Case Report: Yellow Fever Vaccine-Associated Neurotropic Disease and Associated MRI, EEG, and CSF Findings.

Yellow fever vaccine-associated neurotropic disease (YEL-AND) is a rare and serious complication following vaccination with the 17D live attenuated yellow fever vaccine. Cases of YEL-AND have presented as acute inflammatory demyelinating polyneuropathy, acute disseminated encephalomyelitis, and meningoencephalitis. To date, intracranial imaging of the progression and resolution of this disease has been minimally depicted in the literature. We present the case of a 67-year-old woman who developed YEL-AND following vaccination. Her diagnosis was complicated by imaging findings consistent with variant Creutzfeldt Jakob Disease. Her clinical history and the progression of her intracranial imaging is discussed in this case report.

Controversies in Brain Death Declaration: Legal and Ethical Implications in the ICU.

Purpose of review: This article provides a brief overview of the history and complexities of brain death determination. We examine a few legal cases that highlight some of the controversies surrounding the validity of brain death tests in light of varying state laws and institutional policy, the appropriateness of making religious accommodations, the dilemma of continuing organ-sustaining support in a pregnant brain-dead patient, and the issue of whether to obtain informed consent from surrogate decision makers before proceeding to testing. Recent findings: In response to physician concerns about navigating these complex cases, especially with laws that vary from state to state, the American Academy of Neurology has published a position statement in January of 2019 endorsing brain death as the irreversible loss of all functions of the entire brain. It provides positions on the determination of brain death as well as guidance surrounding requests for accommodation. Summary: Although death by neurologic criteria has been accepted as death medically for over 40 years, legal variance exists throughout the states, especially regarding religious accommodations and in pregnancy. Questions of whether to obtain informed consent from surrogate decision makers prior to brain death testing remain, and there is no guideline regarding obtaining ancillary testing. We expect to see continued cases that cause medical, legal, and ethical controversies in our ICUs. As such, uniform training in proper methodology in performing the brain death examination and appropriate use of ancillary testing is crucial, and there is a need for legal consistency in the acceptance of the medical standard.

Zika Virus Disease for the Neurointensivist.

Zika virus (ZIKV) is a mosquito-borne and sexually transmitted flavivirus currently spreading throughout the Pacific and Western Hemisphere. ZIKV infection is often either asymptomatic or causes a self-limiting illness with symptoms such as rash, fever, myalgia, arthralgia, headache, or conjunctivitis. Rarely, ZIKV infection has been associated with conditions such as severe thrombocytopenia, microcephaly and other developmental abnormalities, acute polyneuropathy/Guillain-Barré syndrome, myelitis, meningoencephalitis, transient encephalopathy, provoked seizures, and various ophthalmologic conditions. Optimal treatment of these ZIKV-associated conditions is currently unclear and is largely guided by expert opinion or case reports/series. Further studies are needed to establish best treatment practices. This review concentrates on caring by neurointensivists for the patient affected with Zika virus-expected to flare up again in the summer.

Rescue therapy for refractory vasospasm after subarachnoid hemorrhage.

Vasospasm and delayed cerebral ischemia remain to be the common causes of increased morbidity and mortality after aneurysmal subarachnoid hemorrhage. The majority of clinical vasospasm responds to hemodynamic augmentation and direct vascular intervention; however, a percentage of patients continue to have symptoms and neurological decline. Despite suboptimal evidence, clinicians have several options in treating refractory vasospasm in aneurysmal subarachnoid hemorrhage (aSAH), including cerebral blood flow enhancement, intra-arterial manipulations, and intra-arterial and intrathecal infusions. This review addresses standard treatments as well as emerging novel therapies aimed at improving cerebral perfusion and ameliorating the neurologic deterioration associated with vasospasm and delayed cerebral ischemia.