Wijdicks, Eelco F. M.

Background Resuming anticoagulation in patients with mechanical heart valves after intracranial hemorrhage presents a clinical dilemma. The optimal timing must balance the risk of thromboembolism against hemorrhagic expansion. Prior studies have addressed this issue, but most were limited by small sample sizes. This systematic review and meta‐analysis aimed to determine the optimal timing for anticoagulation resumption in this population. Methods We conducted a systematic review and meta‐analysis using PubMed, Embase, Web of Science, and Scopus from database inception to August 23, 2024. The target population included adults with intracranial hemorrhage who required anticoagulation for mechanical heart valves. Results Thirteen studies involving 788 patients were included: 12 retrospective and 1 prospective observational study. While off anticoagulation, 32 patients developed ischemic stroke, with a pooled event rate of 5.23% (95% CI, 3.80–7.20%) and negligible heterogeneity ( I 2 = 0%). The pooled average time to stroke was 8.08 days (95% CI, 1.99–14.18). After anticoagulation resumption, 73 patients experienced hemorrhagic recurrence, corresponding to a pooled event rate of 10.95%, with nonsignificant heterogeneity ( I 2 = 40.4%). Conclusions Withholding anticoagulation for up to 7 days after intracranial hemorrhage in patients with mechanical heart valves appears relatively safe. Hemorrhagic recurrence after resumption was more common than ischemic stroke during interruption. However, the included studies were observational and carried serious or critical risk of bias. Prospective multicenter studies, and ideally randomized trials, are needed to provide more definitive evidence.

Neurological conditions associated with air entry into the systemic circulation are rare, particularly when compared with other particles. Patients present with an acute decline in the level of consciousness and new focal neurological deficits, often including new hemiparesis. A single seizure may also be a heralding sign. Patients may progress to deep coma. The first line of action, before anything else, is (1) the immediate positioning of the patient in Trendelenburg and in left lateral decubitus; (2) giving oxygen using a closed face mask (10–15 L/min) or high-flow nasal cannulae (up to 60 L/min). We recommend hyperbaric oxygen therapy if facilities can be reached within an 8-hour window. Awakening from coma, improvement of hemiparesis and good functional outcome may occur, but progress is likely to be slow and protracted. The emphasis of this review is on the recognition, immediate and subsequent treatment of air embolism to the brain.

Abstract Background Fever and worsening rigidity in Parkinson's disease (PD) may resemble neuroleptic malignant syndrome (NMS). We examined PD patients diagnosed with NMS—regardless of whether diagnostic criteria were used—to establish the clinical characteristics and etiology. Cases Among 15 cases, 40% (6/15) required ICU admission, 27% (4/15) required mechanical ventilation, 80% (12/15) recovered, and 20% (3/15) died. 27% (4/15) had a reduction in carbidopa‐levodopa as the primary trigger, 27% (4/15) had sepsis in addition to concurrent reductions in carbidopa‐levodopa, 7% (1/15) had sepsis alone, 33% (5/15) were exposed to new or increased antidopaminergic drugs, and 7% (1/15) had deep brain stimulator (DBS) malfunction. Literature Review Several terms to describe exacerbation of parkinsonism including NMS‐like state and parkinsonism hyperpyrexia syndrome (PHS) have been proposed over the years but may be restrictive in their definitions and confounders exist. Conclusions Acute parkinsonism dopamine depletion syndrome (APDDS) might be a more encompassing term to describe to an acute exacerbation of preexisting parkinsonism resulting from recent reduction in dopaminergic or other Parkinson's therapy (eg, DBS failure), or exposure to antidopaminergics. Symptoms include increased rigidity, encephalopathy, hyperthermia, or autonomic instability. Sepsis is a frequent confounder and may be associated with concurrent reduction or discontinuation of carbidopa‐levodopa.

An elderly woman presented with coma secondary to acute-on-chronic liver failure and was found to have severe hyperammonaemia. MR scan of brain showed extensive bilateral and symmetric cortical and thalamic fluid-attenuated inversion recovery hyperintense signals and diffusion restriction. How should clinicians address the prognosis of such cases? Postmortem findings from this case provide new insights in pathophysiology.

Abstract This single authored textbook serves as a comprehensive guide to manage all aspects of critically ill neurologic patients. The book is richly illustrated and with a succinct text closely edited for relevance. It accurately describes the immediacy and rapid-fire decisions that comprise the work life and environment of the neurointensivist. The Practice of Emergency and Critical Care Neurology follows patients from the very moment they enter the emergency department—where the neurologist makes on-the-spot decisions—to their admission to the neurologic intensive care unit—where mostly specialists in the neurosciences assume full responsibility for patient care. This book differs from conventional textbooks by specifically following the time course of clinical complexities as they emerge and change. Great emphasis is placed on management of unstable and deteriorating patients.

Abstract A collection of patients are seen in the neurointensive care unit and other medical and surgical intensive care units. Diagnosis, neuroimaging, and management in acute conditions are discussed in detail. In this new edition, we place more emphasis on how diagnostic and management decisions can go awry. When pertinent, we discuss new care paradigms, the latest support modalities, and new therapies, interventions, and technologies, but the main purpose is to convey a sense of what our specialty is all about. The book is useful for all health care professionals, essential material for learners and fellows in intensive care specialties and informational for staff attending physicians and hospitalists.