Falcine and Tentorial Subdural Hematomas May Not Routinely Require Transfer to a Tertiary Care Center

BACKGROUND

Patients with subdural hematomas (SDH) are frequently transferred to tertiary care centers. Although many prognostic factors, treatment strategies, and outcomes for convexity SDH have been reported, little is known about falcine and tentorial SDH.

OBJECTIVES

To describe features and outcomes of isolated falcine and tentorial SDH.

METHODS

We reviewed clinical/radiographic findings, treatment, length of stay (LOS), and outcome of adult patients transferred to a tertiary care center for acute SDH. Characteristics of patients with isolated falcine/tentorial SDH and outcomes (favorable [discharge to home/acute rehabilitation] vs. unfavorable [death/hospice/skilled nursing facility/long term care]) were assessed with univariate analyses.

RESULTS

Of 210 patients with SDH, mean age was 69.5 years; 117 were male; 98 (47%) underwent surgical SDH evacuation. Twenty-seven patients had isolated falcine or tentorial SDH, with known traumatic etiology in 23. None of the falcine/tentorial SDH patients required surgery or intubation. Compared with convexity SDH, patients with falcine/tentorial SDH were younger (59.7 vs. 70.9 years, p = 0.01), had higher admission Glasgow Coma Scale scores at the referring (p = 0.01) and receiving facility (p = 0.004), and shorter median intensive care unit LOS (1 vs. 3, p < 0.0001). All patients (100%) with falcine/tentorial SDH had favorable outcome vs. 68% with convexity SDH (p = 0.0005).

CONCLUSION

Isolated tentorial/falcine SDH without associated neurological deficits represent a benign entity among acute SDH, with no need for surgical intervention, short LOS, and favorable outcome. Our data indicate that for these patients, in the absence of complicating factors, transfer to a tertiary care center may not be routinely indicated.

Bacterial infections of the central nervous system

Bacterial CNS infections comprise a wide spectrum of diseases, which may be acquired outside or inside the hospital, affect immunocompetent or immunocompromised patients, and be associated with trauma or procedures, as well as other exposures.

Treatment of status epilepticus: an international survey of experts

BACKGROUND

As part of the development of the Neurocritical Care Society (NCS) Status Epilepticus (SE) Guidelines, the NCS SE Writing Committee conducted an international survey of SE experts.

METHODS

The survey consisted of three patient vignettes (case 1, an adult; case 2, an adolescent; case 3, a child) and questions regarding treatment. The questions for each case focused on initial and sequential therapy as well as when to use continuous intravenous (cIV) therapy and for what duration. Responses were obtained from 60/120 (50%) of those surveyed.

RESULTS

This survey reveals that there is expert consensus for using intravenous lorazepam for the emergent (first-line) therapy of SE in children and adults. For urgent (second-line) therapy, the most common agents chosen were phenytoin/fosphenytoin, valproate sodium, and levetiracetam; these choices varied by the patient age in the case scenarios. Physicians who care for adult patients chose cIV therapy for RSE, especially midazolam and propofol, rather than a standard AED sooner than those who care for children; and in children, there is a reluctance to choose propofol. Pentobarbital was chosen later in the therapy for all ages.

CONCLUSION

There is close agreement between the recently published NCS guideline for SE and this survey of experts in the treatment of SE.

Guidelines for the evaluation and management of status epilepticus

Status epilepticus (SE) treatment strategies vary substantially from one institution to another due to the lack of data to support one treatment over another. To provide guidance for the acute treatment of SE in critically ill patients, the Neurocritical Care Society organized a writing committee to evaluate the literature and develop an evidence-based and expert consensus practice guideline. Literature searches were conducted using PubMed and studies meeting the criteria established by the writing committee were evaluated. Recommendations were developed based on the literature using standardized assessment methods from the American Heart Association and Grading of Recommendations Assessment, Development, and Evaluation systems, as well as expert opinion when sufficient data were lacking.

Seven questions about stroke and epilepsy

Seizures and stroke are both common neurologic conditions, but when they occur in close temporal proximity they produce much more concern than either does alone. The stroke specialist (and the family) fear that convulsions will worsen the stroke because of acute hypertension and airway compromise, and the epileptologist is concerned that these acute seizures are the harbingers of later epilepsy. Other less commonly recognized but important aspects of this relationship are that subclinical seizures worsen some forms of stroke, and some anticonvulsants may have more adverse effects on stroke patients than they do in other groups. In surveying the connections between these two conditions, I have attempted to address seven questions. For some questions, there are data to help provide an answer; for others, there is only opinion; and for a maddening few, newer research is making older suggestions less certain.

