Mohamed Srairi

Successful treatment of inverted Takotsubo cardiomyopathy after severe traumatic brain injury with milrinone after dobutamine failure

BACKGROUND Takotsubo cardiomyopathy can occur at the early phase of severe acute brain injuries. In the case of cardiac output decrease or shock, the optimal treatment is still a matter of debate. Due to massive stress hormone release, the infusion of catecholamines may have limited effects and may even aggravate cardiac failure. Other inotropic agents may be an option. Levosimendan has been shown to have potential beneficial effects in this setting, although milrinone has not been studied. METHODS We report a case of a young female presenting with inverted Takotsubo cardiomyopathy syndrome after severe traumatic brain injury. RESULTS Due to hemodynamic instability and increasing levels of infused norepinephrine, dobutamine infusion was begun but rapidly stopped due to tachyarrhythmia. Milrinone infusion stabilized the patients hemodynamic status and improved cardiac output without deleterious effects. CONCLUSION Milrinone could be a good alternative when inotropes are required in Takotsubo cardiomyopathy and when dobutamine infusion is associated with tachyarrhythmia.

Assessment of brain midline shift using sonography in neurosurgical ICU patients

IntroductionBrain midline shift (MLS) is a life-threatening condition that requires urgent diagnosis and treatment. We aimed to validate bedside assessment of MLS with Transcranial Sonography (TCS) in neurosurgical ICU patients by comparing it to CT.MethodsIn this prospective single centre study, patients who underwent a head CT were included and a concomitant TCS performed. TCS MLS was determined by measuring the difference between the distance from skull to the third ventricle on both sides, using a 2 to 4 MHz probe through the temporal window. CT MLS was measured as the difference between the ideal midline and the septum pellucidum. A significant MLS was defined on head CT as >0.5 cm.ResultsA total of 52 neurosurgical ICU patients were included. The MLS (mean ± SD) was 0.32 ± 0.36 cm using TCS and 0.47 ± 0.67 cm using CT. The Pearson’s correlation coefficient (r2) between TCS and CT scan was 0.65 (P <0.001). The bias was 0.09 cm and the limits of agreements were 1.10 and -0.92 cm. The area under the ROC curve for detecting a significant MLS with TCS was 0.86 (95% CI =0.74 to 0.94), and, using 0.35 cm as a cut-off, the sensitivity was 84.2%, the specificity 84.8% and the positive likelihood ratio was 5.56.ConclusionsThis study suggests that TCS could detect MLS with reasonable accuracy in neurosurgical ICU patients and that it could serve as a bedside tool to facilitate early diagnosis and treatment for patients with a significant intracranial mass effect.

What is the gold standard method for midline structures shift assessment using computed tomography

Crit Care Med 2012 Vol. 40, No. 12 evacuation. For example, this technique is interesting when cerebrospinal fluid drainage is abnormal, to differentiate accidental removal of ventricular catheter during patient displacement, early obstruction or ventricular compression due to cerebral edema. Data obtained with transcranial sonography and transcranial Doppler flow analysis, which are issued from the same device, in connection with intracranial pressure and cerebral oxymetry probably optimizes the choice of an adapted treatment during this high risk period. These informations are important for treatment during the flight and also to anticipate the strategy at hospital admission in particular when several wounded soldiers with traumatic brain injury are evacuated at the same time to choose who should be admitted in intensive care unit, directly at computed tomography scan or even directly transferred to the operating room. Lastly, the use of this technique in intensive care unit among craniectomized patients at risk of bleeding complications, in particular nontransportable ones, might be particularly interesting as portable computed tomography is rarely available. Increasing number of patients with severe traumatic brain injury and requiring intra-aortic balloon pump or extracorporeal membrane oxygenation have been reported. These patients are typically often nontransportable and at high risk of bleeding (3). We have used this monitoring to follow known hemorrhagic lesions evolution or to detect hemorrhagic complications in craniectomized patients under intra-aortic balloon pump or extracorporeal membrane oxygenation/extracorporeal life support and those with embolic stroke of cardiac origin with high risk of recidivism. This tool has the theoreti cal advantage to allow early detection of neurologic bleeding, which is frequent under extracorporeal membrane oxygenation/ extracorporeal life support. These informations are important to adapt coagulation and to decide a high-risk transfer for computed tomography evaluation. The authors have not disclosed any potential conflicts of interest.