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Nitric Oxide Synthase Inhibitors in Traumatic Brain Injury

Introduction Since the identification of the gas nitric oxide (NO) as the endothelial-derived relaxing factor, NO has increasingly been recognized as being involved in numerous physiological and pathophysiological processes, in particular those related to inflammation and blood flow. NO can be synthetized by three isoforms of nitric oxide synthase (NOS): nNOS (neuronal NOS) and eNOS (endothelial NOS), which are both constitutive, Ca 2+ -dependent enzymes, and…

Perispinal Etanercept for Traumatic Brain Injury

Background Introduction Traumatic brain injury (TBI) is a leading cause of disability throughout the world ( ). An estimated 3.2–5.3 million Americans (1.1–1.7%) live with long-term mental and/or physical impairments as a result of TBIs ( ). Due to an increase in patients surviving a TBI, it is imperative for novel treatments and therapies to be tested and used for this vulnerable population. Traumatic brain injuries…

The Application of Glibenclamide in Traumatic Brain Injury

Acknowledgments The work in this chapter was supported in part by grants to J. Marc Simard from the Department of Veterans Affairs (Baltimore, MD), the Department of the Army (W81XWH 1010898), the National Heart, Lung and Blood Institute (HL082517), and the National Institute of Neurological Disorders and Stroke (NINDS) (NS061808 and NS060801), as well as to Howard Eisenberg from the Department of Defense (Research Subaward Agreement…

Atorvastatin in the Treatment of Traumatic Brain Injury

Introduction Statins are a widely used class of medications which are inhibitory analogs of the enzyme β-hydroxy-β-methylglutaryl coenzyme A (HMG CoA) reductase. While very extensively used for treatment of hyperlipidemia and in the prevention of cardiovascular disease, their application to traumatic brain injury as neuroprotective agents attenuating secondary neurological injury is still limited. In this chapter, we will review current understanding of the role of statins…

Erythropoietin and Its Derivatives: Mechanisms of Neuroprotection and Challenges in Clinical Translation

Acknowledgments This work was supported by Henry Jackson Foundation Award Number: 306135-7.01-60855 (USU Site No. G192JI), by the Center for Neuroscience and Regenerative Medicine at the Uniformed Services University of the Health Sciences, and by the National Institutes of Health, National Institute of Neurological Disorders and Stroke, Intramural Research Program. Neurodegeneration and Neurogenesis After Traumatic Brain Injury The pathophysiologic damage that results from traumatic brain injury…

Hypothermia for Traumatic Brain Injury: Current Evidence and Future Directions

Introduction Therapeutic hypothermia—the intentional lowering of temperature in an attempt to mitigate injurious processes—has undergone several life cycles in medical practice. Interest in hypothermia may have first been introduced into medical practice from reports centuries ago suggesting that injured soldiers may survive when kept away from heat sources. More recently, neurological protection has been observed in people who have suffered prolonged cardiac arrests while under ice-cold…

Why Did the Phase III Clinical Trials for Progesterone in TBI Fail? An Analysis of Three Potentially Critical Factors

Acknowledgments With thanks to Leslie McCann for her unflagging patience in the editing of the manuscript. And with great appreciation for all of those laboratory scientists who have dedicated so much effort to finding a safe and effective treatment for TBI. Disclosure This paper discusses some concepts presented in other papers by the authors. Although DGS, IS, and Emory University hold patents on the use of…

Lumbar Puncture And Lumbar Drain Placement

Indications A lumbar puncture (LP) is indicated for both diagnostic and therapeutic purposes. It is used to sample the cerebrospinal fluid (CSF) to aid in the diagnosis of infectious, inflammatory, hemorrhagic, and oncologic conditions. An urgent LP is indicated to aid in the diagnosis of meningitis/encephalitis and of suspected subarachnoid hemorrhage in a patient with a negative head computed tomography (CT) scan. Therapeutic indications include the…

External Ventricular Drain

Indications and Contraindications The placement of an external ventricular drain (EVD) is a very common neurosurgical bedside procedure. EVDs are commonly placed to manage hydrocephalus and monitor intracranial pressure (ICP) in a wide variety of pathologies. Despite their widespread use, recommendations on EVD placement and management are based on low-quality data. Several available guidelines include: Brain Trauma Foundation, , American Heart and Stroke Associations, and combined…

