Neurocritical Intensive Care Unit Research Articles

The role of peritoneal dialysis in the treatment of acute kidney injury in neurocritical patients: a retrospective Brazilian study.

Acute kidney injury (AKI) occurs frequently in the neurocritical intensive care unit and is associated with greater morbidity and mortality. AKI and its treatment, including acute kidney replacement therapy, can expose patients to a secondary greater brain injury. This study aimed to explore the role of peritoneal dialysis (PD) in neurocritical AKI patients in relation to metabolic and fluid control, complications related to PD and outcome. Neurocritical AKI patients were treated by PD (prescribed Kt/V = 0.40/session) using a flexible catheter and a cycler and lactate as a buffer. A total of 58 patients were included. The mean age was 61.8 ± 13.2 years, 65.5% were in the intensive care unit, 68.5% needed intravenous inotropic agents, 72.4% were on mechanical ventilation, APACHE II was 16 ± 6.67 and the main neurological diagnoses were stroke (25.9%) and intracerebral haemorrhage (31%). Ischaemic acute tubular necrosis (iATN) was the most common cause of AKI (51.7%), followed by nephrotoxic ATN AKI (25.8%). The main dialysis indications were uraemia and hypervolemia. Blood urea and creatinine levels stabilised after four sessions at around 48 ± 11 mg/dL and 2.9 ± 0.4 mg/dL, respectively. Negative fluid balance and ultrafiltration increased progressively and stabilised around 2.1 ± 0.4 L /day. Weekly delivered Kt/V was 2.6 ± 0.31. The median number of high-volume PD sessions was 6 (4-10). Peritonitis and mechanical complications were not frequent (8.6% and 10.3%, respectively). Mortality rate was 58.6%. Logistic regression identified as factors associated with death in neurocritical AKI patients: age (odds ratio (OR) = 1.14, 95% confidence interval (CI) = 1.09-2.16, p = 0.001), nephrotoxic AKI (OR = 0.78, 95% CI = 0.69- 0.95, p = 0.03), mechanical ventilation (OR = 1.54, 95% CI = 1.17-2.46, p = 0.01), intracerebral haemorrhage as main neurological diagnoses (OR = 1.15, 95% CI = 1.09-2.11, p = 0.03) and negative fluid balance after two PD sessions (OR = 0.94, 95% CI = 0.74-0.97, p = 0.009). Our study suggests that careful prescription may contribute to providing adequate treatment for most neurocritical AKI patients without contraindications for PD use, allowing adequate metabolic and fluid control, with no increase in the number of infectious, mechanical and metabolic complications. Mechanical ventilation, positive fluid balance and intracerebral haemorrhage were factors associated with mortality, while patients with nephrotoxic AKI had lower odds of mortality compared to those with septic and ischaemic AKI. Further studies are needed to investigate better the role of PD in neurocritical patients with AKI.

Narrative Review of Non-Convulsive Status Epilepticus in Adults in Intensive Care

ABSTRACT Background Seizures are common in the Neurocritical Intensive Care Unit. Early identification and treatment of clinical and sub-clinical seizures remain important in managing the neurologically critically ill patient. Aim The aim of this narrative review is to provide an overview of the different types of sub-clinical seizures, diagnosis and detection, correlative physiology, and the importance of prompt treatment. Methods A group of physicians, advanced practice providers, and pharmacists performed a literature search based on their area of expertise and provided the most relevant evidence for the narrative review. Findings There are many types of subclinical seizures and pharmaceutical interventions. Seizures can be complex and early treatment is crucial to good outcomes. Conclusions This review is a narrative overview of sub-clinical seizures seen in the Neurocritical care unit. It is written for all practicing providers to describe the physiology, identification, and treatment of sub-clinical seizures to facilitate improved patient outcomes.

Creatinine Clearance in Acute Brain Injury: A Comparison of Methods.

