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Role of Circular Ribonucleic Acids in the Treatment of Traumatic Brain and Spinal Cord Injury. Mol Neurobiol 2020; 57:4296-4304. [DOI: 10.1007/s12035-020-02027-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/14/2020] [Indexed: 12/19/2022]
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Li M, Mu F, Han Q, Su D, Guo Z, Chen T. Intraventricular fibrinolytic for the treatment of intraventricular hemorrhage: a network meta-analysis. Brain Inj 2020; 34:864-870. [PMID: 32447964 DOI: 10.1080/02699052.2020.1764103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To explore which intraventricular fibrinolytic agent - urokinase (UK) or recombinant tissue plasminogen activator (rt-PA) - combined with extraventricular drainage (EVD) is most suitable for patients with spontaneous intraventricular hemorrhage (IVH). PATIENTS AND METHODS We searched PubMed, MEDLINE, OVID, Embase, and Cochrane Library databases for relevant articles and assessed their quality and extracted statistical analyses using Stata 13.0 and Revman 5.3 software. RESULTS Compared with EVD alone, EVD combined with an agent causing intraventricular fibrinolysis (IVF) improved the survival and prognosis of patients with IVH. Regarding the patients' survival rates and prognoses, the treatments, from best to worst results were EVD + UK, EVD + rt-PA, EVD alone. The proportion of patients with serious disability also increased with these treatments, however, with the highest to lowest proportions being EVD + rt-PA, EVD + UK, EVD alone. In addition, EVD + IVF was associated with a higher risk of intracranial rebleeding (from lowest to highest incidence: EVD alone, EVD + rt-PA, EVD + UK). Finally, EVD + UK is associated with an increased risk of potential intracranial infection (from lowest to highest incidence: EVD + rt-PA, EVD alone, EVD + UK). CONCLUSIONS EVD + UK may be the best approach to improving patients' survival rate and prognosis. However, it also presents the highest risk of intracranial infection and rebleeding. EVD + IVF increased the proportion of patients with serious disability.
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Affiliation(s)
- Mei Li
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital , Tangshan, Hebei Province, China
| | - Fengqun Mu
- Department of Neurology, Gongren Hospital , Tangshan, Hebei Province, China
| | - Qian Han
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital , Tangshan, Hebei Province, China
| | - Dongpo Su
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital , Tangshan, Hebei Province, China
| | - Zhenzhong Guo
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital , Tangshan, Hebei Province, China
| | - Tong Chen
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital , Tangshan, Hebei Province, China
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Wan Y, Gao F, Ye F, Yang W, Hua Y, Keep RF, Xi G. Effects of aging on hydrocephalus after intraventricular hemorrhage. Fluids Barriers CNS 2020; 17:8. [PMID: 32106865 PMCID: PMC7047364 DOI: 10.1186/s12987-020-0169-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 01/16/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Hydrocephalus is a common and major complication that affects outcome after intraventricular hemorrhage (IVH). While aging impacts the occurrence of hydrocephalus in patients with IVH this and the underlying mechanisms have received little attention. The present investigation, therefore, studied the impact of aging on hydrocephalus after IVH in a rat model. METHODS Young and aged (3 and 18 months old, respectively) male Fischer 344 rats had an intraventricular injection of 200 μl autologous blood or saline. Ventricular volume was estimated using magnetic resonance imaging (MRI), while ventricular wall damage, heme oxygenase-1 (HO-1) and epiplexus cell activation were quantified by histological staining and Western blot. Additionally, the impact of intraventricular iron injection was examined in young and aged rats. RESULTS Intraventricular injection of autologous blood induced hydrocephalus in both young and aged rats but ventricular volumes were larger in aged rats compared to young rats from day 3 to day 14 followed IVH. In addition, ventricular wall damage and periventricular HO-1 upregulation were greater in aged versus young rats on day 1 after IVH. Aged rats also had more choroid plexus epiplexus cells on day 14 after IVH. Additionally, organized hematomas were observed in 23% (3/13) of aged rats but not in young rats after IVH. Organized hematomas in aged rats showed larger T2* lesions on MRI compared to rats with non-organized hematomas. Similar to the effects of IVH, intraventricular injection of iron resulted in more epiplexus cells activation and more severe hydrocephalus in aged compared to young rats. CONCLUSIONS IVH causes more severe hydrocephalus in aged compared to young rats. Enhanced ventricular wall damage, epiplexus cell activation and iron overload may contribute to this aggravated hydrocephalus development in aged animals.
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Affiliation(s)
- Yingfeng Wan
- Department of Neurosurgery, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
- Department of Neurosurgery, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Feng Gao
- Department of Neurosurgery, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
- Department of Neurology, 2nd Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Fenghui Ye
- Department of Neurosurgery, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Weiming Yang
- Department of Neurosurgery, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Ya Hua
- Department of Neurosurgery, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Richard F Keep
- Department of Neurosurgery, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA.
| | - Guohua Xi
- Department of Neurosurgery, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA.
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54
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Yamin G, Cheecharoen P, Goel G, Sung A, Li CQ, Chang YHA, McDonald CR, Farid N. Automated CT registration tool improves sensitivity to change in ventricular volume in patients with shunts and drains. Br J Radiol 2020; 93:20190398. [PMID: 31825670 DOI: 10.1259/bjr.20190398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE CT is the mainstay imaging modality for assessing change in ventricular volume in patients with ventricular shunts or external ventricular drains (EVDs). We evaluated the performance of a novel fully automated CT registration and subtraction method to improve reader accuracy and confidence compared with standard CT. METHODS In a retrospective evaluation of 49 ventricular shunt or EVD patients who underwent sequential head CT scans with an automated CT registration tool (CT CoPilot), three readers were assessed on their ability to discern change in ventricular volume between scans using standard axial CT images versus reformats and subtraction images generated by the registration tool. The inter-rater reliability among the readers was calculated using an intraclass correlation coefficient (ICC). Bland-Altman tests were performed to determine reader performance compared to semi-quantitative assessment using the bifrontal horn and third ventricular width. McNemar's test was used to determine whether the use of the registration tool increased the reader's level of confidence. RESULTS Inter-rater reliability was higher when using the output of the registration tool (single measure ICC of 0.909 with versus 0.755 without the tool). Agreement between the readers' assessment of ventricular volume change and the semi-quantitative assessment improved with the registration tool (limits of agreement 4.1 vs 4.3). Furthermore, the tool improved reader confidence in determining increased or decreased ventricular volume (p < 0.001). CONCLUSION Automated CT registration and subtraction improves the reader's ability to detect change in ventricular volume between sequential scans in patients with ventricular shunts or EVDs. ADVANCES IN KNOWLEDGE Our automated CT registration and subtraction method may serve as a promising generalizable tool for accurate assessment of change in ventricular volume, which can significantly affect clinical management.
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Affiliation(s)
- Ghiam Yamin
- Department of Radiology, University of California San Diego School of Medicine, La Jolla, CA
| | - Piyaphon Cheecharoen
- Department of Radiology, University of California San Diego School of Medicine, La Jolla, CA
| | - Gunjan Goel
- Department of Neurosurgery, University of California San Diego School of Medicine, La Jolla, CA
| | - Andrew Sung
- Department of Radiology, University of California San Diego School of Medicine, La Jolla, CA
| | - Charles Q Li
- Department of Radiology, University of California San Diego School of Medicine, La Jolla, CA
| | - Yu-Hsuan A Chang
- Department of Psychiatry, University of California San Diego School of Medicine, La Jolla, CA
| | - Carrie R McDonald
- Department of Psychiatry, University of California San Diego School of Medicine, La Jolla, CA
| | - Nikdokht Farid
- Department of Radiology, University of California San Diego School of Medicine, La Jolla, CA
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Abstract
PURPOSE OF REVIEW The optimal management of external ventricular drains (EVD) in the setting of acute brain injury remains controversial. Therefore, we sought to determine whether there are optimal management approaches based on the current evidence. RECENT FINDINGS We identified 2 recent retrospective studies on the management of EVDs after subarachnoid hemorrhage (SAH) which showed conflicting results. A multicenter survey revealed discordance between existing evidence from randomized trials and actual practice. A prospective study in a post-traumatic brain injury (TBI) population demonstrated the benefit of EVDs but did not determine the optimal management of the EVD itself. The recent CLEAR trials have suggested that specific positioning of the EVD in the setting of intracerebral hemorrhage with intraventricular hemorrhage may be a promising approach to improve blood clearance. Evidence on the optimal management of EVDs remains limited. Additional multicenter prospective studies are critically needed to guide approaches to the management of the EVD.
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Price DA, Grzybowski A, Eikenberry J, Januleviciene I, Verticchio Vercellin AC, Mathew S, Siesky B, Harris A. Review of non-invasive intracranial pressure measurement techniques for ophthalmology applications. Br J Ophthalmol 2019; 104:887-892. [PMID: 31704702 DOI: 10.1136/bjophthalmol-2019-314704] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 10/23/2019] [Accepted: 10/30/2019] [Indexed: 11/04/2022]
Abstract
Assessment and monitoring of intracranial pressure (ICP) are important in the management of traumatic brain injury and other cerebral pathologies. In the eye, ICP elevation and depression both correlate with optic neuropathies, the former because of papilledema and the latter related to glaucoma. While the relationship between ICP elevation and papilledema is well established, the relationship between low ICP and glaucoma is still poorly understood. So far, ICP monitoring is performed invasively, but this entails risks including infection, spurring the study of non-invasive alternatives. We review 11 methods of non-invasive estimation of ICP including correlation to optic nerve sheath diameter, intraocular pressure, ophthalmodynamometry and two-depth transcranial Doppler of the ophthalmic artery. While none of these methods can fully replace invasive techniques, certain measures show great potential for specific applications. Although only used in small studies to date, a MRI based method known as MR-ICP, appears to be the best non-invasive technique for estimating ICP, with two-depth transcranial ultrasound and ophthalmodynamometry showing potential as well.
