**4.4 Management**

Once the patient has been diagnosed with an SAH, treatment should focus on limiting secondary neurologic injuries to improve the patient's functional outcome.

#### **4.5 Pharmacologic treatments**

#### *4.5.1 Antiepileptic drugs*

In patients with a suspected ruptured aneurysm, seizures can lead to aneurysmal rebleeding and result in intracranial hypertension and herniation, the

**193**

*Endovascular Treatment of Brain Aneurysms DOI: http://dx.doi.org/10.5772/intechopen.88964*

antiepileptic drugs in SAH [87].

*Flowchart of management aSAH [1, 10–12].*

**4.7 Blood pressure management**

agents recommended by the ASA [86].

only level IA evidence recommended by the ASA [86].

**4.6 Nimodipine**

**Figure 5.**

risk of being highest in patients with poor Hunt and Hess grade and those with thick subarachnoid blood [85]. Routine prophylactic antiepileptic drug use in patients with SAH is a common practice despite limited evidence The American Stroke Association (ASA) guideline recommends consideration of short-term prophylactic antiepileptic drug use in the immediate post hemorrhage period [86]. No randomized controlled trials have investigated the safety and effectiveness of

Delayed cerebral ischemia (DCI) is one of the most serious complications associated with SAH, occurring in one-third of patients surviving the initial hemorrhage and results in poor outcome in half of the patients with this complication [86]. Nimodipine is a calcium antagonist that is thought to reduce the rate of cerebral vasospasm by reducing the influx of calcium into the vascular smooth muscle cells. The administration of nimodipine to reduce the risk of poor outcome and DCI is the

There is general consensus that hypertension should be controlled after SAH and until the ruptured aneurysm is secured. However, specific parameters for blood pressure have not been defined and data are sparse. Early retrospective studies suggest a higher rate of rebleeding with SBP greater than 160 mm Hg and severity of initial hemorrhage [88]. Therefore, the ASA and Neurocritical Care Society recommend maintaining SBP less than 160 mm Hg and mean arterial pressure less than 110 mm Hg before the ruptured aneurysm is secured to reduce the risk of rebleeding [86, 87, 89, 90]. The ideal antihypertensive to use in SAH would be a parenteral agent that produces a rapid and reproducible dose response while concurrently minimizing adverse cerebral effects. Labetalol, nicardipine, and clevidipine are

*New Insight into Cerebrovascular Diseases - An Updated Comprehensive Review*

**Grade Glasgow coma scale (GCS) Neurological exam** 15 No motor deficit 13–14 No motor deficit 13–14 Motor deficit 7–12 With/without motor deficit 5–6 With/without motor deficit

Once the patient has been diagnosed with an SAH, treatment should focus on limiting secondary neurologic injuries to improve the patient's functional outcome.

**Grade Criteria Survival** I Asymptomatic, mild headache, slight nuchal rigidity 70%

*World Federation of Neurological Surgeons Grading System for Subarachnoid Hemorrhage - (WFNS) scale.*

cranial nerve palsy

III Drowsiness/confusion and mild focal neurological deficit 50% IV Stupor, moderate to severe hemiparesis 20% V Coma, decerebrate positioning 10%

**Grade Appearance of blood on CT Risk of cerebral**

(VH)

 Minimal SAH, No VH in 2 lateral ventricles 6% Minimal SAH, VH in 2 lateral ventricles 14% Large SAH, No VH in 2 lateral ventricles 12% Large SAH, VH in 2 lateral ventricles 28%

60%

**hemorrhage**

0%

II Moderate to severe headache, nuchal rigidity, no neurological deficit other than

• Resuscitation of a patient with SAH should follow all established protocols

• After stabilization of the airway and circulation, treatments specific to SAH

In patients with a suspected ruptured aneurysm, seizures can lead to aneurysmal rebleeding and result in intracranial hypertension and herniation, the

with immediate attention to airway and circulatory support.

0 No sub arachnoid hemorrhage (SAH) or ventricular hemorrhage

**192**

**4.4 Management**

*Modified fisher grading system [82].*

**Table 2.**

**Table 1.**

**Table 3.**

*Hunt and Hess scale.*

can begin.