Neurocritical care of patients with central nervous system infections

Bacterial meningitis and viral encephalitis are life-threatening infections with high mortality rates. Patients who survive these infections often remain permanently disabled. Potential neurologic complications requiring careful attention include impaired consciousness, elevated intracranial pressure (ICP), hydrocephalus, stroke, and seizures. Systemic complications are also common and are frequently the immediate cause of death. The importance of emergent administration of appropriate antimicrobial therapy cannot be overstated, but critical care of these patients should focus not only on treatment of the underlying infection and its immediate complications but also on minimizing secondary brain injury. Given the increasing complexity of the diagnostic and therapeutic modalities available to manage central nervous system (CNS) infections, the involvement of neurocritical care units and neurointensivists may be particularly helpful in improving outcomes. It is our opinion that ICP measurement should be strongly considered in selected patients with CNS infections, particularly those who are comatose. Treatments for intracranial hypertension, specifically in the setting of CNS infection, are described in this paper. For bacterial meningitis, intravenous dexamethasone should be administered, beginning concomitantly with the initial dose of antibiotics, at least until Streptococcus pneumoniae can be excluded as a pathogen. Clinicians should maintain a high index of suspicion for nonconvulsive seizures. Deterioration in neurologic status should also prompt early use of CT or magnetic resonance angiography and venography to exclude cerebrovascular complications.

Status epilepticus and the use of continuous EEG monitoring in the intensive care unit

PURPOSE OF REVIEW

Status epilepticus (SE) is one of the major neurologic emergencies. Newer data about the genesis and treatment of this condition are available to help improve our understanding and management.

RECENT FINDINGS

Approximately 150,000 cases of generalized convulsive SE occur in the United States each year. Clinically apparent seizures complicate about 8% of intensive care unit admissions, and another 10% of ICU patients suffer electrographic seizures in the course of another critical illness. Some of these cases result from previously under-recognized epileptogenic effects of commonly used drugs, such as cefepime. Continuous EEG (cEEG) recording is necessary for both diagnosis and management in these patients, especially since anticonvulsant drugs may abolish motor activity without stopping seizures. Recent studies have underscored the utility of benzodiazepines as the first-line agents for SE termination. The recently published Rapid Anticonvulsant Medication Prior to Arrival Trial (RAMPART) demonstrates that the more rapidly treatment is administered, the more effective it will be. When SE fails to respond to usual doses of benzodiazepines, it should be considered refractory to conventional anticonvulsants, and a general anesthetic approach is likely to be necessary.

SUMMARY

While definitions have varied, patients should be managed for SE after 5 minutes of seizure activity. Management of a patient with SE involves three phases: termination of SE, prevention of recurrence, and treatment of complications. The typical anticonvulsants have limited ability to terminate SE; lorazepam is the most useful, controlling SE in 65% of patients experiencing generalized convulsive SE. If the first conventional anticonvulsant fails, others are unlikely to be useful, and one of the newer anticonvulsants or a general anesthetic agent should be considered. EEG is crucial in the diagnosis and classification of potential seizures. cEEG monitoring helps to guide anticonvulsant therapy in patients with SE and those with frequent seizures. In addition, cEEG has the potential for presymptomatic diagnosis of delayed neurologic deterioration in patients with subarachnoid hemorrhage and for the differential diagnosis of stroke subtypes, especially when cEEG is subjected to signal processing.

Research priorities in neurocritical care

This summary of the last session of the First Neurocritical Care Research Conference reviews the discussions about research priorities in neurocritical care. The first presentation reviewed current projects funded by the National Institute of Neurological Disorders and Stroke at the National Institutes of Health and potential models to follow including an independent Neurocritical Care Network or the creation of such a network with the goal of collaborating with already existing ones. Experienced neurointensivists then presented their views on the most common and important research questions that need to be answered and investigated in the field. Finally, utility of clinical registries was discussed emphasizing their importance as hypothesis generators. During the group discussion, interests in comparative effectiveness research, the use of physiological endpoints from monitoring and alternate trial design were expressed.

Abstract 3879: Symptomatic Cerebral Vasospasm and Cerebral Infarct do not significantly contribute to In-Hospital Mortality after Subarachnoid Hemorrhage

Background: The International Cooperative Study on the Timing of Aneurysm Surgery suggested that delayed cerebral vasospasm is a significant contributor to mortality (at 6 months) after subarachnoid hemorrhage (SAH). However, the Cincinnati population based study did not find cerebral vasospasm to be a significant contributor to short-term mortality.

