoint of this study was in-house mortality, as a dependent variable from surgical timing. Secondary endpoint was modified Rankin scale at discharge. Results In a cohort of 110 patients, the timing of surgery did not influence mortality or functional outcome ( p =0.060). Patients undergoing late DC were however significantly older ( p =0.008), and those undergoing ultra-early DC showed a trend towards a lower GCS at admission. Conclusions Our results add to the evidence supporting an extension of the time window for DC in stroke beyond 48 h. Further criteria beyond clinical and imaging signs of herniation should be considered when selecting patients for DC after stroke to identify patients who would benefit from the procedure
Rapidity of hematoma resolution after fibrinolytic therapy for intracerebral hemorrhage has a favorable effect on functional outcome
Full text linkFibrinolytic therapy with tissue plasminogen activator (rtPA) is considered a promising treatment option for intracerebral hemorrhage (ICH), but a large randomized controlled study (i.e., MISTIE III) failed to show a benefit for the long-term outcome. This study investigated whether the rapidity of hematoma volume reduction influences outcome of ICH-patients undergoing fibrinolytic therapy. Patients with supratentorial ICH with or without a secondary extension to the ventricular system receiving fibrinolytic therapy from 2010 to 2020 were retrospectively analyzed. Patients with primarily intraventricular hemorrhage were excluded. A catheter was placed into the hematoma via burr hole and by means of neuronavigation. After confirming a correct catheter position rtPA was injected through the catheter with subsequent passive drainage of the hematoma. Hematoma volume was measured initially and 24/48/72 hours after treatment and the relative volume reduction was calculated. The functional outcome at discharge was assessed using the modified Rankin scale (mRS) regarding a mRS of 4 or lower as favorable outcome. A total of 280 patients with mean age of 69.6 years and mean hematoma volume of 55.6 ml were analyzed. The odds of reaching favorable outcome were four-fold higher in patients with a volume reduction of more than 50% after 24 h (OR 4.23, 95%CI 3.05 to 5.66, p = 0.007). Patients with a residual volume of less than 30 ml after 24 h had a two-fold higher chance of having favorable outcome (OR 2.9, 95%CI 1.78 to 4.63, p < 0.0001). A fast volume reduction of at least 50% within 24 h resulted into a favorable outcome in ICH-patients undergoing fibrinolytic therapy. Not just the amount but also the rapidity of hematoma volume reduction seems to be an important factor for a good clinical result after fibrinolytic therapy
Clinical Course and Monitoring Parameters After Continuous Interventional Intra-Arterial Treatment in Patients with Refractory Cerebral Vasospasm
No full textBACKGROUND: In aneurysmal subarachnoid haemorrhage cerebral vasospasm leads to clinical worsening and poor outcome. Interventional treatment with nimodipine might be a therapeutic option. OBJECTIVE: To evaluate the clinical course of patients with different interventional treatment types. METHODS: A retrospective, observational analysis was performed. Inclusion criteria were aneurysmal subarachnoid haemorrhage, clinical and/or radiologic evidence of vasospasm and interventional intra-arterial treatment. Patients were divided into 3 groups: continuous nimodipine infusion, repetitive nimodipine infusions, and singular nimodipine infusion. Pre- and postinterventional parameters were analyzed to evaluate the efficacy of the procedure in terms of responder status. Outcome was determined using the modified Rankin scale. RESULTS: A total of 163 interventions (97 patients) were examined. Patients with continuous treatment showed a greater World Federation of Neurological Surgeons grade. Response to intra-arterial nimodipine in the continuous group was comparatively worse. Transcranial Doppler monitoring as well as brain tissue oxygenation measuring showed good correlation with imaging results. The rate of intraprocedural complications in the continuous treatment group was significantly greater. We observed a worse clinical outcome in the patients who underwent continuous treatment. None of the patients in the continuous group achieved favorable outcome after 3 months. CONCLUSIONS: Facing the poor clinical outcome and the greater complication rate, continuous intra-arterial infusion of nimodipine in patients with angiographically refractory cerebral vasospasm has to be indicated strictly. Transcranial Doppler and brain tissue oxygenation monitoring seem to be reliable tools for evaluation of the clinical postinterventional course
