Intravenous fluid therapy is a fundamental treatment in intensive care units (ICUs). Although most clinical trials have focused on patients requiring active resuscitation of the intravascular volume, such as those experiencing shock or sepsis, neurocritically ill patients may also benefit from intravenous fluid therapy during crises involving elevated intracranial pressure or reduced cerebral perfusion pressure. This review provides a comprehensive history of the evolution of intravenous fluid therapy, highlighting the development of crystalloids and the challenges associated with colloids. Previously favored for their theoretical advantages in sustaining intravascular volume, colloids have recently come under scrutiny due to safety concerns, including adverse renal outcomes. In contrast, crystalloids, particularly balanced crystalloids, are now preferred. Balanced crystalloids improve acid-base status and pose a lower risk of hyperchloremic metabolic acidosis than 0.9% saline. This review summarizes the key findings of recent clinical trials comparing the efficacy and safety profiles of crystalloids and colloids in ICU settings with a specific focus on neurocritical care populations.

Background: Nonaneurysmal perimesencephalic subarachnoid hemorrhage (NAPH) is a form of subarachnoid hemorrhage (SAH) occurring predominantly in the perimesencephalic region, in the absence of an aneurysm or other source of bleeding on diagnostic angiography. The underlying cause of NAPH remains unclear. Case report: Herein, we describe three patients who developed NAPH during strenuous activity in the absence of trauma after traveling to an altitude of approximately 7,500 feet. The patients were treated conservatively without any residual neurological deficits. Conclusions This case series suggests that hypoxia and vigorous exercise could be risk factors for NAPH. Patients traveling to higher altitudes should be counseled to increase their exercise intensity gradually.

Background: Granulomatous amebic encephalitis (GAE) is caused by Acanthamoeba species or Balamuthia mandrillaris, which are microscopic, free-living amoebas found worldwide. People with compromised immune systems are at an increased risk of fatal cerebral infection caused by Acanthamoeba species, whereas B. mandrillaris can affect both immunocompromised and immunocompetent patients. Infections can involve the central nervous system causing GAE.Case Report: A 71-year-old Caucasian woman, previously diagnosed with chronic lymphocytic leukemia and undergoing chemotherapy, arrived at the emergency department exhibiting seizure-like symptoms. Brain imaging revealed bilateral cerebral masses with central necrosis and hemorrhage, among other findings. The patient underwent a biopsy and was diagnosed with GAE. Conclusion Unfortunately, even with the correct diagnosis, GAE leads to rapid deterioration and a higher risk of mortality. This case demonstrates the rapid and severe nature of GAE and emphasizes the need for ongoing studies and better treatment options to improve GAE outcomes.

Background: Diabetic ketoacidosis (DKA) is a common hyperglycemic emergency characterized by hyperglycemia, metabolic acidosis, and ketonemia. DKA is a rare but serious complication of sodium-glucose cotransporter-2 (SGLT2) inhibitors that requires careful monitoring.Case Report: We present two cases of acute ischemic stroke in patients who developed DKA during the administration of SGLT2 inhibitors. Case 1 was a 70-year-old woman with a right middle cerebral artery (MCA) infarction who developed severe metabolic acidosis and ketonemia on hospital day 5, which resolved after insulin and fluid therapy. Case 2 was a 52-year-old woman with a right MCA infarction and carotid stenosis who developed DKA on hospital day 3. Despite initial resolution, DKA recurred after SGLT2 inhibitor re-administration and permanent discontinuation was necessary. Conclusion These cases highlight the risk of DKA in the acute phase of ischemic stroke in patients treated with SGLT2 inhibitors.

Background: Myasthenia gravis is an autoimmune disorder which affects the neuromuscular junction, resulting in muscle weakness and respiratory complications. Recurrent myasthenic crises may necessitate mechanical ventilation due to respiratory failure.Case Report: We present a 21-year-old female with myasthenia gravis who experienced recurrent myasthenic crises requiring mechanical ventilation. She underwent plasma exchange therapy and inspiratory muscle training (IMT) program to improve respiratory function. Gradual ventilator adjustments and a structured IMT protocol led to significant improvements in oxygenation and carbon dioxide elimination. The patient met the weaning criteria, including the PaO2/FiO2 ratio and rapid shallow breathing index, and was successfully extubated after 12 days of mechanical ventilation. Conclusion This case highlights the importance of a multidisciplinary approach in managing myasthenic crises and suggests that IMT may expedite weaning from mechanical ventilation.