Currently, the measurement of glomerular filtration rate is very complex and costly, so its daily evaluation is performed using endogenous markers, of which creatinine is the most frequently used. It allows the estimation of glomerular filtration rate by means of its clearance or by formulas based on its serum and urine concentration. Augmented renal clearance (ARC) is frequent among critically ill patients and is defined as creatinine clearance (CrCl) > 130ml/min/1.73 m2. The aim of this study was to compare measured CrCl (MCC) and estimated CrCl obtained with the Cockcroft-Gault formula (CG), the Modification of Diet in Renal Disease Study equation (MDRD), and the Chronic Kidney Disease Epidemiology Collaboration formula (CKD-EPI) in patients with severe traumatic brain injury and nontraumatic subarachnoid hemorrhage. The second aim was to assess the incidence of ARC in this population of neurocritical patients. This was a prospective, observational, single center study from a cohort of 74 patients admitted to the neurocritical intensive care unit due to traumatic brain injury or subarachnoid hemorrhage. Serum creatinine (at 7 a.m.) and a 6-h urine collection were analyzed, and CrCl was measured and estimated by using CG, MDRD, and CKD-EPI. The intraclass correlation coefficient (ICC) was evaluated for each pair, and Bland-Altman plots were used to assess clinical significance. Among 74 patients, the median age was 53 (interquartile range [IQR] 36-65), and the median Glasgow Coma Scale score at admission was 6. The median MCC at admission was 176 (IQR 135-214). The medians of CG, MDRD and CKD-EPI were, respectively, 129ml/min/1.73 m2(IQR 95-176), 158 (IQR 115-202), and 116 (97-132). An ICC was applied to evaluate the correlation between MCC and estimated methods and showed a weak correlation between MCC and estimated CrCl obtained with the three different methods. The strongest ICC statistical correlation was found between MCC and MDRD, and the weakest correlation was found between MCC and CKD-EPI. Bland-Altman plots showed that differences between each pair were not clinically acceptable. ARC was present in 78% of measurements, using MCC. A weak correlation was observed between MCC and calculated CrCl. CG, MDRD, and CKD-EPI overestimated MCC when MCC ≤ 130ml/min/1.73 m2 and underestimated it when MCC > 130ml/min/1.73 m2. In this population, there was a weak statistical correlation between measured and estimated methods. In patients with ARC, formulas underestimated MCC. MCC should probably be the preferred methodology for renal function assessment in the clinical setting to better adjust drug dosage and guarantee drug effectiveness.

Peritoneal dialysis and acute kidney injury in acute brain injury patients.

Acute kidney injury (AKI) is a heterogeneous syndrome with multiple etiologies. It occurs frequently in the neurocritical intensive care unit and is associated with greater morbidity and mortality. In this scenario, AKI alters the kidney-brain axis, exposing patients who receive habitual dialytic management to greater injury. Various therapies have been designed to mitigate this risk. Priority has been placed by KDIGO guidelines on the use of continuous over intermittent acute kidney replacement therapies (AKRT). On this background, continuous therapies have a pathophysiological rationale in patients with acute brain injury. A low-efficiency therapy such as PD and CRRT could achieve optimal clearance control and potentially reduce the risk of secondary brain injury. Therefore, this work will review the evidence on peritoneal dialysis as a continuous AKRT in neurocritical patients, describing its benefits and risks so it may be considered as an option when deciding among available therapeutic options.

Routine postoperative admission to the neurocritical intensive care unit after microvascular decompression: necessary or can it be abandoned?