Spontaneous intracerebral hemorrhage – patients retrospectively consent to fibrinolytic surgery despite poor neurological outcome and reduced health-related quality of life
Full text linkSpontaneous intracerebral hemorrhage (ICH) might lead to devastating consequences. Nonetheless, subjective interpretation of life circumstances might vary. Recent data from ischemic stroke patients show that there might be a paradox between clinically rated neurological outcome and self-reported satisfaction with quality of life. Our hypothesis was that minimally invasive surgically treated ICH patients would still give their consent to stereotactic fibrinolysis despite experiencing relatively poor neurological outcome. In order to better understand the patients’ perspective and to enhance insight beyond functional outcome, this is the first study assessing disease-specific health-related quality of life (hrQoL) in ICH after fibrinolytic therapy. We conducted a retrospective analysis of patients with spontaneous ICH treated minimally invasive by stereotactic fibrinolysis. Subsequently, using standardized telephone interviews, we evaluated functional outcome with the modified Rankin Scale (mRS), health-related Quality of Life with the Quality of life after Brain Injury Overall scale (QOLIBRI-OS), and assessed retrospectively if the patients would have given their consent to the treatment. To verify the primary hypothesis that fibrinolytic treated ICH patients would still retrospectively consent to fibrinolytic therapy despite a relatively poor neurological outcome, we conducted a chi-square test to compare good versus poor outcome (mRS) between consenters and non-consenters. To investigate the association between hrQoL (QOLIBRI-OS) and consent, we conducted a Mann-Whitney U-test. Moreover, we did a Spearman correlation to investigate the correlation between functional outcome (mRS) and hrQoL (QOLIBRI-OS). The analysis comprised 63 data sets (35 men, mean age: 66.9 ± 11.8 years, median Hemphill score: 3 [2-3]). Good neurological outcome (mRS 0–3) was achieved in 52% (33/63) of the patients. Patients would have given their consent to surgery retrospectively in 89.7% (52/58). These 52 consenting patients comprised all 33 patients (100%) who achieved good functional outcome and 19 of the 25 patients (76%) who achieved poor neurological outcome (mRS 4–6). The mean QOLIBRI-OS value was 49.55 ± 27.75. A significant association between hrQoL and retrospective consent was found (p = 0.004). This study supports fibrinolytic treatment of ICH even in cases when poor neurological outcome would have to be assumed since subjective perception of deficits could be in contrast with the objectively measured neurological outcome. HrQoL serves as a criterion for success of rtPa lysis therapy in ICH
Sedation of Patients with Acute Aneurysmal Subarachnoid Hemorrhage with Ketamine Is Safe and Might Influence the Occurrence of Cerebral Infarctions Associated with Delayed Cerebral Ischemia
No full textBACKGROUND: Ketamine has neuroprotective characteristics as well as beneficial cardiocirculatory properties and may thus reduce vasopressor consumption. In contrast, sedation with ketamine (like any other sedative drug) has side effects. This study assesses the influence of ketamine on intracranial pressure (ICP), on the consumption of vasopressors in induced hypertension therapy, and on the occurrence of delayed cerebral ischemia (DCI)-associated cerebral infarctions, with particular focus on the complications of sedation in patients with aneurysmal subarachnoid hemorrhage (SAH). METHODS: This is a retrospective, observational study. Sixty-five patients with SAH who underwent a period of sedation were included. The clinical course variables (Richmond Agitation and Sedation scale score, ICP values, consumption of vasopressors, complications of sedation, outcome, and other clinical parameters) were analyzed. Cranial computed tomography results were analyzed. RESULTS: Forty-one patients underwent sedation including ketamine (63.1%). Ketamine decreased the ICP in 92.7% of the cases. Vasopressors was reduced in 53.6%. DCI-associated cerebral infarctions occurred significantly less often in the patient cohort being treated with sedation including ketamine (7.3% vs. 25% in the nonketamine group; P = 0.04). The rate of major complications was not higher in the ketamine group. Outcome was not different regarding the groups if they were sedated with or without ketamine. CONCLUSIONS: Ketamine decreases the ICP and is not associated with a higher rate of complications. The rate of DCI-associated cerebral infarctions was lower in the ketamine group. Ketamine administration led to a reduction of vasopressors used for induced hypertension
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