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What is new in neurocritical care: 2012
autoregulation . Spreading depolarization, a wave of destiny. This has been investigated in patients with SAH
depolarization with alteration of the ionic gradients, depres-  followed-up at 6 months. Interestingly, the majority
sion of electrical activity and neuronal swelling, is receiving of survivors, including those more severely affected,
more attention, both as a consequence and as a potential trigger showed a trend of improvement over time.
of further ischaemia . Rescuing brain tissue after ischaemic stroke is a matter
Protection of the brain against further insults after SAH of time, and for this reason stroke care requires
organizais extremely important. Magnesium, which inhibits excit- tion to bring the right candidates to the appropriate
atory glutamate release, and blocks the NMDA-glutamate hospital, with the shortest door to needle time.
Intravereceptors and voltage-dependent calcium channels, can be nous thrombolysis improves survival and independence
considered a neuroprotectant, and has been tested in sev- when performed up to 4.5 h after stroke. This interval may
eral trials. The latest randomized trial of magnesium perhaps be extended to 6 h according to the findings of a
sulphate for SAH was recently published . More than large ([3,000 patients) multicentre trial . Interestingly,
1,200 patients with aneurysmal SAH were randomized in patients older than 80 years, often excluded from previous
Europe and Chile to receive a fixed daily dose of 64 mmol studies, constituted more than 50 % of those randomized,
magnesium sulphate or placebo for up to 20 days. Mag- and benefits were also documented in this subgroup.
nesium had no effect on outcome, unfortunately. A meta- Older and sicker patients with TBI or ischaemic stroke
analysis including this study and six previous randomized have to be treated. New mechanisms should be explored
trials using magnesium for SAH has confirmed that intra- to better understand and treat ischaemia after SAH. Old
venous magnesium does not affect outcome . certainties, such as ICP monitoring, have to be
A lesson learned from TBI is that recovery after acute cussed. Long-term outcome, well beyond ICU discharge,
brain injury takes time, and that outcome at discharge needs to be considered. Neurocritical care has to adapt to
from the ICU does not capture the patients subsequent a changing world.