Methods: We reviewed 350 consecutive non-traumatic SAH patients who were hospitalized at our institution from August 1, 2006 to June 30, 2010. Data were collected on demographics, Hunt and Hess grade, presence of cerebral infarct, symptomatic vasospasm, and in-hospital mortality. Symptomatic vasospasm was defined as cerebral vasospasm that required intra-arterial therapy (pharmacologic vasodilators or angioplasty). Cerebral infarct was defined as any new radiographic infarct seen on CT or MRI (of any cause).

Results: Among 350 patients with non-traumatic SAH, the mean age was 56.7 years (range, 21.5 to 89.1) and 68% were aneurysmal. The overall in-hospital mortality rate was 20.2% (71 patients). The causes of in-hospital mortality were withdrawal of support in 53 (75%), brain death in 14 (20%), and cardiopulmonary death in 4 (8%). The mean time to death was 8.1 (range 0 to 31) days, with 36% of deaths occurring within the first 2 days of hospitalization. Among patients with symptomatic cerebral vasospasm or cerebral infarct , 19% (26/139) died. In univariate and multivariate analyses, symptomatic cerebral vasospasm and cerebral infarct were not associated with in-hospital mortality. When the analysis was restricted to patients with aneurysmal SAH, cerebral vasospasm and cerebral infarct were still not predictive of in-hospital mortality. In multivariable analysis, the variables most associated with in-hospital mortality were Hunt and Hess score (HH) (p <0.0001), rebleed (p <0.0001), and age ≥ 80 (p 0.0017).

Conclusions: In-hospital mortality after SAH is associated with initial severity of hemorrhage, rebleeding, and age. Symptomatic cerebral vasospasm and cerebral infarct were not significant contributors of overall in-hospital mortality, and approximately one-third of in-hospital mortality after SAH occurs within the first 2 days of hospitalization. By design, studies that exclude patients with severe SAH tend to over-estimate the contribution of cerebral vasospasm on short-term mortality.

The relationship of 26 clinical factors to weaning outcome

BACKGROUND

The Burns Wean Assessment Program (BWAP) assessment checklist is designed to assist clinicians in the systematic evaluation of 26 clinical factors important to weaning. The authors recently described the relationship of the BWAP score (derived from the checklist) to weaning trial outcomes (weaning success or failure) in patients receiving mechanical ventilation for 3 days or longer in 5 adult critical care units. A BWAP score of 50 or higher was significantly associated with weaning success regardless of the specific category of patient (surgical, medical, cardiovascular, etc). This secondary analysis extends the evaluation of the BWAP checklist as it focuses on the importance of each individual BWAP factor to weaning outcomes in 5 different populations of patients.

OBJECTIVES

To identify the relative importance of the 26 BWAP factors to weaning success in patients undergoing mechanical ventilation for 3 days or longer in 5 adult critical care units.

METHODS

BWAP checklists were completed within 24 hours of a weaning attempt in surgical-trauma, medical, neurological, thoracic-cardiovascular, and coronary care units in a 5-year period. Advanced practice nurses using a multidisciplinary pathway, the BWAP checklist, protocols for weaning trials, and sedation guidelines managed the patients similarly.

RESULTS

A total of 20 BWAP factors were significantly associated with successful weaning in all units combined (P ≤ .02). However, some differences in the importance of the BWAP factors to weaning outcome exist between units, with the neuroscience intensive care unit deviating the most from the other units.

CONCLUSIONS

Although not all BWAP factors are significantly associated with weaning success, most are predictive. Restructuring the BWAP as a unit-specific weaning checklist and potential predictor may assist clinicians to address factors that may impede weaning more efficiently and effectively.

Treatment of neuroterrorism

Bioterrorism is defined as the intentional use of biological, chemical, nuclear, or radiological agents to cause disease, death, or environmental damage. Early recognition of a bioterrorist attack is of utmost importance to minimize casualties and initiate appropriate therapy. The range of agents that could potentially be used as weapons is wide, however, only a few of these agents have all the characteristics making them ideal for that purpose. Many of the chemical and biological weapons can cause neurological symptoms and damage the nervous system in varying degrees. Therefore, preparedness among neurologists is important. The main challenge is to be cognizant of the clinical syndromes and to be able to differentiate diseases caused by bioterrorism from naturally occurring disorders. This review provides an overview of the biological and chemical warfare agents, with a focus on neurological manifestation and an approach to treatment from a perspective of neurological critical care.