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Affiliation(s)
- David Andrew Price
- Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Andrzej Grzybowski
- Department of Ophthalmology, Poznan City Hospital, Poznan, Poland.,Medcial Faculty, University of Warmia and Mazury, Olsztyn, Poland
| | - Jennifer Eikenberry
- Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | | | - Sunu Mathew
- Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Brent Siesky
- Ophthalmology, Icahn School of Medicine at Mount Sinai Hospital, New York City, New York, USA
| | - Alon Harris
- Ophthalmology, Icahn School of Medicine at Mount Sinai Hospital, New York City, New York, USA
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Fam MD, Stadnik A, Zeineddine HA, Girard R, Mayo S, Dlugash R, McBee N, Lane K, Mould WA, Ziai W, Hanley D, Awad IA. Symptomatic Hemorrhagic Complications in Clot Lysis: Evaluation of Accelerated Resolution of Intraventricular Hemorrhage Phase III Clinical Trial (CLEAR III): A Posthoc Root-Cause Analysis. Neurosurgery 2019; 83:1260-1268. [PMID: 29294116 DOI: 10.1093/neuros/nyx587] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 11/16/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND As intraventricular thrombolysis for intraventricular hemorrhage (IVH) has developed over the last 2 decades, hemorrhagic complications have remained a concern despite general validation of its safety in controlled trials in the Clot Lysis: Evaluation of Accelerated Resolution of Intraventricular Hemorrhage Phase III (CLEAR-IVH) program. OBJECTIVE To analyze factors associated with symptomatic bleeding following IVH with and without thrombolysis in conjunction with the recently completed CLEAR III trial. METHODS We reviewed safety reports on symptomatic bleeding events reported during the first year after randomization among subjects enrolled in the CLEAR III trial. Clinical and imaging data were retrieved through the trial database as part of ongoing quality and safety monitoring. A posthoc root-cause analysis was performed to identify potential factors predisposing to rebleeding in each case. Cases were classified according to onset of rebleeding (during dosing, early after dosing and delayed), the pattern of bleeding, and treatment rendered (alteplase vs saline). RESULTS Twenty subjects developed a secondary symptomatic intracranial hemorrhage constituting 4% of subjects. Symptomatic rebleeding events occurred during the dosing protocol (n = 9, 67% alteplase), early after the protocol (n = 5, 40% alteplase), and late (n = 6, 0% alteplase). Catheter-related hemorrhages were the most common (n = 7, 35%) followed by expansion or new intraventricular (n = 6, 30%) and intracerebral (n = 5, 25%) hemorrhages. Symptomatic hemorrhages during therapy resulted from a combination of treatment- and patient-related factors and were at most partially attributable to alteplase. Rebleeding after the dosing protocol primarily reflected patients' risk factors. CONCLUSION Intraventricular thrombolysis marginally increases the overall risk of symptomatic hemorrhagic complications after IVH, and only during the treatment phase.
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Affiliation(s)
- Maged D Fam
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine, Chicago, Illinois
| | - Agnieszka Stadnik
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine, Chicago, Illinois
| | - Hussein A Zeineddine
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine, Chicago, Illinois
| | - Romuald Girard
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine, Chicago, Illinois
| | | | - Rachel Dlugash
- Brain Injury Outcomes Unit, Johns Hopkins University, Baltimore, Maryland
| | - Nichol McBee
- Brain Injury Outcomes Unit, Johns Hopkins University, Baltimore, Maryland
| | - Karen Lane
- Brain Injury Outcomes Unit, Johns Hopkins University, Baltimore, Maryland
| | - W Andrew Mould
- Brain Injury Outcomes Unit, Johns Hopkins University, Baltimore, Maryland
| | - Wendy Ziai
- Brain Injury Outcomes Unit, Johns Hopkins University, Baltimore, Maryland
| | - Daniel Hanley
- Brain Injury Outcomes Unit, Johns Hopkins University, Baltimore, Maryland
| | - Issam A Awad
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine, Chicago, Illinois
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58
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Ge X, Xu X, Yu X, Chen X, Li D, Xu Y, Zhang Y. Smartphone-assisted endoscopic surgery via Kocher's point for intraventricular hemorrhage caused by thalamic hemorrhage: A comparison with external ventricular drainage. Exp Ther Med 2019; 18:1870-1876. [PMID: 31537987 DOI: 10.3892/etm.2019.7740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 05/23/2019] [Indexed: 11/06/2022] Open
Abstract
The aim of the present study was to investigate the efficacy of endoscopic surgery via a Kocher point approach for intraventricular hemorrhage (IVH) caused by thalamic hemorrhage (TH), in comparison with external ventricular drainage (EVD). Between January 2016 and August 2017, a total of 40 patients with IVH caused by TH were enrolled. The patients were assigned to an EVD group and an endoscopic surgery group in a non-randomized manner. The pre-operative characteristics recorded included age, pre-operative Glasgow Coma Scale (GCS) score, hemorrhage volume, length of neuro-intensive care unit stay and Graeb score of IVH. Outcomes included the GCS score at 2 weeks after surgery, 30-day and 90-day mortality rates, modified Rankin scale at 6 months after ictus and ventriculo-peritoneal (VP) shunt rate. The baseline characteristics were not significantly different between the two groups. The VP shunt rate in the EVD group was significantly higher compared with that in the endoscopic surgery group (50.0 vs. 15.0%; P=0.02; odds ratio, 5.7). In conclusion, smartphone-assisted endoscopic surgery via Kocher's point is feasible and safe, and significantly reduces permanent shunt dependency for IVH caused by TH.
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Affiliation(s)
- Xin Ge
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing 100853, P.R. China.,Department of Neurosurgery, Central Hospital of Jinzhou, Jinzhou, Liaoning 121001, P.R. China.,Department of Neuro-ICU, Central Hospital of Jinzhou, Jinzhou, Liaoning 121001, P.R. China
| | - Xinhua Xu
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing 100853, P.R. China
| | - Xinguang Yu
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing 100853, P.R. China
| | - Xiaolei Chen
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing 100853, P.R. China
| | - Duo Li
- Department of Neurosurgery, Central Hospital of Jinzhou, Jinzhou, Liaoning 121001, P.R. China
| | - Yanhua Xu
- Department of Neurosurgery, Central Hospital of Jinzhou, Jinzhou, Liaoning 121001, P.R. China.,Department of Neuro-ICU, Central Hospital of Jinzhou, Jinzhou, Liaoning 121001, P.R. China
| | - Yue Zhang
- Department of Neurosurgery, Central Hospital of Jinzhou, Jinzhou, Liaoning 121001, P.R. China.,Department of Neuro-ICU, Central Hospital of Jinzhou, Jinzhou, Liaoning 121001, P.R. China
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Cameron S, Gillio-Meina C, Ranger A, Choong K, Fraser DD. Collection and Analyses of Cerebrospinal Fluid for Pediatric Translational Research. Pediatr Neurol 2019; 98:3-17. [PMID: 31280949 DOI: 10.1016/j.pediatrneurol.2019.05.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/23/2019] [Accepted: 05/27/2019] [Indexed: 12/18/2022]
Abstract
Cerebrospinal fluid sample collection and analysis is imperative to better elucidate central nervous system injury and disease in children. Sample collection methods are varied and carry with them certain ethical and biologic considerations, complications, and contraindications. Establishing best practices for sample collection, processing, storage, and transport will ensure optimal sample quality. Cerebrospinal fluid samples can be affected by a number of factors including subject age, sampling method, sampling location, volume extracted, fraction, blood contamination, storage methods, and freeze-thaw cycles. Indicators of sample quality can be assessed by matrix-associated laser desorption/ionization time-of-flight mass spectrometry and include cystatin C fragments, oxidized proteins, prostaglandin D synthase, and evidence of blood contamination. Precise documentation of sample collection processes and the establishment of meticulous handling procedures are essential for the creation of clinically relevant biospecimen repositories. In this review we discuss the ethical considerations and best practices for cerebrospinal fluid collection, as well as the influence of preanalytical factors on cerebrospinal fluid analyses. Cerebrospinal fluid biomarkers in highly researched pediatric diseases or disorders are discussed.
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Affiliation(s)
| | | | - Adrianna Ranger
- Pediatrics, Western University, London, Ontario, Canada; Clinical Neurological Sciences, Western University, London, Ontario, Canada
| | - Karen Choong
- Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Douglas D Fraser
- Pediatrics, Western University, London, Ontario, Canada; Children's Health Research Institute, London, Ontario, Canada; Clinical Neurological Sciences, Western University, London, Ontario, Canada; Physiology and Pharmacology, Western University, London, Ontario, Canada; Translational Research Centre, London, Ontario, Canada.
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60
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Kawsar KA, Inam MB, Watts C. Diabetes insipidus-an extremely rare complication from replacement of an external ventricular drain. Acta Neurochir (Wien) 2019; 161:1377-1380. [PMID: 31073783 DOI: 10.1007/s00701-019-03937-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 04/29/2019] [Indexed: 11/25/2022]
Abstract
Insertion of an external ventricular drain (EVD) is one of the most common and most important lifesaving procedures encountered in the neurologic intensive care unit, but often done by the junior members of the team. A good number of complications may follow the insertion of EVD. In the available literature, only one case was reported with the placement of EVD in suprasellar cistern. There is no report of insertion or replacement of an EVD in the sella. Diabetes insipidus (DI) is also an unheard of complication of EVD. Here, we report a case where a patient with subarachnoid haemorrhage (SAH) with acute hydrocephalus needed CSF diversion and had an EVD, during replacement of which through the same tract, the new EVD went into the sellar floor and she developed diabetes insipidus (DI) eventually. The catheter was pulled out and the DI settled. DI may occur as a consequence of SAH. The rationale behind reporting this case is to differentiate the cause of DI; as following insertion of EVD in a patient of SAH, the development of DI should raise the suspicion of misplaced EVD, should not be left as a consequence of SAH and appropriate imaging should be obtained. To prevent this happening, preoperative verification of CT, image-guided insertion, measurement of the length of the tubing and careful anchorage of EVD to surrounding tissue are necessary.