Background: Most aneurysmal subarachnoid hemorrhages (SAHs) are accompanied by focal neurological deficits caused by a thunderclap headache. The neurological symptoms of aneurysmal SAH rarely present as vasospasm-induced cerebral ischemia.Case Report: A 51-year-old male presented to the emergency department with weakness in the left upper and lower limbs combined with dysarthria, which developed on the day of admission. An initial brain computed tomography scan revealed no clear signs of hemorrhage. However, the patient’s age (51 years) and history of thunderclap headache prompted further evaluation. Finally, the patient was diagnosed with vasospasm-induced ischemic stroke, caused by a ruptured cerebral aneurysm. Conclusion For patients with abrupt focal neurological deficits and severe thunderclap headaches, further consideration of aneurysmal rupture and the resulting vasospasm-induced cerebral ischemia may prevent the worst complications of stroke due to misdiagnosis.

Background: Alpha coma and its variants theta coma and alpha-theta coma (ATC) are clinical coma states characterized by electroencephalographic patterns resembling those of wakefulness. The complete (unreactive) form of these states is invariably associated with poor outcomes among post-anoxic comatose patients.Case Report: Herein, we present three adult comatose patients (aged 21, 45, and 51 years) with unreactive ATC patterns, who exhibited remarkable neurological improvement. Two patients experienced post-cardiopulmonary arrest (due to electrocution and viral myocarditis, respectively), while the third had severe septic encephalopathy. Electroencephalograms (EEGs) taken at least 24 hours after coma onset revealed unreactive ATC patterns. All patients survived, achieving significant neurological improvement. Remarkably, in one patient, the only symptom was minor incoordination during ambulation upon discharge. Conclusion These cases challenge the grave prognosis associated with this EEG pattern, particularly in post-anoxic comatose patients. Factors such as younger age, presence of shockable rhythms, and cause of arrest may have contributed to these favorable outcomes.

Background: Posterior reversible encephalopathy syndrome (PRES) is characterized by reversible neurotoxicity. The symptoms include headache, altered consciousness, seizures, visual disturbances, and focal neurological deficits. The severe variant, known as malignant PRES, is rare and involves diffuse cerebral edema, leading to irreversible damage. Chronic kidney disease (CKD) with impaired blood pressure regulation is a known risk factor for malignant PRES.Case report: We report the case of a patient with CKD who presented with hypertensive crisis and later developed malignant PRES in the background of status epilepticus refractory to antiepileptic treatment. Conclusions This case highlights the importance of considering malignant PRES in hypertensive crises and emphasizes the need for further research to elucidate its pathophysiology and develop effective treatment strategies.

Background: Extracorporeal membrane oxygenation (ECMO) is a critical life-support intervention for severe cardiopulmonary failure. Venoarterial (VA)-ECMO presents unique challenges in neuroradiological assessment due to hemodynamic alterations and the presence of imaging artifacts. Case Report: This case report describes an adult post-heart transplant patient on peripheral VA-ECMO who developed left-sided hemiparesis, suggestive of cerebrovascular events. While our patient developed multifocal ischemic infarcts, the initial computed tomography perfusion (CTP) imaging indicated hypoperfusion of the entire right hemisphere. Given the discrepancy in the patient’s clinical assessment, which was suggestive of a more circumscribed right hemispheric involvement, and the CTP findings, subsequent digital subtraction angiography was performed, which demonstrated adequate vascular filling with no large vessel occlusion. Conclusion These findings highlight the diagnostic complexities of ECMO-related artifacts, even in the presence of neurological complications that can mimic true perfusion deficits and potentially lead to misdiagnosis.