*4.5.1 Antiepileptic drugs*

**4.5 Pharmacologic treatments**

#### **Figure 5.** *Flowchart of management aSAH [1, 10–12].*

risk of being highest in patients with poor Hunt and Hess grade and those with thick subarachnoid blood [85]. Routine prophylactic antiepileptic drug use in patients with SAH is a common practice despite limited evidence The American Stroke Association (ASA) guideline recommends consideration of short-term prophylactic antiepileptic drug use in the immediate post hemorrhage period [86]. No randomized controlled trials have investigated the safety and effectiveness of antiepileptic drugs in SAH [87].


Preface

Despite the discovery of microbial biofilms as far back as the seventeenth century, in recent years, scientists have increased their attention of these dense colonies of bacteria that pro‐ duce extracellular polymeric substances that bind a community of different microorganisms together and anchor them to both living and inanimate surfaces. Biofilms are not only re‐ sponsible for chronic bacterial infection account for more than 80% of all microbial infec‐ tions of the human body, infection on medical devises, deterioration of water quality, and the contamination of food, but they also can promote remediation of contaminated ground‐ water and soils and they play an important natural role in cycling of nitrogen, sulfur, and metals. The protective nature of the biofilm structure makes the bacteria embedded within them remarkably difficult to treat with antimicrobials; biofilms are resistant to doses of anti‐ microbials 100- to 1000-fold over the minimum lethal dose for microbes outside of biofilms. Hence, understanding "the good and the bad" characteristics of biofilms under diverse con‐ ditions is of great interest.

In this book "Microbial Biofilms: Importance and applications", eminent scientists provide an up-to-date review of the present and future trends on biofilm-related research. This book is divided with four subdivisions as biofilm fundamentals, applications, health aspects, and their control. Moreover, this book also provides a comprehensive account on microbial in‐ teractions in biofilms, pyocyanin, and extracellular DNA in facilitating *Pseudomonas aerugi‐ nosa* biofilm formation, atomic force microscopic studies of biofilms, biofilms in beverage industry, *Staphylococcus* and Salmonella biofilms, wound biofilm and therapeutic strategies, oral microbiome in dental biofilm formation, antimicrobial strategy against mature oral bio‐ film, and novel models to manage biofilms on microtextured dental implant surfaces.

The book comprises a total of 21 chapters from valued contributions from world–leading experts in Australia, Bulgaria, Canada, China, Serbia, Germany, Italy, Japan, the United Kingdom, the Kingdom of Saudi Arabia, Republic of Korea, Mexico, Poland, Portugal, and Turkey. We are grateful to the experts who have provided state-of-the-art valued contribu‐ tions of this book. This book may be used as a text or reference for everyone interested in biofilms and their applications. It is also highly recommended for environmental microbiol‐ ogists, soil scientists, medical microbiologists, bioremediation experts, and microbiologists working in biocorrosion, biofouling, biodegradation, water microbiology, quorum sensing, and many other related areas. Scientists in academia, research laboratories and industry will also find it of interest.

We offer our special thanks and appreciation to Ms. Dajana Pemac, Publishing Process Man‐ ager for their encouragement and help in bringing out the book in the present form. We are also indebted to InTech publisher for their concern, efforts, and encouragement in the task

#### XVI Preface

of publishing this volume. Appreciations are due to our research scholars for their sincere efforts and diligence towards this volume.

#### **Dr. Dharumadurai Dhanasekaran**

Department of Microbiology Bharathidasan University Tiruchirappalli India **Biofilm Fundamentals**

**Section 1**

#### **Dr. Nooruddin Thajuddin**

Department of Microbiology Bharathidasan University Tiruchirappalli India


**3.2 Embryonic cells**

Embryo freezing, allowing the preservation of both male and female ways, is the main way to recreate quickly a population from thawed embryo transfer. Most of the time, embryos are frozen at compacted morula stage (65h~72h *post coïtum*) even if freezing at earlier stage (4 cells stage) is possible. They can be produced *in vivo* from superovulated females or not, or *in vitro* after *In Vitro* Fertilization and *in vitro* culture. Embryos freezing from a planned mating ( at n generation) permits to obtain progenies (at n+1 generation) after thawing and transfer in recipient females.