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Affiliation(s)
| | - Masna Bin Inam
- Queen Elizabeth Hospital, Mindelsohn Way, Birmingham, B15 2TH, UK
| | - Colin Watts
- Queen Elizabeth Hospital, Mindelsohn Way, Birmingham, B15 2TH, UK
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61
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Xia D, Jiang X, Li Z, Jin Y, Dai Y. External ventricular drainage combined with continuous lumbar drainage in the treatment of ventricular hemorrhage. Ther Clin Risk Manag 2019; 15:677-682. [PMID: 31213820 PMCID: PMC6549662 DOI: 10.2147/tcrm.s207750] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 04/30/2019] [Indexed: 12/02/2022] Open
Abstract
Objective: Intraventricular hemorrhage (IVH) is characterized by acute onset, rapid progression, and high disability and mortality rates. In this study, we investigated the clinical effect of external ventricular drainage combined with continuous lumbar drainage in IVH treatments. Methods: 114 patients with IVH treated at the Department of Neurosurgery, First Affiliated Hospital of Wannan Medical College from January 2015 to December 2017, were included in the study. Based on the different surgical methods, patients were divided into control (n=79) and study groups (n=35). The control group was treated with external ventricular drainage, whereas the study group was treated with external ventricular drainage combined with continuous lumbar drainage. The incidence of intracranial infection and hydrocephalus was compared between the two groups. The Glasgow coma scale (GCS) and the Glasgow outcome scale (GOS) were compared between the two groups 7 days postoperatively and at follow-up visits, respectively. Results: The incidence of intracranial infection and hydrocephalus in the study group was significantly lower compared with those in the control group (P<0.05). Seven days postoperatively, the GCS score of the study group was significantly higher than that of the control group (P<0.05). At the 3-month follow-up visit, the GOS score of the study group was higher than that of the control group (P<0.05). Conclusions: Using external ventricular drainage combined with continuous lumbar drainage can reduce the incidence of intracranial infection and hydrocephalus and improve the prognoses and quality of life in patients with IVH.
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Affiliation(s)
- Dayong Xia
- Department of Neurosurgery, The First Affiliated Hospital of Wannan Medical College, Wuhu 241000, Anhui Province, People's Republic of China
| | - Xiaochun Jiang
- Department of Neurosurgery, The First Affiliated Hospital of Wannan Medical College, Wuhu 241000, Anhui Province, People's Republic of China
| | - Zhenbao Li
- Department of Neurosurgery, The First Affiliated Hospital of Wannan Medical College, Wuhu 241000, Anhui Province, People's Republic of China
| | - Yuelong Jin
- School of Public Health, Wannan Medical College, Wuhu 241000, Anhui Province, People's Republic of China
| | - Yi Dai
- Department of Neurosurgery, The First Affiliated Hospital of Wannan Medical College, Wuhu 241000, Anhui Province, People's Republic of China
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Safety and Efficacy of Intraventricular Delivery of Bone Marrow-Derived Mesenchymal Stem Cells in Hemorrhagic Stroke Model. Sci Rep 2019; 9:5674. [PMID: 30952961 PMCID: PMC6450980 DOI: 10.1038/s41598-019-42182-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 03/21/2019] [Indexed: 01/01/2023] Open
Abstract
External ventricular drain (EVD) is used clinically to relieve intracranial pressure and occasionally to deliver medications following intracerebral hemorrhage (ICH). Mesenchymal stem cell (MSC) therapy has been shown to be neuroprotective and can induce neuroregeneration in stroke models. We evaluated the safety and efficacy of delivering MSCs intraventricularly in a rat hemorrhagic stroke model. Using autologous blood, hemorrhagic stroke was induced at specific coordinates in the right basal ganglia. After 30 minutes, rats were treated with either bone marrow-derived MSCs or a phosphate-buffered saline placebo via direct intraventricular infusion. Three dosages (2 × 105/kg, 5 × 105/kg, and 1 × 106/kg) of MSCs were administered. Forelimb use asymmetry test was employed to evaluate functional improvement after cell therapy. At the end of the experiment, peripheral blood samples and organs were harvested; biochemistry, cytokine, and growth factor analysis and histology evaluations were performed to explore cell toxicity and cell fate, and the effects of MSC therapy on injury volume, anti-inflammation, and neurogenesis. Intraventricular administration of MSCs in ICH rat model showed improved behavior and alleviated brain damage. Additionally, treated ICH rats showed significantly reduced expression of IL-1α, IL-6, and IFN-γ. No obvious cell toxicity was noticed through blood chemistry and histology evaluation. None of the infused MSCs were detected at the end of the experiment. EVD is safe and effective to use as a method of delivering MSCs to treat ICH. Intraventricularly delivered MSCs have anti-inflammatory properties and a capacity to induce neurogenesis and improve function following ICH injury.
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Haber MA, Abd-El-Barr M, Gormley W, Mukundan S, Sodickson AD, Potter CA. Neurosurgical complications: what the radiologist needs to know. Emerg Radiol 2019; 26:331-340. [PMID: 30761443 DOI: 10.1007/s10140-019-01672-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 01/08/2019] [Indexed: 10/27/2022]
Abstract
Visits to the emergency department by patients who have recently undergone neurosurgery are a common occurrence, and these patients frequently receive emergent cross-sectional head imaging in order to evaluate for complications. Different neurosurgical approaches may have typical postoperative imaging findings that can be confused with pathology. Furthermore, particular abnormal postoperative imaging findings may signal an evolving complication. It is essential for the radiologist to understand common neurosurgical procedures and their potential complications in order to provide proper diagnostic evaluation of the postoperative neurosurgical patient. The purpose of this review is to assist radiologists in the evaluation of the postoperative neurosurgical patient and educate them on associated complications. Familiarity with common neurosurgical techniques and postoperative complications will help radiologists make the correct diagnosis, communicate effectively with the neurosurgeon, and expedite patient care.
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Affiliation(s)
- Matthew A Haber
- Department of Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Harvard Medical School, Boston, MA, USA.
| | - Muhammad Abd-El-Barr
- Department of Neurosurgery, Duke University Medical Center, 40 Duke Medicine Circle, Durham, NC, 27710, USA
| | - William Gormley
- Harvard Medical School, Boston, MA, USA.,Department of Neurosurgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Srinivasan Mukundan
- Harvard Medical School, Boston, MA, USA.,Division of Neuroradiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Aaron D Sodickson
- Harvard Medical School, Boston, MA, USA.,Division of Emergency Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Christopher A Potter
- Harvard Medical School, Boston, MA, USA.,Division of Neuroradiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Division of Emergency Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
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64
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Hemorrhagic Complications of External Ventriculostomy in the Aspirin and P2Y12 Response Assay Era. World Neurosurg 2019; 122:e961-e968. [DOI: 10.1016/j.wneu.2018.10.181] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 10/25/2018] [Accepted: 10/27/2018] [Indexed: 11/20/2022]
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65
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Guo R, Chen R, Yu Z, Tian R, Ren Y, You C, Ma L. Clinical Features and Prognosis of Primary Intraventricular Hemorrhage in Elderly: Single-Center Experience. World Neurosurg 2019; 124:e445-e452. [PMID: 30610977 DOI: 10.1016/j.wneu.2018.12.114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 12/11/2018] [Accepted: 12/13/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Primary intraventricular hemorrhage (PIVH) is rare in the aging population and remains a challenge for cerebrovascular surgeons. In the present study, the authors reviewed the patient characteristics, angiographic results, and treatments and determined clinical outcomes in 34 patients older than 60 years of age who were treated at West China Hospital between 2010 and 2014. METHODS The medical records of elderly patients were queried. The parameters regarding patient demographics, presenting symptoms, treatment modalities, angiographic results, and clinical outcomes were assessed and analyzed. RESULTS There were 19 male (55.9%) and 15 female (44.1%) patients, with an average age (±SD) of 67.9 ± 7.7 years in our study. The most common symptoms on presentation were headache (50%), followed by disturbance of consciousness (26.5%). Only 5 patients (14.3%) were diagnosed with underlying cerebrovascular etiologies including Moyamoya disease (5.9%), arteriovenous malformations (2.9%), and aneurysms (5.9%). Idiopathic PIVH was diagnosed in 29 patients (85.7%). Thirteen patients (38.2%) underwent surgical intervention, while 21 patients (61.8%) received conservative treatment. Twelve patients (35.3%) had an unfavorable outcome at discharge, and an unfavorable outcome was observed in 14 patients (41.2%) at the 3-month follow-up. Patients with higher Graeb score might be associated with an unfavorable outcome both in short-term and long-term follow-up. CONCLUSIONS Most PIVH patients were diagnosed with idiopathic PIVH in the elderly. Surgical treatment of aging patients should be optimized to improve clinical outcomes. The admission Graeb scores were considered to be the independent prognostic factors for both short-term and long-term outcomes.
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Affiliation(s)
- Rui Guo
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Ruiqi Chen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Zhiyuan Yu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Rui Tian
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Yanming Ren
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China.
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66
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Safety and Feasibility of Out-of-Bed Mobilization for Patients With External Ventricular Drains in a Neurosurgical Intensive Care Unit. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2018. [DOI: 10.1097/jat.0000000000000085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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67
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Berger-Estilita J, Passer M, Giles M, Wiegand J, Merz TM. Modalities and accuracy of diagnosis of external ventricular drainage-related infections: a prospective multicentre observational cohort study. Acta Neurochir (Wien) 2018; 160:2039-2047. [PMID: 30066191 DOI: 10.1007/s00701-018-3643-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 07/23/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Device infection is a major complication of placement external ventricular drains (EVD). Diagnostic features are often masked by underlying disease or cerebrospinal fluid (CSF) contamination by blood. We aim to assess which diagnostic modalities are applied for EVD-related infection (ERI) diagnosis and evaluate their accuracy. METHODS This observational prospective study included 187 adult patients with an EVD. Modalities of clinical diagnosis of ERI diagnosed by treating physicians on clinical grounds and blood and CSF analysis (clinically diagnosed ERI (CD-ERI)) were assessed prospectively. Additionally, the diagnostic accuracy of clinical and laboratory parameters for the diagnosis of culture proven ERI (CP-ERI) was evaluated, using data of the study patients and including a retrospective cohort of 39 patients with CP-ERI. RESULTS Thirty-one CD-ERIs were diagnosed in the prospective cohort. Most physicians used CSF analysis to establish the diagnosis. ROC analysis revealed an AUC of 0.575 (p = 0.0047) for the number of positive SIRS criteria and AUC of 0.5420 (p = 0.11) for the number of pathological neurological signs for diagnosis of CP-ERI. Diagnostic accuracy of laboratory values was AUC 0.596 (p = 0.0006) for serum white blood cell count (WBCC), AUC 0.550 (p = 0.2489) for serum C-reactive protein, AUC 0.644 (p < 0.0001) for CSF WBCC and AUC 0.690 for CSF WBC/red blood cell count ratio (both p < 0.0001). Neither a temporal trend in potential predictors of CP-ERI nor a correlation between clinical diagnosis and proven CSF infection was found. CONCLUSIONS Clinicians base their diagnosis of ERI mostly on CSF analysis and occurrence of fever, leading to over-diagnosis. The accuracy of the clinical diagnosis is low. Commonly used clinical and laboratory diagnostic criteria have a low sensitivity and specificity for ERI.