Postoperative neurocritical intensive care unit (NICU) admission of patients who underwent craniotomy for close observation is common practice. In this study, we performed a comparative analysis to determine if there is a real need for NICU admission after microvascular decompression (MVD) for cranial nerve disorders or whether it may be abandoned. The present study evaluates a consecutive series of 236 MVD surgeries performed for treatment of trigeminal neuralgia (213), hemifacial spasm (17), vagoglossopharyngeal neuralgia (2), paroxysmal vertigo (2), and pulsatile tinnitus (2). All patients were operated by the senior surgeon according to a standard protocol over a period of 12years. Patients were admitted routinely to NICU during the first phase of the study (phase I), while in the second phase (phase II), only patients with specific indications would go to NICU. While 105 patients (44%) were admitted to NICU postoperatively (phase I), 131 patients (56%) returned to the ward after a short stay in a postanaesthesia care unit (PACU) (phase II). Specific indications for NICU admission in phase I were pneumothorax secondary to central venous catheter insertion (4 patients), AV block during surgery, low blood oxygen levels after extubation, and postoperative dysphagia and dysphonia (1 patient, respectively). There were no significant differences in the distribution of ASA scores or the presence of cardiac and pulmonary comorbidities like congestive heart failure, arterial hypertension, or chronic obstructive pulmonary disease between groups. There were no secondary referrals from PACU to NICU. Our study shows that routine admission of patients after eventless MVD to NICU does not provide additional value. NICU admission can be restricted to patients with specific indications. When MVD surgery is performed in experienced hands according to a standard anaesthesia protocol, clinical observation on a neurosurgical ward is sufficient to monitor the postoperative course. Such a policy results in substantial savings of costs and human resources.

Sustitución del tubo nasal/orotraqueal para reducir la duración de la ventilación mecánica en pacientes neurocríticos: análisis de emparejamiento por puntuación de propensión

Introduction and objectivesNasotracheal intubation was advocated to increase patients comfort and tube tolerance, but no study showed a clear benefit of nasotracheal intubation over orotracheal intubation. Neurocritically ill patients are a fragile group with specific requirements regarding ventilation and sedation.The aim of this study was to evaluate whether nasotracheal intubation might reduce length of mechanical ventilation in neurocritically ill patients. Materials and methodsWe conducted a retrospective cohort study with propensity matched analysis including all patients who underwent prolonged mechanical ventilation in the neurocritical Intensive Care Unit. ResultsA total of 4030 patients were admitted during the period of interest and 312 entered the final analysis. Propensity score analysis identified 74 matched couples. Length of mechanical ventilation in patients who underwent early nasotracheal intubation resulted to be statistically significantly shorter than patients who underwent orotracheal intubation. Accordingly, length of sedation was significantly lower in patients with nasotracheal intubation, while no difference in complications occurred with similar length of stay. ConclusionsIn critical care units using nasotracheal intubation in the standard management of patients, the nasotracheal route was associated with lesser need for sedatives leading to shorter mechanical ventilation in neurocritical patients. However, causality has to be proven by future randomized controlled trials.

Extensively drug-resistant and multidrug-resistant gram-negative pathogens in the neurocritical intensive care unit.

Abrupt increase of multidrug-resistant, extensively drug-resistant, and pandrug-resistant bacteria may complicate the course, management, and costs of neurocritical patients and is associated with high morbidity and mortality rates. No data exists regarding risk factors for colonization by gram-negative pathogens in neurocritical patients. The aim of the study was to identify risk factors associated with colonization by multidrug-resistant, extensively drug-resistant, and pandrug-resistant gram-negative bacteria in neurocritical patients. We conducted a retrospective cohort study in a neurointensive care unit over a period of 3years. We included adult neurocritical patients admitted for more than 48h. We analyzed several factors including both anamnestic factors and admission diagnosis. Four hundred twenty neurocritical patients were retrospectively enrolled. Seventy-three patients developed colonization by multidrug-resistant and 53 by extensively drug-resistant gram negative pathogens. Logistic regression identified intensive care unit length of stay (LOS) as the strongest predictor for both multidrug-resistant (AUC 0.877; 95% CI 0.841-0.913) and extensively drug-resistant (AUC 0.839 0.787-0.892) gram negative pathogens. In addition, external ventricular drainage and intracerebral pressure monitoring catheter were risk factors for XDR. Survival analysis revealed that MDR bacteria colonization happens earlier (log-rank test p= 0.017). Optimization of healthcare strategies is required in order to reduce patients' length of stay to prevent multi- and extensively-drug gram-negative colonizations. Indeed, an early external ventricular drainage and intracerebral pressure monitoring catheter removal is deemed necessary as soon as clinically appropriate.

