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Erdman M.J.,University of Florida | Doepker B.A.,Ohio State University | Gerlach A.T.,Ohio State University | Phillips G.S.,Ohio State University | And 4 more authors.
Critical Care Medicine | Year: 2014

OBJECTIVE:: Dexmedetomidine and propofol are commonly used sedatives in neurocritical care as they allow for frequent neurologic examinations. However, both agents are associated with significant hemodynamic side effects. The primary objective of this study is to compare the prevalence of severe hemodynamic effects in neurocritical care patients receiving dexmedetomidine and propofol. DESIGN:: Multicenter, retrospective, propensity-matched cohort study. SETTING:: Neurocritical care units at two academic medical centers with dedicated neurocritical care teams and board-certified neurointensivists. PATIENTS:: Neurocritical care patients admitted between July 2009 and September 2012 were evaluated and then matched 1:1 based on propensity scoring of baseline characteristics. INTERVENTIONS:: Continuous sedation with dexmedetomidine or propofol. MEASUREMENTS AND MAIN RESULTS:: A total of 342 patients (105 dexmedetomidine and 237 propofol) were included in the analysis, with 190 matched (95 in each group) by propensity score. The primary outcome of this study was a composite of severe hypotension (mean arterial pressure < 60 mm Hg) and bradycardia (heart rate < 50 beats/min) during sedative infusion. No difference in the primary composite outcome in both the unmatched (30% vs 30%, p = 0.94) or matched cohorts (28% vs 34%, p = 0.35) could be found. When analyzed separately, no differences could be found in the prevalence of severe hypotension or bradycardia in either the unmatched or matched cohorts. CONCLUSIONS:: Severe hypotension and bradycardia occur at similar prevalence in neurocritical care patients who receive dexmedetomidine or propofol. Providers should similarly consider the likelihood of hypotension or bradycardia before starting either sedative. © 2014 by the Society of Critical Care Medicine.

Taylor D.R.,University of Tennessee Health Science Center | Weaver J.A.,Semmes Murphey Neurologic and Spine Institute
Journal of Neurosurgery: Spine | Year: 2015

Radiosurgery for primary and metastatic tumors of the central nervous system is increasing in utility and intensity. Known complications in the brain include radiation necrosis and the well-documented phenomenon of pseudoprogression. Known complications of radiosurgery to spinal column tumors include radiation myelopathy and delayed vertebral compression fractures; however, the concept of pseudoprogression of spinal column tumors has not been previously described. The authors review 2 cases of spinal metastasis treated with stereotactic radiosurgery (SRS) and attempt to define the concept of spine tumor pseudoprogression. Two patients who had undergone SRS to the spine for metastatic disease presented in early follow-up (3 and 7 weeks) with symptomatic complaints consisting of axial pain, radicular pain, or evidence of cord compression. In both patients, MRI revealed evidence of tumor enlargement. In one patient, the lesion had grown by 9 mm and 7.7 mm in the axial and sagittal planes, respectively. In the other patient, the tumor growth resulted in a 5-mm decrease in spinal canal diameter with epidural compression and right foraminal encroachment. Because of the absence of progressive neurological deficit, myelopathy, mechanical symptomatology of instability, or vertebral compression fracture, the first patient was treated expectantly with a corticosteroid taper and had improvement of symptoms at 1 month and near-total radiographic resolution of the tumor. In the second patient, worsening symptoms suggested a need for surgical intervention to address presumed radiosurgical failure and tumor progression. During surgery, only necrotic tumor cells were observed, without viable tumor. Follow-up imaging over 1 year showed ongoing local control. To their knowledge, the authors report the first description of pseudoprogression involving spinal column metastasis in the literature and aim to alert the treating physician to this clinical situation. Unlike brain tumor pseudoprogression, spine tumor pseudoprogression is a relatively early posttreatment phenomenon, measured in days to 2 months. The authors believe that the acute inflammatory response associated with tumor necrosis and disruption of the tumor capillary integrity caused by radiotherapy is an important component in the development of pseudoprogression. Future studies will be fundamental in assigning clinical significance, defining the incidence and predictors, and affecting future management of this phenomenon. ©AANS, 2015.

Aquilina K.,Frenchay Hospital | Boop F.A.,Semmes Murphey Neurologic and Spine Institute
Journal of Neurosurgery: Pediatrics | Year: 2011

Primary neoplasms of the pituitary gland are uncommon in children. Physiological enlargement of the gland, however, is universal and can sometimes be confused with a tumor. Due to widespread availability of MR imaging, the number of children referred to pediatric neurosurgeons with an enlarged pituitary associated with nonspecific symptoms, most commonly headache, is increasing. In this review, the authors illustrate two common causes of pituitary enlargement in children, namely physiological hypertrophy of puberty, more commonly seen in females, and secondary hyperplasia caused by hypothyroidism. The importance of early and accurate diagnosis, without recourse to extensive endocrine investigations or inappropriate surgery, is underscored. ©1944-2011 by the American Association of Neurosurgeons.

DeCuypere M.,University of Tennessee Health Science Center | Klimo P.,University of Tennessee Health Science Center | Klimo P.,Semmes Murphey Neurologic and Spine Institute
Surgical Clinics of North America | Year: 2012

Traumatic brain injury (TBI) involves significant damage of the brain parenchyma, and is the leading cause of morbidity and mortality after trauma. It is thus essential for all physicians involved in acute care medicine and surgery to have a thorough understanding of TBI. Management of the patient with TBI is a rapidly advancing field, characterized by an improved understanding of intracranial pathophysiology and decreasing overall mortality largely because of improved neurocritical and surgical care. This article summarizes the classification system, management approaches, and recent controversies in the care of mild, moderate, and severe TBI. © 2012 Elsevier Inc.

Young J.C.,Memphis Veterans Affairs Medical Center | Sawyer R.J.,Memphis Veterans Affairs Medical Center | Roper B.L.,Memphis Veterans Affairs Medical Center | Baughman B.C.,Semmes Murphey Neurologic and Spine Institute
Clinical Neuropsychologist | Year: 2012

The Digit Span subtest was significantly revised for the WAIS-IV as an ordinal sequencing trial was added to increase working memory demands. The present investigation sought to validate an expanded version of Reliable Digit Span (RDS-R) as well as age-corrected scaled score (ACSS) from the recently revised Digit Span. Archival data were collected from 259 veterans completing the WAIS-IV Digit Span subtest and Word Memory Test (WMT). Veterans failing the WMT performed significantly worse (p<.001) on the ACSS, RDS-R, and traditional RDS. Operational characteristics of the ACSS, RDS-R, and RDS were essentially equivalent; however, sensitivity was quite modest when selecting cutoffs with strong specificity. While current results suggest that Digit Span effort indices can contribute to the detection of suboptimal effort, additional symptom validity indicators should be employed to compensate for limited sensitivity. © 2012 Copyright Taylor and Francis Group, LLC.

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