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68
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High CM, Andrews AW. Rehabilitation for a complex patient following cerebellar hemorrhage and obstructive hydrocephalus: A case report. Physiother Theory Pract 2018; 36:965-971. [PMID: 30198821 DOI: 10.1080/09593985.2018.1519007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND AND PURPOSE Inpatient rehabilitation facilities play an integral role in patient progress post-stroke. Cerebellar hemorrhages are an infrequent type of stroke and are therefore less discussed in the literature; however, inpatient rehabilitation continues to be an integral part of patient recovery. The purpose of this case report is to discuss the physical therapy interventions, challenges, and successes for a complex patient with a large cerebellar hemorrhage with obstructive hydrocephalus. Case Description: The patient is a 32-year-old male admitted to an inpatient rehabilitation facility. Prior to admission, the patient spent 1 month at a local hospital following a complicated recovery status post cerebellar hemorrhage with obstructive hydrocephalus. Interventions: The patient participated in at least 3 hours of combined therapy a day, split into 30- and 60-min sessions, and divided between physical, occupational, and speech therapy. Physical therapy interventions focused on various gait and coordination activities. Outcomes: The patient spent 47 days in an inpatient rehabilitation facility and demonstrated improvements in all aspects of the Functional Independence Measure®. The patient improved from an 18 to a 90 on the total FIM® score, allowing the patient to ultimately be discharged home with family able to provide 24/7 supervision.
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Affiliation(s)
| | - A Williams Andrews
- Department of Physical Therapy Education, Elon University , Elon, NC, USA
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69
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Retrospective Analysis of Ventriculitis in External Ventricular Drains. Neurol Res Int 2018; 2018:5179356. [PMID: 30245876 PMCID: PMC6139185 DOI: 10.1155/2018/5179356] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 08/14/2018] [Indexed: 01/06/2023] Open
Abstract
Background Nosocomial EVD-related ventriculitis is a major complication and a significant cause of morbidity and mortality in critically ill neurological patients. Questions remain about best management of EVDs. The purpose of this study is to compare our incidence of ventriculitis to studies using different catheters and/or antibiotic coverage schemes and determine whether c-EVD with prolonged antibiotics given for the duration of drain placement is inferior to ac-EVD with pp-abx or ac-EVD with prolonged antibiotics for prevention of ventriculitis. Methods A retrospective chart review of all patients who had EVDs placed from January 2010 through December 2015 at home institution was performed. Statistical analysis was performed using Fisher's exact test to compare incidence of ventriculitis identified in other studies with that of home institution. Results The study included 107 patients, 66 (61.7%) males and 41 (38.3%) females. Average age was 56 years ranging from 18 to 95 years. Average length of drain placement was 7.8 days ranging from 2 to 23 days. Average length of drain placement in infected drains was 13.3 days ranging from 11 to 15 days. There were 3 cases with positive CSF cultures (Staphylococcus haemolyticus and Staphylococcus epidermidis x 2). There were 2 cases with a CSF having a positive gram stain but failed to yield any bacterial growth on culture and did not meet predefined criteria. Conclusions The c-EVD with prolonged antibiotics given for the duration of drain placement is not inferior to ac-EVD with pp-abx or ac-EVD with prolonged antibiotics for prevention of ventriculitis. The c-EVD with prolonged antibiotics is superior to c-EVD with pp-abx and conventional EVD without antibiotics for prevention of ventriculitis. Selection should include considerations for antibiotic stewardship and cost effectiveness. Future studies should also utilize clinical and CSF profile criteria in addition to positive CSF cultures for identifying ventriculitis to prevent line colonization from classification as ventriculitis in analysis.
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70
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Gender and Population Variation in Craniometry and Freehand Pass Ventriculostomy. World Neurosurg 2018; 117:e194-e203. [DOI: 10.1016/j.wneu.2018.05.240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 05/30/2018] [Accepted: 05/31/2018] [Indexed: 12/25/2022]
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71
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Niesen WD, Reinhard M, Gierthmuehlen M, Fuhrer H. Sonographic-Assisted Catheter-Positioning in Intracerebral Hemorrhage. Front Neurol 2018; 9:651. [PMID: 30131765 PMCID: PMC6090040 DOI: 10.3389/fneur.2018.00651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 07/20/2018] [Indexed: 11/13/2022] Open
Abstract
Introduction: Intracerebral structures and pathologies such as intracerebral hemorrhages (ICH) can be displayed sufficiently by transcranial sonography (TCS). In some patients with ICH clot evacuation via surgery or catheter drainage to reduce secondary parenchymal injuries may be necessary. We hypothesized that bedside-placement of drainage-catheters, which is a minimal invasive evacuation-technique complicated by a higher rate of catheter misplacement can be optimized via TCS. Methods: Eleven consecutive ICH-patients diagnosed via computertomography (CT) were included in this prospective observational pilot study. All patients were examined via TCS, firstly in order to illustrate the hematoma, secondly to optimize catheter placement. Catheter placement was primarily validated via CT. Results: The TCS-depiction of ICH-extension was optimal in 10 patients; one patient showed a partially insufficient transtemporal bone window. Catheter positioning could be traced and adapted correctly via TCS-examination in all patients. Follow-up CT-scans confirmed TCS-description of catheter-positioning in all patients without any complications. Reduction of symptoms and ICH-volumes confirmed effectiveness of treatment. Conclusions: The illustration of ICH and the drainage-placement is possible via TCS in a cost- and time-efficient way.
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Affiliation(s)
- Wolf-Dirk Niesen
- Department of Neurology, Medical Center-University of Freiburg, Freiburg, Germany
| | - Matthias Reinhard
- Department of Neurology, Medical Center-University of Freiburg, Freiburg, Germany.,Department of Neurology, Medical Center Esslingen, Teaching Hospital of the University of Tuebingen, Esslingen, Germany
| | | | - Hannah Fuhrer
- Department of Neurology, Medical Center-University of Freiburg, Freiburg, Germany
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72
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Preoperative lumbar drainage placement for surgical cranioplasty. J Clin Neurosci 2018; 52:88-91. [DOI: 10.1016/j.jocn.2018.03.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/12/2018] [Indexed: 11/22/2022]
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73
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Hemorrhagic Complications Associated with Ventriculostomy in Patients Undergoing Endovascular Treatment for Intracranial Aneurysms: A Single-Center Experience. Neurocrit Care 2018; 27:11-16. [PMID: 28000128 DOI: 10.1007/s12028-016-0350-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Currently, a complete understanding of post-ventriculostomy hemorrhagic complications in subarachnoid hemorrhage due to ruptured aneurysms remains unknown. The present study evaluates the impact of periprocedural risk factors on rates of external ventricular drain (EVD)-associated hemorrhage in the setting of endovascular treatment of intracranial aneurysms. METHODS A retrospective chart review of 107 patients who underwent EVD placement within 24 h of endovascular coiling was performed. CT of head without contrast was obtained after drain placement and before endovascular treatment. Post-procedural CT was also obtained within 48 h of embolization and was reviewed for new/worsened track hemorrhages. Chi-squared test was used in evaluation. RESULTS Ninety-three of the 107 patients reviewed met the inclusion criteria. Four (25%) of the 16 patients on antiplatelet medications at presentation experienced post-EVD hemorrhage compared to 11 (14.3%) of 77 that were not (p = 0.29). Of the 13 patients given intraprocedural antiplatelets, 3 (23.1%) demonstrated hemorrhage compared to 12 (15%) of 80 not administered these medications (p = 0.46). Further, of 36 patients with intraprocedural anticoagulation, 6 (16.7%) exhibited hemorrhage compared to 9 (15.8%) of 57 in those without (p = 0.91). In 17 patients who received DVT prophylaxis, 2 (11.8%) exhibited hemorrhage compared to 13 (17.1%) of 76 who did not (p = 0.59). No post-EVD hemorrhage had attributable neurologic morbidity. CONCLUSION Our results, demonstrating no significant risk factor related to EVD-associated hemorrhage rates, support the safety of EVD placement in the peri-endovascular treatment period.
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74
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Ye Z, Ai X, Hu X, Fang F, You C. Clinical features and prognostic factors in patients with intraventricular hemorrhage caused by ruptured arteriovenous malformations. Medicine (Baltimore) 2017; 96:e8544. [PMID: 29137064 PMCID: PMC5690757 DOI: 10.1097/md.0000000000008544] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Intraventricular hemorrhage (IVH) was associated with poor outcomes in patients with intracerebral hemorrhage. IVH had a high incidence in patients with ruptured arteriovenous malformations (AVMs). In this study, we aimed to discuss the clinical features and prognostic factors of outcomes in the patients with AVM-related IVH.From January 2010 to January 2016, we collected the data of the patients with AVM-related IVH retrospectively. The data, including clinical and radiological parameters, were collected to evaluate the clinical features. Univariate and multivariate logistic regression analyses were used to identify the prognostic factors for clinical outcomes (hydrocephalus, 6-month outcomes measured by the modified Rankin scale) in our cohort.A total of 67 eligible patients were included and 19 patients (28%) only presented with IVH. Thirty-three patients (49%) presented hydrocephalus, and 12 patients (18%) presented brain ischemia. Nineteen patients (28%) had a poor outcome after 6 months. In multivariate logistic regression, subarachnoid hemorrhage (SAH) (P = .028) was associated with hydrocephalus and higher Graeb score (P = .080) tended to increase the risk of hydrocephalus. The high Glasgow coma scale (P = .010), large hematoma volume of parenchyma (P = .006), and high supplemented Spetzler-Martin (sup-SM) score (P = .041) were independent factors of the poor outcome.IVH was common in ruptured AVMs and increased the poor outcomes in patients with the ruptured AVMs. The AVM-related IVH patients had a high incidence of hydrocephalus, which was associated with brain ischemia and SAH. Patients with lower Glasgow coma scale, lower sup-SM score, and smaller parenchymal hematoma had better long-term outcomes.