Executive Summary: Post-Intensive Care Syndrome in the Neurocritical Intensive Care Unit.

ABSTRACTBackground: Post–intensive care syndrome (PICS) is a constellation of cognitive, physical, emotional, or psychiatric impairments that begins during or immediately after intensive care unit (ICU) hospitalization and persists beyond discharge. This executive review summarizes literature on PIC

Lateralized Periodic Discharges are Predictive of Seizures in Patients with Intracerebral Hemorrhage.

Background:Patients with intracerebral hemorrhages (ICHs) have higher incidence of seizures. Previous studies have suggested that location and size of hemorrhage may increase epileptogenicity. We aim to evaluate seizure development risk factors from clinical examination, imaging, and continuous electroencephalography (cEEG) in critically ill patients with ICH.Methods:We reviewed 57 consecutive patients with ICH admitted to a neurocritical intensive care unit over a 24-month period who were monitored on cEEG. Their demographic and examination data, ICH score, Glasgow Coma Scale (GCS), location of bleed, cEEG patterns, and discharge status were analyzed.Results:Sixteen (28%) patients from our study cohort had seizures at a mean duration of 7.46 h from cEEG hookup. Fifteen (93%) of those patients had only electrographic seizures. The finding of lateralized periodic discharges (LPDs) was significantly (P = 0.019) associated with seizures. Other variables, such as ICH score, size and location of hemorrhage, GCS, mental status, and other cEEG patterns, were not significantly associated with seizures.Conclusion:We found that LPDs were predictive of seizures in ICH patients. cEEG for longer than 24 h is preferred for detection of seizures as they occurred at a mean later than 7 h and most were without clinical signs.

Abstract TP395: Lateralized Periodic Discharges are Predictive of Seizures in Patients With Intracerebral Hemorrhage

Background: Patients with intracerebral hemorrhages (ICH) have a higher incidence of seizures. Previous studies have suggested that the location and size of hemorrhage may increase epileptogenicity. We aim to evaluate seizure development risk factors from clinical examination, imaging, and continuous electroencephalography (CEEG) in critically ill patients with ICH. Methods: We reviewed 57 consecutive patients with ICH admitted to a neurocritical intensive care unit over a 24-month period who were monitored on CEEG. Their demographic and examination data, ICH score, Glasgow coma scale (GCS), location of bleed, CEEG patterns, and discharge status were analyzed. Results: Sixteen (28%) patients from our study cohort had seizures at a mean duration of 7.46 hours from CEEG hookup. Fifteen (93%) of those patients had electrographic only seizures. The finding of lateralized periodic discharges (LPDs) was significantly (p=0.019) associated with seizures. Other variables, such as ICH score, size and location of hemorrhage, GCS, mental status, and other CEEG patterns, were not significantly associated with seizures. Conclusion: We found that LPDs were predictive of seizures in ICH patients. CEEG for longer than 24-hours is preferred for detection of seizures as they occurred at a mean later than seven hours and most were without clinical signs.

Evaluation of a novel noninvasive ICP monitoring device in patients undergoing invasive ICP monitoring: preliminary results.