Intracranial Pressure Monitor

Indications and Contraindications Intracranial pressure (ICP) monitors directly measure ICPs in the epidural, subdural, intraparenchymal, or intraventricular space. Although they do not allow for direct cerebrospinal fluid (CSF) drainage, unlike external ventricular drains (EVD), ICP monitors are associated with fewer complications (e.g. hemorrhage, ventriculitis), and may be preferred in cases of ventricular displacement or effacement following traumatic brain injury. The different types of ICP monitors include…

Shunt Tap

Indications and Contraindications A shunt tap has both diagnostic and therapeutic purposes. Two commonly encountered reasons to tap a shunt include determining if there is proper flow of cerebrospinal fluid (CSF) within the shunt and sampling the CSF for diagnostic studies. A shunt reservoir may also be accessed to inject a radiotracer for shunt patency studies. Contraindications to a shunt tap include bacteremia, scalp infection overlying…

Change In Exam After Brain Tumor Biopsy

Consult Page Hi there, for room 21, patient seems sleepier, please come evaluate him. Initial Imaging None Walking Thoughts π Why is the patient admitted? Did the patient have surgery and if so, what type of surgery and when did it occur? π Where is the patient currently located (e.g. floor vs. neurocritical care unit)? π If applicable, what was the patient’s immediate postoperative exam? Are…

Hemiparesis With A Previously Treated Arteriovenous Malformation

Consult Page Pt w known AVM, here with weakness. Initial Imaging Walking Thoughts ▪ How weak is the patient? Where is the patient’s weakness? How long has he been symptomatic? ▪ Does the patient have any other deficits on examination? ▪ What is the patient’s arteriovenous malformation (AVM) history? Has he had any prior hemorrhages or treatments? ▪ Did the AVM hemorrhage? You’re Reading a Preview…

Leakage From Spinal Incision With Headaches

Consult Page 55F s/p spine surgery with leakage from wound and headaches Initial Imaging Walking Thoughts ■ What surgery did the patient have? When was the patient’s surgery? ■ Were there any complications? Was there a durotomy or a cerebrospinal fluid (CSF) leak noted during surgery? ■ What was her postoperative course? When and where did she discharge to? ■ What is the patient’s baseline neurological…

Incisional Swelling And Drainage After Spine Surgery

Consult Page 61F h/o prior lumbar spine surgery here with drainage from incision Initial Imaging Walking Thoughts ▪ What was the patient’s prior surgery? When was the surgery? ▪ Is there hardware present? ▪ How was the patient’s postoperative course? ▪ What does the patient’s incision look like (e.g. erythema, swelling) and is there any drainage? ▪ If there is drainage, what does it look like?…

Drainage From Cranial Incision

Consult Page 47F with recent brain surgery presenting with drainage from wound Initial Imaging Walking Thoughts ▪ What was the patient’s prior surgery? When was the surgery? ▪ How was the patient’s postoperative course? ▪ How long has the patient had drainage from the incision? ▪ Is there wound dehiscence? If so, is it deep or superficial? ▪ What does the drainage look like (e.g. purulent…

Postoperative Leg Weakness, Numbness, And Urinary Incontinence

Consult Page 58M acute BLE weakness and urinary incontinence, postop neurosurgery patient Initial Imaging Walking Thoughts ▪ What surgery did the patient have? When was the patient’s surgery? ▪ Were there any complications or concerns from the prior operation? ▪ What was his postoperative course? When and where did he discharge? ▪ What is the patient’s baseline neurological function, and what was his function after surgery?…

Postoperative Lethargy And Left Sided Weakness After Craniotomy

Consult Page Postop patient with lethargy and left sided weakness, please come assess. Initial Imaging None Walking Thoughts ■ What surgery did the patient have? When did the surgery occur? ■ Where is the patient currently located (e.g. floor vs. neurocritical care unit)? ■ What was the patient’s immediate postoperative exam? Are these symptoms new or expected? ■ What is the patient’s current neurological examination? ■…

Right Arm Swelling After Surgery

Consult Page 30F with recent spine surgery, here with right arm swelling Initial Imaging None Walking Thoughts ■ What surgery did she have? How long ago was her surgery? ■ What was her postoperative course? When and where did she discharge? ■ What is her level of mobility? ■ What are the patient’s current vital signs? Is she hemodynamically stable? ■ What is the mechanism and…