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75
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Stretz C, Gao C, Greer DM, Loomis C, Gilmore EJ, Kundishora AJ, Matouk CC, Hwang DY. Intracerebral Hemorrhage with Intraventricular Extension—Getting the Prognosis Right Early. Front Neurol 2017; 8:418. [PMID: 28861039 PMCID: PMC5562676 DOI: 10.3389/fneur.2017.00418] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 07/31/2017] [Indexed: 11/25/2022] Open
Abstract
Background Early accurate outcome prognostication for patients with intracerebral hemorrhage (ICH) and accompanying intraventricular hemorrhage (IVH) is often challenging (1). Acute hydrocephalus often contributes to a poor clinical exam (2) and can portend significant morbidity and mortality (3). Accordingly, the inpatient neurologist may feel inclined to recommend limitations of care for an ICH patient admitted with a large IVH burden and poor exam. Case presentation We present a patient with significant IVH and minimal ICH who deteriorated rapidly to coma after presentation. Despite this exam, an initially non-functioning diversion of cerebrospinal fluid (CSF) and temporary halt of further attempts of CSF diversion in the setting of an early “do not resuscitate order,” our patient gradually improved and, with supportive ICU care and rehabilitation, was able to communicate and ambulate with assistance at 12 weeks. Conclusion Patients with ICH with IVH do have the capacity to improve dramatically even with relatively conservative management. Unless previous limitations of care exist, we recommend that early judgments of prognosis for patients with ICH and/or IVH should be delayed for at least 72 h until the patient’s clinical trajectory over time is better understood.
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Affiliation(s)
- Christoph Stretz
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT, United States
- *Correspondence: Christoph Stretz,
| | - Catherine Gao
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States
| | - David M. Greer
- Department of Neurology, Boston University School of Medicine, Boston, MA, United States
| | - Caitlin Loomis
- Division of Vascular Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT, United States
| | - Emily J. Gilmore
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT, United States
| | - Adam J. Kundishora
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, United States
| | - Charles C. Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, United States
- Department of Radiology and Biomedical Engineering, Yale School of Medicine, CT, United States
| | - David Y. Hwang
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT, United States
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Li Y, Yang R, Li Z, Tian B, Zhang X, Wang J, Zheng L, Wang B, Li L. Urokinase vs Tissue-Type Plasminogen Activator for Thrombolytic Evacuation of Spontaneous Intracerebral Hemorrhage in Basal Ganglia. Front Neurol 2017; 8:371. [PMID: 28824528 PMCID: PMC5540957 DOI: 10.3389/fneur.2017.00371] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 07/17/2017] [Indexed: 11/13/2022] Open
Abstract
Spontaneous intracerebral hemorrhage (ICH) is a devastating form of stroke, which leads to a high rate of mortality and poor neurological outcomes worldwide. Thrombolytic evacuation with urokinase-type plasminogen activator (uPA) or tissue-type plasminogen activator (tPA) has been showed to be a hopeful treatment for ICH. However, to the best of our knowledge, no clinical trials were reported to compare the efficacy and safety of these two fibrinolytics administrated following minimally invasive stereotactic puncture (MISP) in patients with spontaneous basal ganglia ICH. Therefore, the authors intended here to evaluate the differential impact of uPA and tPA in a retrospective study. In the present study, a total of 86 patients with spontaneous ICH in basal ganglia using MISP received either uPA (uPA group, n = 45) or tPA (tPA group, n = 41), respectively. The clinical baseline characteristics prior to the operation were collected. In addition, therapeutic responses were assessed by the short-term outcomes within 30 days postoperation, as well as long-term outcomes at 1 year postoperation. Our findings showed that, in comparison with tPA, uPA was able to better promote hematoma evacuation and ameliorate perihematomal edema, but the differences were not statistically significant. Moreover, the long-term functional outcomes of both groups were similar, with no statistical difference. In conclusion, these results provide evidence supporting that uPA and tPA are similar in the efficacy and safety for thrombolytic evacuation in combination with MISP in patients with spontaneous basal ganglia ICH.
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Affiliation(s)
- Yuqian Li
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Ruixin Yang
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Zhihong Li
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Bo Tian
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xingye Zhang
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Jiancai Wang
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Longlong Zheng
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Boliang Wang
- Department of Emergency, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Lihong Li
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
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Local Fibrinolytic Therapy for Intraventricular Hemorrhage: A Meta-Analysis of Randomized Controlled trials. World Neurosurg 2017; 107:1016-1024.e1. [PMID: 28778779 DOI: 10.1016/j.wneu.2017.07.135] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 07/20/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND The safety and efficacy of intraventricular fibrinolysis (IVF) in patients with intraventricular hemorrhage (IVH) are unclear. We aimed to determine these issues and to evaluate whether there are differences between recombinant tissue-plasminogen activator (rt-PA) and urokinase according to subgroup analyses. METHODS A meta-analysis was undertaken of randomized controlled trials in patients with IVH that compared the administration of rt-PA or urokinase through extraventricular drainage (EVD) with normal saline through EVD or EVD placement alone. RESULTS Six randomized controlled trials involving 607 patients with IVH were included; 2 trials investigated urokinase and 4 rt-PA. IVF reduced death from any cause at the end of follow-up (risk ratio [RR] 0.63, 95% confidence interval [CI] 0.47-0.83), which was driven mostly by rt-PA (RR 0.65, 95% CI 0.48-0.86). Urokinase did not reduce mortality (RR 0.30, 95% CI 0.06-1.53). However, rt-PA did not reduce the proportion of survivors with poor functional outcome (RR 1.36, 95% CI 1.04-1.77), or the composite endpoint of death and poor functional outcome (RR 0.96, 95% CI 0.83-1.11). IVF neither reduced the need for shunt placement (RR 1.06, 95% CI 0.75-1.49) nor increased ventriculitis (RR 0.57, 95% CI 0.35-0.93) and rebleeding (RR 1.65, 95% CI 0.79-3.45). CONCLUSIONS Although the use of IVF in patients with IVH appears generally safe, its benefit is limited to a reduction in mortality at the expense of an increased number of survivors with moderately-severe to severe disability. Subgroup analyses do not suggest an advantage of IVF with urokinase over rt-PA.
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78
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Perioperative Management of Adult Patients With External Ventricular and Lumbar Drains: Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care. J Neurosurg Anesthesiol 2017; 29:191-210. [DOI: 10.1097/ana.0000000000000407] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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79
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Risk Factors for Poor Outcome in Hypertensive Intraventricular Hemorrhage Treated by External Ventricular Drainage with Intraventricular Fibrinolysis. World Neurosurg 2017; 102:240-245. [DOI: 10.1016/j.wneu.2017.03.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 03/05/2017] [Accepted: 03/07/2017] [Indexed: 11/20/2022]
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80
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Yamamoto Y, Välitalo PA, van den Berg DJ, Hartman R, van den Brink W, Wong YC, Huntjens DR, Proost JH, Vermeulen A, Krauwinkel W, Bakshi S, Aranzana-Climent V, Marchand S, Dahyot-Fizelier C, Couet W, Danhof M, van Hasselt JGC, de Lange ECM. A Generic Multi-Compartmental CNS Distribution Model Structure for 9 Drugs Allows Prediction of Human Brain Target Site Concentrations. Pharm Res 2016; 34:333-351. [PMID: 27864744 PMCID: PMC5236087 DOI: 10.1007/s11095-016-2065-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 11/07/2016] [Indexed: 12/19/2022]
Abstract
Purpose Predicting target site drug concentration in the brain is of key importance for the successful development of drugs acting on the central nervous system. We propose a generic mathematical model to describe the pharmacokinetics in brain compartments, and apply this model to predict human brain disposition. Methods A mathematical model consisting of several physiological brain compartments in the rat was developed using rich concentration-time profiles from nine structurally diverse drugs in plasma, brain extracellular fluid, and two cerebrospinal fluid compartments. The effect of active drug transporters was also accounted for. Subsequently, the model was translated to predict human concentration-time profiles for acetaminophen and morphine, by scaling or replacing system- and drug-specific parameters in the model. Results A common model structure was identified that adequately described the rat pharmacokinetic profiles for each of the nine drugs across brain compartments, with good precision of structural model parameters (relative standard error <37.5%). The model predicted the human concentration-time profiles in different brain compartments well (symmetric mean absolute percentage error <90%). Conclusions A multi-compartmental brain pharmacokinetic model was developed and its structure could adequately describe data across nine different drugs. The model could be successfully translated to predict human brain concentrations. Electronic supplementary material The online version of this article (doi:10.1007/s11095-016-2065-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yumi Yamamoto
- Division of Pharmacology, Cluster Systems Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Pyry A Välitalo
- Division of Pharmacology, Cluster Systems Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Dirk-Jan van den Berg
- Division of Pharmacology, Cluster Systems Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Robin Hartman
- Division of Pharmacology, Cluster Systems Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Willem van den Brink
- Division of Pharmacology, Cluster Systems Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Yin Cheong Wong
- Division of Pharmacology, Cluster Systems Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Dymphy R Huntjens
- Quantitative Sciences, Janssen Research & Development, a Division of Janssen Pharmaceutica NV, Beerse, Belgium
| | - Johannes H Proost
- Division of Pharmacokinetics, Toxicology and Targeting, University of Groningen, Groningen, The Netherlands
| | - An Vermeulen
- Quantitative Sciences, Janssen Research & Development, a Division of Janssen Pharmaceutica NV, Beerse, Belgium
| | - Walter Krauwinkel
- Department of Clinical Pharmacology & Exploratory Development, Astellas Pharma BV, Leiden, The Netherlands
| | - Suruchi Bakshi
- Division of Pharmacology, Cluster Systems Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | | | - Sandrine Marchand
- Department of Medicine and Pharmacy, University of Poitiers, Poitiers, France
| | - Claire Dahyot-Fizelier
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Center of Poitiers, Poitiers, France
| | - William Couet
- Department of Medicine and Pharmacy, University of Poitiers, Poitiers, France
| | - Meindert Danhof
- Division of Pharmacology, Cluster Systems Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Johan G C van Hasselt
- Division of Pharmacology, Cluster Systems Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Elizabeth C M de Lange
- Division of Pharmacology, Cluster Systems Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands.
- Leiden University Gorlaeus Laboratories, Einsteinweg 55, 2333CC, Leiden, The Netherlands.