OBJECTIVE There is no established method of noninvasive intracranial pressure (NI-ICP) monitoring that can serve as an alternative to the gold standards of invasive monitoring with external ventricular drainage or intraparenchymal monitoring. In this study a new method of NI-ICP monitoring performed using algorithms to determine ICP based on acoustic properties of the brain was applied in patients undergoing invasive ICP (I-ICP) monitoring, and the results were analyzed. METHODS In patients with traumatic brain injury and subarachnoid hemorrhage who were undergoing treatment in a neurocritical intensive care unit, the authors recorded ICP using the gold standard method of invasive external ventricular drainage or intraparenchymal monitoring. In addition, the authors simultaneously measured the ICP noninvasively with a device (the HS-1000) that uses advanced signal analysis algorithms for acoustic signals propagating through the cranium. To assess the accuracy of the NI-ICP method, data obtained using both I-ICP and NI-ICP monitoring methods were analyzed with MATLAB to determine the statistical significance of the differences between the ICP measurements obtained using NI-ICP and I-ICP monitoring. RESULTS Data were collected in 14 patients, yielding 2543 data points of continuous parallel ICP values in recordings obtained from I-ICP and NI-ICP. Each of the 2 methods yielded the same number of data points. For measurements at the ≥ 17-mm Hg cutoff, which was arbitrarily chosen for this preliminary analysis, the sensitivity and specificity for the NI-ICP monitoring were found to be 0.7541 and 0.8887, respectively. Linear regression analysis indicated that there was a strong positive relationship between the measurements. Differential pressure between NI-ICP and I-ICP was within ± 3 mm Hg in 63% of data-paired readings and within ± 5 mm Hg in 85% of data-paired readings. The receiver operating characteristic-area under the curve analysis revealed that the area under the curve was 0.895, corresponding to the overall performance of NI-ICP monitoring in comparison with I-ICP monitoring. CONCLUSIONS This study provides the first clinical data on the accuracy of the HS-1000 NI-ICP monitor, which uses advanced signal analysis algorithms to evaluate properties of acoustic signals traveling through the brain in patients undergoing I-ICP monitoring. The findings of this study highlight the capability of this NI-ICP device to accurately measure ICP noninvasively. Further studies should focus on clinical validation for elevated ICP values.

Postoperative Care of Patients with High-grade Glioma: Is There a Real Need for the Neurocritical ICU and Early CT Scan?

Pressure on economic resources now requires a careful rationalization of services. For adult patients with supratentorial gliomas, there is no consensus on the real need for care in a postoperative neurocritical intensive care unit (NICU) and on the timing of a postsurgical computed tomography (CT) scan. In this retrospective nonrandomized study, we assessed if and when there is a real need for NICU and if an early CT scan could be justified in the absence of neurologic worsening. Of 264 patients, 21 were admitted to the NICU after the procedure as planned before the surgery for their clinical features (Karnofsky performance status < 70, American Society of Anesthesiologists score > 2, or Charlson Comorbidity Index > 5). The mean stay in the NICU was 19.7 hours. One of these patients had developed a postoperative hematoma that was subsequently removed, and died afterward. The other 243 patients were followed clinically after the procedure: 219 underwent a cerebral CT scan 24 hours after the procedure and were discharged in good condition. The other 24 patients had a cerebral CT scan within 24 hours after the procedure. The early CT showed the presence of a local edema in five cases and a hematoma surgically treated with a subsequent admission to the NICU in two cases. Considering our data, we suggest that NICU should not always be used after craniotomy for supratentorial gliomas. Clinical observation was sufficient to predict early postoperative complications. A CT scan before 24 hours after surgery is not recommended in the absence of clinical worsening.

Incidence and Prevalence of Deep Vein Thrombosis Among Neurocritical Intensive Care Unit Patients

Incidence and Prevalence of Deep Vein Thrombosis Among Neurocritical Intensive Care Unit Patients

Nutrition in the neurocritical care unit

AbstractThe aim of intensive care is to support the physiology of the body till the treatment or the reparative process of the body kicks in to the rescue. Maintaining an adequate nutrition during this period is of vital importance to counteract the catabolic effect of the critical disease process. The guidelines for nutritional care in the neuro intensive care unit (ICU) are sparse. This article collates the current evidence and best practice recommendations as applicable to the critically ill patient in the neuro ICU. The use of screening tests to identify patients at a risk of malnutrition and related complications is presently recommended for all patients with an emphasis on early initiation of caloric support. Over-aggressive feeding in an attempt to revert the catabolic effects of critical illness have not proven beneficial, just as the attempts to improve patient outcomes by altering the routes of nutrition administration. Special patient population such as traumatic brain injury, stroke, subarachnoid haemorrhage or spinal cord injury may have varying nutritional requirements; individualised approach in the neurocritical ICU with the help of the intensivist, nutritionist and pharmacology team may be of benefit.

