Intracranial treatment

Cbnvulsions, steroid-induced catatonia, increased intracranial pressure with papilledema (usually after treatment is discontinued), vertigo, headache, neuritis or paresthesia, steroid psychosis, insomnia... 

Ehtesham M, Kabos P, Kabosova A, Neuman T, Black KL, Yu JS (2002b) The use of interleukin 12-secreting neural stem cells for the treatment of intracranial glioma. Cancer Res 62 5657-5663... 

The clinical role of permeability imaging has yet to be assessed by a large clinical trial, but these techniques continue to hold promise for the future, as intracranial hemorrhage is the most significant potential complication of what is currently the only FDA-approved treatment for acute stroke. 

OR 1.81, 95% Cl 1.46-2.24), most of which were related to symptomatic intracranial hemorrhage (OR 3.37, 95% Cl 2.68. 22). In addition, a pooled analysis of six major randomized placebo-controlled IV rt-PA stroke trials (Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke (ATLANTIS) I and II, European Cooperative Acute Stroke Study (ECASS) I and II, and NINDS I and II), including 2775 patients who were treated with IV rt-PA or placebo within 360 minutes of stroke onset, confirmed the beneht up to 3 hours and suggested a potential beneht beyond 3 hours for some patients. The pattern of a decreasing chance of a favorable 3-month outcome as the time interval from stroke onset to start of treatment increased was consistent with the findings of the original NINDS study. ... 

Internal Carotid Artery Occlusion Acute stroke due to a distal ICA T (T = terminus) occlusion carry a much worse prognosis than MCA occlusions. In a recent analysis of 24 consecutive patients (median NIHSS 19) presenting with T occlusions of the ICA who were treated by lAT using urokinase at an average of 237 minutes from symptom onset, only four patients (16.6%) had a favorable outcome at 3 months. Partial recanalization of the intracranial ICA was achieved in 15 (63%), of the MCA in 4 (17%), and of the ACA in 8 patients (33%). Complete recanalization did not occur. The presence of good leptomeningeal collaterals and age <60 years were the only predictors of a favorable clinical outcome. New treatment strategies, such as the combination of IV rt-PA and lAT, or the use of new mechanical devices may improve the outcome in these patients. 

Henkes H, Miloslavski E, Lowens S, Reinartz J, Liebig T, Kuhne D. Treatment of intracranial atherosclerotic stenoses with balloon dilatation and self-expanding stent deployment (WingSpan). Neuroradiology 2005 47 222-228. 

Wylie EJ, Hein ME, Adams JE. Intracranial hemorrhage following surgical revascularization for treatment of acute strokes. J Neurosurg 1964 21 212-215. 

Urgent anticoagulation is not recommended for treatment of patients with moderate-to-severe stroke because of a high risk of serious intracranial bleeding complications (grade A). 

Suarez JI, Qureshi AI, Bhardwaj A, Williams MA, Schnitzer MS, Mirski M, Hanley DF, Ulatowski JA. Treatment of refractory intracranial hypertension with 23.4% saline. Crit Care Med 1998 26(6) 1118-1122. 

Qureshi A, Suarez JI. Use of hypertonic saline solutions in treatment of cerebral edema and intracranial hypertension. Crit Care Med 2000 28(9) 3301-3313. 

Doses and contraindications to glycoprotein Ilb/IIIa receptor blockers are described in Table 5-2. Major bleeding and rates of transfusion are increased with administration of a glycoprotein Ilb/IIIa receptor inhibitor in combination with aspirin and an anticoagulant,30 but there is no increased risk of intracranial hemorrhage in the absence of concomitant fibrinolytic treatment. The risk of thrombocytopenia with tirofiban and eptifibatide appears lower than that with abciximab. Bleeding risks appear similar between agents. 

Acute complications of stroke include cerebral edema, increased intracranial pressure, seizures, and hemorrhagic conversion. In the acute setting, several supportive interventions and treatments to prevent acute complications should be initiated. 

Evidence of intracranial hemorrhage on Cl scan of the brain prior to treatment... 

Children treated with GH replacement therapy rarely experience significant adverse effects, whereas adults are more susceptible to dose-related adverse effects. Treatment with GH may mask underlying hypothyroidism. GH-induced symptoms, such as edema, arthralgia, myalgia, and carpal tunnel syndrome, are common and necessitate dose reductions in up to 40% of adults. Benign increases in intracranial pressure may occur with GH therapy and generally are reversible with discontinuation of treatment. Often, GH therapy can be restarted with smaller doses without symptom recurrence. 

The treatment of ITP is determined by the symptom severity (Table 64-9). In some cases, no therapy is needed. The initial treatment of children with ITP is controversial because more than 70% of cases resolve spontaneously irrespective of pharmacologic intervention. Currently, therapy is indicated in children with platelet counts less than 10,000 to 20,000/mm3 (10-20 x 103/ j,L or 10-20 x 109/L) because most intracranial hemorrhages occur when platelets are in this range.32... 

Acute neurologic events, such as stroke, will require hospitalization and close monitoring. Patients should have physical and neurologic examinations every 2 hours.27 Acute treatment may include exchange transfusion or simple transfusion to maintain hemoglobin at around 10 g/dL (100 g/L or 6.2 mmol/L) and HbS concentration at less than 30%. Patients with a history of seizure may need anticonvulsants, and interventions for increased intracranial pressure should be initiated if necessary. Children with a history of stroke should be initiated on chronic transfusion therapy. Adults presenting with ischemic stroke should be considered for thrombolytic therapy if it has been less than 3 hours since the onset of symptoms.6,27... 

Radiation therapy is the treatment of choice for chemotherapy-resistant tumors such as non-small cell lung cancer (NSCLC) or in chemotherapy-refractory patients with SVCS. Between 70% and 90% of patients will experience relief of symptoms. Radiation therapy also may be combined with chemotherapy for chemotherapy-sensitive tumors such as SCLC and lymphoma. In the rare emergency situations of airway obstruction or elevated intracranial pressure, empirical radiotherapy prior to tissue diagnosis should be used. In most patients, symptoms resolve within 1 to 3 weeks. 

The answer is c (HardmanT pp 695-697.) Mannitol increases serum osmolarity and therefore pulls water out of cells, cerebrospinal fluid (C5F), and aqueous humor. This effect can be useful in the treatment of elevated intraocular or intracranial pressure. However, by expanding the intravascular volume, mannitol can exacerbate CHF... 

Patients with acute stroke should be monitored intensely for the development of neurologic worsening, complications, and adverse effects from treatments. The most common reasons for clinical deterioration in stroke patients are (1) extension of the original lesion in the brain (2) development of cerebral edema and raised intracranial pressure (3) hypertensive emergency (4) infection (e.g., urinary and respiratory tract) (5) venous thromboembolism (6) electrolyte abnormalities and rhythm disturbances and (7) recurrent stroke. The approach to monitoring stroke patients is summarized in Table 13-3. 

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