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Guo R, Ma L, Shrestha BK, Yu Z, Li H, You C. A retrospective clinical study of 98 adult idiopathic primary intraventricular hemorrhage cases. Medicine (Baltimore) 2016; 95:e5089. [PMID: 27759637 PMCID: PMC5079321 DOI: 10.1097/md.0000000000005089] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The aim of the study is to define the clinical features, risk factors, treatment and prognosis of idiopathic primary intraventricular hemorrhage (IPIVH).We retrospectively collected the data of consecutively admitted patients who were diagnosed and treated for IPIVH in our hospital from January 2010 to December 2014. The clinical information, treatment, and prognosis at the 6-month follow-up were analyzed.Among the 3798 cases of spontaneous intracranial hemorrhage (ICH), 98 IPIVH (2.58%) patients were recruited for the study. The study population consisted of 60 males and 38 females, with an average age (± standard deviation, SD) of 51.20 ± 15.48 years. The initial symptoms were headache (75 cases) and impaired consciousness (23 cases). The surgical treatments included hematoma evacuation under a microscope or an endoscope in 8 cases (8.16%), external ventricular drainage (EVD) in 11 cases (11.22%), lumbar drainage (LD) in 10 cases (10.20%), and a combination of EVD and LD in 11 cases (11.22%). In total, 4 patients died in the hospital (4.08%). At the 6-month follow-up, 73 patients (74.49%) had an improved outcome (modified Rankin scale [mRS] < 3), and 21 patients (21.43%) had a poor outcome (mRS ≥ 3 points) at the end of the 6-month follow-up.IPIVH is rare in clinical practice, and hypertension is the most common risk factor. Furthermore, the treatment of IPIVH is still controversial. Hematoma evacuation under a microscope or an endoscope, EVD, LD and a combination of EVD and LD could be surgical options for the treatment of IPIVH patients. The outcomes for IPIVH patients could be relatively favorable with individualized treatment.
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Affiliation(s)
| | | | | | | | | | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
- Correspondence: Chao You, Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China (e-mail: )
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Cho S, Bales J, Tran TK, Korab G, Khandelwal N, Joffe AM. Effects of 14 Versus 21 Days of Nimodipine Therapy on Neurological Outcomes in Aneurysmal Subarachnoid Hemorrhage Patients. Ann Pharmacother 2016; 50:718-24. [PMID: 27273676 DOI: 10.1177/1060028016653138] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Oral nimodipine is standard therapy for patients suffering an aneurysmal subarachnoid hemorrhage (aSAH). During a national drug shortage, nimodipine therapy was shortened from a 21-day course to a 14-day course at our institution. OBJECTIVE The objective of this study was to compare neurological outcomes among patients who had previously received the standard duration of therapy compared with those who received a shortened duration as a result of the national drug shortage. METHODS This retrospective cohort study evaluated adult patients receiving nimodipine for aSAH from January 2012 to August 2013. Neurological outcome, graded by Modified Rankin Scale (mRS) at hospital discharge, was compared between patients receiving a shortened course and those receiving the standard duration of nimodipine. RESULTS A total of 199 aSAH patients were included in the analysis. There were 164 patients in the standard-duration and 35 patients in the shortened-duration group. Baseline patient severity of illness, assessed by SAPS II (Simplified Acute Physiology Score), and severity of aSAH, assessed by Fisher grade, and Hunt and Hess grade scores, did not differ between the treatment groups. A shortened duration of nimodipine was not associated with a higher risk of a poor neurological outcome defined by mRS (odds ratio = 1.85; 95% CI = 0.54-6.32; P = 0.32). Mortality rates were similar between the groups. CONCLUSIONS A 14-day course of nimodipine therapy was not associated with worse neurological outcomes in aSAH patients at one institution. More studies are needed prior to recommending a shortened duration of nimodipine therapy in all aSAH patients.
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Affiliation(s)
- Susan Cho
- University of Washington Medical Center, Seattle, WA, USA
| | - James Bales
- University of Washington Medical Center, Seattle, WA, USA
| | | | - Gina Korab
- Harborview Medical Center, Seattle, WA, USA
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Ducis K, Thakrar R, Tranmer B. Ventriculostomies without dressings: Low infection rates but room for quality improvement. TRAUMA-ENGLAND 2016. [DOI: 10.1177/1460408615613099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective Ventriculostomies are common procedures for patients with severe neurologic insults including trauma, aneurysmal rupture, tumor, infection or following an operation. Infection secondary to a ventriculostomy, meningitis or ventriculitis, carries a high morbidity and mortality. Insertion practices and maintenance of these interventions was evaluated. Methods A retrospective review was completed of patients receiving ventriculostomies at a single institution from October 2007 through September 2013. Basic patient demographics, methods of insertion and presence of infection were collected and analyzed. Results The mean of age of patients receiving ventriculostomies was 49 years of age and the most common indications for insertion were trauma, infection and nontraumatic intracranial hemorrhage (aneurysmal subarachnoid hemorrhage (SAH), hemorrhagic stroke, arteriovenous malformation (AVM)). External ventricular drains (EVDs) were inserted after minimal hair removal at the time of procedure, tunneling following procedure and securement of EVDs with suture at exit of skin and remainder of drain stapled to scalp without additional dressing applied. The infection rate using this practice was 5.1%. Conclusion Ventriculostomies with minimal hair removal and no dressing have equivalent infection rates with the most recent published national average.
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Affiliation(s)
- Katrina Ducis
- University of Vermont Medical Center, Burlington, VT, USA
| | - Raj Thakrar
- University of Vermont Medical Center, Burlington, VT, USA
| | - Bruce Tranmer
- University of Vermont Medical Center, Burlington, VT, USA
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Godoy DA, Piñero GR, Koller P, Masotti L, Napoli MD. Steps to consider in the approach and management of critically ill patient with spontaneous intracerebral hemorrhage. World J Crit Care Med 2015; 4:213-229. [PMID: 26261773 PMCID: PMC4524818 DOI: 10.5492/wjccm.v4.i3.213] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 03/03/2015] [Accepted: 06/08/2015] [Indexed: 02/06/2023] Open
Abstract
Spontaneous intracerebral hemorrhage is a type of stroke associated with poor outcomes. Mortality is elevated, especially in the acute phase. From a pathophysiological point of view the bleeding must traverse different stages dominated by the possibility of re-bleeding, edema, intracranial hypertension, inflammation and neurotoxicity due to blood degradation products, mainly hemoglobin and thrombin. Neurological deterioration and death are common in early hours, so it is a true neurological-neurosurgical emergency. Time is brain so that action should be taken fast and accurately. The most significant prognostic factors are level of consciousness, location, volume and ventricular extension of the bleeding. Nihilism and early withdrawal of active therapy undoubtedly influence the final result. Although there are no proven therapeutic measures, treatment should be individualized and guided preferably by pathophysiology. The multidisciplinary teamwork is essential. Results of recently completed studies have birth to promising new strategies. For correct management it’s important to establish an orderly and systematic strategy based on clinical stabilization, evaluation and establishment of prognosis, avoiding secondary insults and adoption of specific individualized therapies, including hemostatic therapy and intensive control of elevated blood pressure. Uncertainty continues regarding the role of surgery.
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Hughes JD, Puffer R, Rabinstein AA. Risk factors for hydrocephalus requiring external ventricular drainage in patients with intraventricular hemorrhage. J Neurosurg 2015; 123:1439-46. [PMID: 26186024 DOI: 10.3171/2015.1.jns142391] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT External ventricular drainage (EVD) after intraventricular hemorrhage (IVH) without symptomatic hydrocephalus is controversial. The object of this study was to examine indicators or the timeframe for hydrocephalus in patients not immediately treated with EVD after IVH. METHODS Records from 2007 to 2014 were searched for "intraventricular hemorrhage" or "IVH." Inclusion criteria were IVH after intracerebral hemorrhage (ICH), trauma, tumor, or vascular anomalies. Exclusion criteria were IVH with more than minimal subarachnoid hemorrhage, catastrophic ICH, layering IVH only, or hydrocephalus treated immediately with EVD. IVH was measured with the modified Graeb Score (mGS). An mGS of 5 indicates a full ventricle with dilation. Statistics included chi-square, Student's t-test, and Mann-Whitney tests; receiver operating characteristics; and uni- and multivariate logistic regression. RESULTS One hundred five patients met the criteria; of these, 30 (28.6%) required EVD. Panventricular IVH was the most common pattern (n = 49, 46.7%), with 25 of these patients (51%) requiring EVD. The median mGS was 18 ± 5.4 (range 12-29) and 9 ± 4.5 (range 2-21) in the EVD and No-EVD groups, respectively (p < 0.001). Factors associated with EVD were radiological hydrocephalus at presentation, midline shift > 5 mm, Glasgow Coma Scale (GCS) score < 8, mGS > 13, third ventricle mGS = 5, and fourth ventricle mGS = 5. On multivariate analysis, GCS score < 8 [4.02 (range 1.13-14.84), p = 0.032], mGS > 13 [3.83 (range 1.02-14.89), p = 0.046], and fourth ventricle mGS = 5 [5.01 (range 1.26-22.78), p = 0.022] remained significant. Most patients treated with EVD (n = 25, 83.3%) required it soon after presentation [6.4 ± 3.3 (range 1.5-14) hrs]. The remaining 5 patients (16.7%) had a delayed EVD requirement [70.7 ± 22.7 (range 50-104.5) hrs]. CONCLUSIONS In this study population, the risk for EVD was variable, but greater with mGS > 13, coma, and a dilated fourth ventricle. While the need for EVD occurs within the 1st day after IVH in most patients, a minority require EVD after 48 hours.