P17.26 * IS NICU MANDATORY AFTER SURGERY IN ADULT HGG? A SINGLE CENTER EXPERIENCE

Surgery in high grade gliomas (HGG) is often related to peri-operative complications, that may require neurocritical intensive care unit (NICU) admittance. Actually there is no consensus whether there is real need for NICU for this patients; often the possibility is related to surgeon preferences. In literature there are still little data on clinical parameters associated with long-term outcome after neurocritical care. We retrospectively analyzed 175 patients, that underwent surgical resection for HGG in our division; 15 of which needed NICU admittance after surgery. We compare this group with a homogeneous control group of 15 patients that did not need NICU after surgery. Statistical analysis (p value set at 0.05) did not show any statistical difference between the two groups and we suggest that NICU should not always be used after craniotomy for supratentorial HGG.

PS-060 Use of venous thromboprophylaxis in critical illness in a traumatic intensive care unit (ICU)

BackgroundVenous thromboembolism (VTE) is a common and potentially lethal complication from hospitalisation. Critically ill patients have multiple risk factors for VTE such as prolonged immobility, use of central venous catheters,...

Development of Contrast-Induced Nephropathy in Subarachnoid Hemorrhage: a Single Center Perspective

The use of iodinated contrast-enhanced imaging studies is increasing in acute cerebrovascular diseases, especially in subarachnoid hemorrhage (SAH). In SAH, such studies are essential for both diagnosis and treatment of the cause and sequela of hemorrhage. These patients are often subjected to multiple contrast studies such as computed tomographic angiography, computed tomographic perfusion, and cerebral angiography. They are also predisposed to intravascular volume depletion as a part of the disease process from cerebral salt wasting (CSW) and as a result of multiple contrast exposure can develop contrast-induced nephropathy (CIN). Data regarding CIN in this population are scarce. We aimed to examine the incidence of CIN in SAH and identify potential associative risk factors. We analyzed data from a prospectively collected patient database of patients with SAH admitted to the neurocritical intensive care unit in a single center over a period of 1 year. CIN was defined as an increase in serum creatinine by >1.5 times or >0.3 mg/dl greater than the admission value, or urine output <0.5 ml/kg/h during one 6-h block. In this cohort of 75 patients with SAH who had undergone at least one contrast study, the mean age was 57.3 ± 15.6 years and 70.7% were women. Four percent developed CIN which resolved within 72 h and none required renal replacement therapy or dialysis. Patients older than 75 years (20%, p < 0.05), those with borderline renal function (14.3%, p = 0.26), diabetics (11.1%, p = 0.32), and those with lower recommended "maximum contrast dose" volume (33.3%, p = 0.12) had a trend toward development of CIN, although most were not statistically significant. Twenty-seven patients (36 %) were on 3% hypertonic saline (HTS) for CSW during the contrasted study but none developed CIN. The incidence of CIN in SAH patients is comparable to previously published reports on non-neurological cohorts. No definite association was noted with any predisposing factors postulated to be responsible for CIN, except for advanced age. Concurrent use of 3% HTS was not associated with CIN in this population.