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Cui Z, Wang B, Zhong Z, Sun Y, Sun Q, Yang G, Bian L. Impact of antibiotic- and silver-impregnated external ventricular drains on the risk of infections: A systematic review and meta-analysis. Am J Infect Control 2015; 43:e23-32. [PMID: 25934064 DOI: 10.1016/j.ajic.2015.03.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 03/18/2015] [Accepted: 03/19/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND PURPOSE External ventricular drainage (EVD) is one of the most common and effective procedures in neurosurgery practice. However, catheter-related infection (CRI), which is associated with significant mortality and morbidity, plagues this procedure. We evaluated the efficacy of antibiotic-impregnated EVD (AI-EVD) and silver-impregnated EVD (SI-EVD) catheters compared with plain EVD catheters for the prevention of CRI. METHODS The authors performed an independent search of Medline, Embase, and the Cochrane Library to identify eligible studies published between January 2002 and August 2014. We searched all relevant literature using an exhaustive search strategy. Randomized controlled trials or observational studies that compared AI-EVD catheters with plain EVD catheters for the prevention of CRI were included. The quality of each included study was assessed using a risk of bias assessment tool and the Newcastle-Ottawa Scale. RevMan5.3 software (The Cochrane Collaboration, Oxford, UK) was used to perform this meta-analysis, and publication bias was investigated using funnel plot constructions and Egger test. RESULTS A total of 4 randomized and 10 observational studies involving 4,399 patients were included in this meta-analysis. Pooled results comparing AI-EVD catheters with plain EVD catheters in the management of patients with acute high intracranial pressure demonstrated the superiority of antimicrobial EVDs for the prevention of CRI with a risk induction of 62% (95% confidence interval [CI], 0.25-0.58; P < .00001). Subgroup analyses of pooled data from separate analyses of AI-EVDs and SI-EVDs showed the efficacy of both measures for CRI prevention, with a risk ratio (RR) of 0.31 (95% CI, 0.18-0.55; P < .0001) and an RR of 0.59 (95% CI, 0.40-0.88; P = .010), respectively. The protective effects of these AI-EVD catheters remained significant in the subgroup of randomized controlled trials with an RR of 0.48 (95% CI, 0.25-0.90; P = .02). A similar result was also seen after a pooled analysis of observational studies with an RR of 0.35 (95% CI, 0.21-0.60; P = .0001). The heterogeneity among studies was moderate (I(2) = 49%) and was primarily attributed to the inclusion of 1 large, positive cohort study. Publication bias was unlikely in the current meta-analysis. CONCLUSIONS Our restults indicate that both AI-EVDs and SI-EVDs are more effective than plain EVDs for the prevention of CRI. There is no conclusive evidence on the preference of AI-EVDs vs SI-EVDs because of insufficient data. Further well-designed, multicenter randomized controlled trials are required to confirm the findings of this meta-analysis.
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87
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Kwon YM, Jang SH. Neural injury by frontal approach of external ventricular drainage in stroke patients. Int J Neurosci 2015; 125:742-6. [DOI: 10.3109/00207454.2015.1012665] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Muralidharan R. External ventricular drains: Management and complications. Surg Neurol Int 2015; 6:S271-4. [PMID: 26069848 PMCID: PMC4450504 DOI: 10.4103/2152-7806.157620] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 03/26/2015] [Indexed: 01/10/2023] Open
Abstract
Background: Insertion of an External Ventricular Drain (EVD) is arguably one of the most common and important lifesaving procedures in neurologic intensive care unit. Various forms of acute brain injury benefit from the continuous intracranial pressure (ICP) monitoring and cerebrospinal fluid (CSF) diversion provided by an EVD. After insertion, EVD monitoring, maintenance and troubleshooting essentially become a nursing responsibility. Methods: Articles pertaining to EVD placement, management, and complications were identified from PubMed electronic database. Results: Typically placed at the bedside by a neurosurgeon or neurointensivist using surface landmarks under emergent conditions, this procedure has the ability to drain blood and CSF to mitigate intracranial hypertension, continuously monitor intracranial pressure, and instill medications. Nursing should ensure proper zeroing, placement, sterility, and integrity of the EVD collecting system. ICP waveform analysis and close monitoring of CSF drainage are extremely important and can affect clinical outcomes of patients. In some institutions, nursing may also be responsible for CSF sampling and catheter irrigation. Conclusion: Maintenance, troubleshooting, and monitoring for EVD associated complications has essentially become a nursing responsibility. Accurate and accountable nursing care may have the ability to portend better outcomes in patients requiring CSF drainage.
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Choudhri O, Gupta M, Feroze AH, Heit JJ, Do HM. Endovascular management of external ventricular drain-associated cerebrovascular injuries. Surg Neurol Int 2015; 5:167. [PMID: 25558425 PMCID: PMC4278086 DOI: 10.4103/2152-7806.145930] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 09/27/2014] [Indexed: 11/09/2022] Open
Abstract
Background: Placement of external ventricular drains (EVDs) is a common, life-saving neurosurgical procedure indicated across a variety of settings. While advances have made the procedure quite safe, the potential for iatrogenic morbidity and mortality continues. We document our experience with the endovascular management of three pseudoaneurysms associated with EVD placement and discuss the endovascular treatment options for EVD-associated cerebrovascular injury. Methods: We performed a retrospective analysis to identify all EVDs placed from 2008 through 2013 at our institution. In instances of EVD-associated cerebrovascular injury, all admission and subsequent radiographic studies were reviewed, including cerebral angiograms and computed tomography (CT) scans where available. Angiograms were reviewed to record the extent of vascular injury and outcomes after treatment. Results: One female and two male patients (age range, 40-75 years) were found to have developed vascular injuries associated with EVD placement. Three pseudoaneurysms, of the posterior communicating artery (PCOM), pericallosal artery branch, and the middle meningeal artery, respectively, were treated by coil and/or glue embolization. Conclusions: Although EVD-associated cerebrovascular injury remains a rare phenomenon, such procedures are not entirely benign. Endovascular repair for such lesions proves a viable, effective option.
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Affiliation(s)
- Omar Choudhri
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California 94305, USA
| | - Mihir Gupta
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California 94305, USA
| | - Abdullah H Feroze
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California 94305, USA
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, California 94305, USA
| | - Huy M Do
- Department of Radiology, Stanford University School of Medicine, Stanford, California 94305, USA
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Non-assisted versus neuro-navigated and XperCT-guided external ventricular catheter placement: a comparative cadaver study. Acta Neurochir (Wien) 2014; 156:777-85; discussion 785. [PMID: 24567037 DOI: 10.1007/s00701-014-2026-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Accepted: 01/30/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND PURPOSE Accurate placement of an external ventricular drain (EVD) for the treatment of hydrocephalus is of paramount importance for its functionality and in order to minimize morbidity and complications. The aim of this study was to compare two different drain insertion assistance tools with the traditional free-hand anatomical landmark method, and to measure efficacy, safety and precision. METHODS Ten cadaver heads were prepared by opening large bone windows centered on Kocher's points on both sides. Nineteen physicians, divided in two groups (trainees and board certified neurosurgeons) performed EVD insertions. The target for the ventricular drain tip was the ipsilateral foramen of Monro. Each participant inserted the external ventricular catheter in three different ways: 1) free-hand by anatomical landmarks, 2) neuronavigation-assisted (NN), and 3) XperCT-guided (XCT). The number of ventricular hits and dangerous trajectories; time to proceed; radiation exposure of patients and physicians; distance of the catheter tip to target and size of deviations projected in the orthogonal plans were measured and compared. RESULTS Insertion using XCT increased the probability of ventricular puncture from 69.2 to 90.2 % (p = 0.02). Non-assisted placements were significantly less precise (catheter tip to target distance 14.3 ± 7.4 mm versus 9.6 ± 7.2 mm, p = 0.0003). The insertion time to proceed increased from 3.04 ± 2.06 min. to 7.3 ± 3.6 min. (p < 0.001). The X-ray exposure for XCT was 32.23 mSv, but could be reduced to 13.9 mSv if patients were initially imaged in the hybrid-operating suite. No supplementary radiation exposure is needed for NN if patients are imaged according to a navigation protocol initially. CONCLUSION This ex vivo study demonstrates a significantly improved accuracy and safety using either NN or XCT-assisted methods. Therefore, efforts should be undertaken to implement these new technologies into daily clinical practice. However, the accuracy versus urgency of an EVD placement has to be balanced, as the image-guided insertion technique will implicate a longer preparation time due to a specific image acquisition and trajectory planning.
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Kwon HG, Jang SH. Cingulum injury by external ventricular drainage procedure: diffusion tensor tractography study. Clin Neuroradiol 2013; 25:65-7. [PMID: 24221532 DOI: 10.1007/s00062-013-0269-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2013] [Accepted: 10/21/2013] [Indexed: 12/20/2022]
Affiliation(s)
- H G Kwon
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Taegu, Republic of Korea
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Which side of lateral ventricles to choose during external ventricular drainage in patients with intraventricular hemorrhage: ipsilateral or contralateral? J Surg Res 2013; 183:720-5. [DOI: 10.1016/j.jss.2013.03.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Revised: 02/28/2013] [Accepted: 03/01/2013] [Indexed: 11/23/2022]
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Fiorella D, Peeling L, Denice CM, Sarmiento M, Woo HH. Integrated flat detector CT and live fluoroscopic-guided external ventricular drain placement within the neuroangiography suite. J Neurointerv Surg 2013; 6:457-60. [PMID: 23892444 PMCID: PMC4112487 DOI: 10.1136/neurintsurg-2013-010856] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Purpose To demonstrate the feasibility of the application of integrated flat detector (FD) CT and fluoroscopic guidance (iGuide) for the placement of external ventricular drains (EVD) within the neuroangiography suite. Methods A retrospective review of a prospectively maintained endovascular database identified six patients who underwent EVD placement using iGuide. Patient characteristics, operator, number of passes, accuracy of placement, immediate and delayed periprocedural complications and radiation exposure were assessed. Results Five patients with subarachnoid hemorrhage and one patient with a large cerebellar infarct (average age 45.5 years (range 39–53), four women) underwent EVD placement within the angiography suite using iGuide. Four procedures were performed by a neuroradiologist and two by a neurosurgeon. All catheters were placed with a single pass and all terminated within the frontal horn of the ipsilateral lateral ventricle. No parenchymal or intraventricular hemorrhages were encountered after catheter placement. No patients experienced any immediate or delayed periprocedural complications. Radiation exposure related to the FD CTs required for placement was 593.7 mGy (range 539–673). Conclusions EVD placement under combined CT and fluoroscopic control within the neuroangiography suite is feasible. The technique predictably allows optimized EVD catheter placement with a single pass. We propose that this technique could improve the accuracy, and potentially reduce the complications, of EVD insertion in cerebrovascular patients.