Prestação de terapia intensiva: um problema global

1. Critical Care Medicine, St George’s Healthcare NHS Trust and St George’s, University of London, UK. 2. Neurocritical Intensive Care Unit, Hospital de Sao Jose, Centro Hospitalar de Lisboa Central, E.P.E. Lisboa, Portugal. Recently, many countries have described a growing gap between the supply and the demand of intensivists and the consequent capability of the country to provide adequate intensive care.(1,2) This gap is mainly driven by the increasing population size of many nations, together with the recognition that life expectancy is increasing in tandem with the proliferation of the socalled “civilisation” diseases, such as diabetes, coronary heart disease, stroke and obesity. These aged groups of patients, who have (or will have) significant comorbid diseases, are the very population that present to intensive care medicine in North America and in most European countries; often being admitted to the hospital because of an acute illness or a complication after major elective surgery.(3) The proper use of intensive care medicine can save a significant number of these patients and may enable them to return to an active life; however, these efforts will also consume a great deal of resources for a group of patients who may not benefit. Unless this increased demand for beds is appropriately managed, there will be problems, as a skilled and trained staff will not have been identified and be available. Consequently, healthcare providers will need to either provide intensive care using untrained and unqualified staff, or they will need to change to a model of providing intensive care that uses professional groups with delegated competency from physicians working according to protocols and guidelines. Either option will permit these healthcare providers to operate with limited understanding of their work and the available treatment alternatives for any specific patient. The first step towards planning for a change (in this case, an increase in the provided services) is to understand what is currently provided. Unfortunately, this understanding is rarely present and needs to be urgently addressed. Recent studies assessing the provision of intensive care between countries and the surgical outcomes provide interesting insights into this issue.(4-6) Most of these studies have been designed to look at European populations; however, many of the salient factors present in Europe likely exist in Brazil, and the lessons derived from these studies are equally relevant. If intensive care bed numbers are restricted either formally or informallypatient selection must occur; this practice is commonly referred to as rationing.(7) When intensive care is not available, services react in different manners, including the early or premature discharge of patients already in the service, delayed admission of presenting patients, changing thresholds for the withdrawal of care, cancellation of elective patients who are planned to be admitted after routine surgery or restriction of admission to certain patient Conflicts of interest: None.

Hemodinámica cerebral en pacientes con traumatismo craneoencefálico evaluada por doppler transcraneal y duplex transcraneal con codificación en color: Estudio comparativo

To compare the number of vessels identified and mean velocity and pulsatility index values obtained by transcranial doppler (TCD) and transcranial color coded sonography (TCCS) in patients with traumatic brain injury (TBI). Thirty patients suffering from TBI admitted in our neurocritical Intensive Care Unit (ICU) were studied. We performed consecutive studies by TCD and TCCS. The number of Circle of Willis vessels insonated and the hemodynamic parameters were compared. Mean age was 50 years. Twenty patients were male. By using TCCS, internal carotid artery was insonated in 95%, middle cerebral artery (MCA) in 95%, anterior cerebral artery (ACA) in 91% and posterior cerebral artery (PCA) in 92% of the studies. Using conventional TCD they were insonated in 29%, 93% 67% and 35% of the studies respectively. Mean velocity values measured by CCS and TCD in MCA were 79 cm/sec vs 59 cm/sec respectively (p< 0.0001), in ACA were 61 cm/sec vs 42 cm/sec (p< 0.0001) and in PCA were 43 cm/sec vs 33 cm/sec (p< 0.0001). TCCS allows a high quality hemodynamic study of TBI patients admitted to the ICU. Further studies must define its impact on outcome of TBI patients.

What to do when a patient refuses evidence-based treatment: An ethical dilemma

Ethical dilemmas are posed when patients do not agree or comply with health professionals' advice. This case study discusses the ethical dilemma and values which emerged following a patient's refusal to follow safe swallowing advice in a neuro-critical intensive care unit. Central to this dilemma are the principles of informed refusal of care (involving autonomy and patients' preferences) and the professional's desire to protect the patient from harm. In the environment of a neuro-critical intensive care unit, expressing a beneficent paternalism may enable the health professional to tie all the loose ends of a complex case where different principles clamour to be heard. Complex ethical dilemmas in neurorehabilitation require communication, discussion and reflection on ethical theories and principles.