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Affiliation(s)
- David Fiorella
- Department of Neurological Surgery, Stony Brook University Medical Center, Stony Brook, New York, USA
| | - Lissa Peeling
- Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Christine M Denice
- Department of Neurological Surgery, Stony Brook University Medical Center, Stony Brook, New York, USA
| | | | - Henry H Woo
- Department of Neurological Surgery, Stony Brook University Medical Center, Stony Brook, New York, USA
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Abstract
Central nervous system (CNS) infections—i.e., infections involving the brain (cerebrum and cerebellum), spinal cord, optic nerves, and their covering membranes—are medical emergencies that are associated with substantial morbidity, mortality, or long-term sequelae that may have catastrophic implications for the quality of life of affected individuals. Acute CNS infections that warrant neurointensive care (ICU) admission fall broadly into three categories—meningitis, encephalitis, and abscesses—and generally result from blood-borne spread of the respective microorganisms. Other causes of CNS infections include head trauma resulting in fractures at the base of the skull or the cribriform plate that can lead to an opening between the CNS and the sinuses, mastoid, the middle ear, or the nasopharynx. Extrinsic contamination of the CNS can occur intraoperatively during neurosurgical procedures. Also, implanted medical devices or adjunct hardware (e.g., shunts, ventriculostomies, or external drainage tubes) and congenital malformations (e.g., spina bifida or sinus tracts) can become colonized and serve as sources or foci of infection. Viruses, such as rabies, herpes simplex virus, or polioviruses, can spread to the CNS via intraneural pathways resulting in encephalitis. If infection occurs at sites (e.g., middle ear or mastoid) contiguous with the CNS, infection may spread directly into the CNS causing brain abscesses; alternatively, the organism may reach the CNS indirectly via venous drainage or the sheaths of cranial and spinal nerves. Abscesses also may become localized in the subdural or epidural spaces. Meningitis results if bacteria spread directly from an abscess to the subarachnoid space. CNS abscesses may be a result of pyogenic meningitis or from septic emboli associated with endocarditis, lung abscess, or other serious purulent infections. Breaches of the blood–brain barrier (BBB) can result in CNS infections. Causes of such breaches include damage (e.g., microhemorrhage or necrosis of surrounding tissue) to the BBB; mechanical obstruction of microvessels by parasitized red blood cells, leukocytes, or platelets; overproduction of cytokines that degrade tight junction proteins; or microbe-specific interactions with the BBB that facilitate transcellular passage of the microorganism. The microorganisms that cause CNS infections include a wide range of bacteria, mycobacteria, yeasts, fungi, viruses, spirochaetes (e.g., neurosyphilis), and parasites (e.g., cerebral malaria and strongyloidiasis). The clinical picture of the various infections can be nonspecific or characterized by distinct, recognizable clinical syndromes. At some juncture, individuals with severe acute CNS infections require critical care management that warrants neuro-ICU admission. The implications for CNS infections are serious and complex and include the increased human and material resources necessary to manage very sick patients, the difficulties in triaging patients with vague or mild symptoms, and ascertaining the precise cause and degree of CNS involvement at the time of admission to the neuro-ICU. This chapter addresses a wide range of severe CNS infections that are better managed in the neuro-ICU. Topics covered include the medical epidemiology of the respective CNS infection; discussions of the relevant neuroanatomy and blood supply (essential for understanding the pathogenesis of CNS infections) and pathophysiology; symptoms and signs; diagnostic procedures, including essential neuroimaging studies; therapeutic options, including empirical therapy where indicated; and the perennial issue of the utility and effectiveness of steroid therapy for certain CNS infections. Finally, therapeutic options and alternatives are discussed, including the choices of antimicrobial agents best able to cross the BBB, supportive therapy, and prognosis.
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Affiliation(s)
- A Joseph Layon
- Pulmonary and Critical Care Medicine, Geisinger Health System, Danville, Pennsylvania USA
| | - Andrea Gabrielli
- Departments of Anesthesiology & Surgery, University of Florida College of Medicine, Gainesville, Florida USA
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Abstract
Intracranial hemorrhage (ICH) accounts for 10-15 % of all strokes, however it causes 30-50 % of stroke related mortality, disability and cost. The prevalence increases with age with only two cases/100,000/year for age less than 40 years to almost 350 cases/100,000/year for age more than 80 years. Several trials of open surgical evacuation of ICH have failed to show clear benefit over medical management. However, some small trials of minimal invasive hematoma evacuation in combination with thrombolytics have shown encouraging results. Based on these findings larger clinical trials are being undertaken to optimize and define therapeutic benefit of minimally invasive surgery in combination with thrombolytic clearance of hematoma. In this article we will review some of the background of minimally invasive surgery and the use of thrombolytics in the setting of ICH and intraventricular hemorrhage (IVH) and will highlight the early findings of MISTIE and CLEAR trials for these two entities respectively.
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El Ahmadieh TY, Adel JG, El Tecle NE, Daou MR, Aoun SG, Nanney AD, Bendok BR. Surgical treatment of elevated intracranial pressure: decompressive craniectomy and intracranial pressure monitoring. Neurosurg Clin N Am 2013; 24:375-91. [PMID: 23809032 DOI: 10.1016/j.nec.2013.03.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Surgical techniques that address elevated intracranial pressure include (1) intraventricular catheter insertion and cerebrospinal fluid drainage, (2) removal of an intracranial space-occupying lesion, and (3) decompressive craniectomy. This review discusses the role of surgery in the management of elevated intracranial pressure, with special focus on intraventricular catheter placement and decompressive craniectomy. The techniques and potential complications of each procedure are described, and the existing evidence regarding the impact of these procedures on patient outcome is reviewed. Surgical management of mass lesions and ischemic or hemorrhagic stroke occurring in the posterior fossa is not discussed herein.
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Affiliation(s)
- Tarek Y El Ahmadieh
- Department of Neurological Surgery, McGaw Medical Center, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 2210, Chicago, IL 60611, USA
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98
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Weber C, Jakola AS, Gulati S, Nygaard ØP, Solheim O. Evidence-based clinical management and utilization of new technology in European neurosurgery. Acta Neurochir (Wien) 2013; 155:747-54. [PMID: 23440373 DOI: 10.1007/s00701-013-1640-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 02/06/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Evidence-based medicine (EBM) has become one of the pillars of modern patient care. However, neurosurgery has always been an experience-based and technology-driven discipline, and it remains unknown to which extent European neurosurgeons follow high-level evidence-based recommendations. METHODS We conducted a Web-based survey with a 15-item questionnaire about evidence-based clinical management and utilization of new technology among European neurosurgeons. Two different sum scores were calculated from the questions concerning clinical practice; evidence-based treatment score and new technology score. A high evidence-based treatment score means that more clinical conditions (i.e., study questions) were managed in compliance with the available highest levels of evidence from published clinical trials. A high new technology score reflects the use of a high number of modern tools in neurosurgical practice. RESULTS A total of 239 neurosurgeons from 30 different European countries answered the questionnaire. There were large variations among European neurosurgeons in providing evidence-based care and in utilization of various modern tools. There were significant regional differences in evidence-based treatment scores and modern technology scores with higher scores in northern and western Europe. High-volume institutions were not associated with better evidence-based treatment scores, but had significantly higher new technology scores. There were significantly higher new technology scores at university hospitals and a trend towards higher evidence-based treatment scores compared to other hospitals. CONCLUSIONS Clinical management in neurosurgery does not always comply with the best available evidence and there are large regional differences in clinical management and in utilization of various modern tools. The position of evidence-based medicine in European neurosurgery seems weak and this may be a threat to the quality of care.
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99
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Kubilay Z, Amini S, Fauerbach LL, Archibald L, Friedman WA, Layon AJ. Decreasing ventricular infections through the use of a ventriculostomy placement bundle: experience at a single institution. J Neurosurg 2013; 118:514-20. [DOI: 10.3171/2012.11.jns121336] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Ventricular infection after ventriculostomy placement carries a high mortality rate. Responding to ventriculostomy infection rates, a multidisciplinary performance improvement team was formed, a comprehensive protocol for ventriculostomy placement was developed, and the efficacy was evaluated.
Methods
A best-practice protocol was developed, including hand hygiene before the procedure; prophylactic antibiotics; sterile gloves changed between preparation, draping, and procedure; hair removal by clipping for dressing adherence; skin preparation using iodine povacrylex (0.7% available iodine) and isopropyl alcohol (74%); full body and head drape; full surgical attire for the surgeon and other bedside providers; and an antimicrobial-impregnated catheter. A checklist of critical components was used to confirm proper insertion and to monitor practice. Procedure-specific infection rates were calculated using the number of infections divided by the number of patients in whom an external ventricular drainage (EVD) device was inserted × 100 (%). Data were reported back to providers and to the committee. Bundle compliance was monitored over a 4-year period.
Results
At the authors' institution, 2928 ventriculostomies were performed between the beginning of the fourth quarter of 2006 and the end of the first quarter of 2012. Although the best-evidence bundle was applied to all patients, only 588 (20.1%) were checklist monitored (increasing from 7% to 23% over the study period). The infection rate for the 2 quarters before bundle implementation was 9.2%. During the study period, the rate decreased quarterly to 2.6% and then to 0%. Over a 4-year period, the rate was 1.06% (2007), 0.66% (2008), 0.15% (2009), and 0.34% (2010); it was 0% in 2011 and the first quarter of 2012. The overall EVD infection rate was 0.46% after bundle implementation.
Conclusions
Bundle implementation including an antimicrobial-impregnated catheter dramatically decreased EVD-related infections. Training and situational awareness of appropriate practice, assisted by the checklist, plus use of the antibiotic-impregnated catheter resulted in sustained reduction in ventriculitis.
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Affiliation(s)
- Zeynep Kubilay
- 1Department of Critical Care Medicine, Geisinger Health System, Danville, Pennsylvania
| | - Shahram Amini
- 2Division of Critical Care Medicine, Department of Anesthesiology, University of Florida College of Medicine
| | | | - Lennox Archibald
- 3Department of Infection Control, Shands Hospital at the University of Florida; and
| | - William A. Friedman
- 4Department of Neurological Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - A. Joseph Layon
- 2Division of Critical Care Medicine, Department of Anesthesiology, University of Florida College of Medicine
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Abstract
Acute subarachnoid hemorrhage (SAH) is a severe and acute life-threatening cerebrovascular disease. Approximately 80% of all acute non-traumatic SAHs are the result of a ruptured cerebrovascular aneurysm. Despite advances in diagnosis and treatment a high morbidity and mortality still exists. Apart from the primary cerebral damage there are also secondary complications, such as vasospasm, rebleeding, hydrocephalus, cerebral edema or hydrocephalus. For an appropriate therapy an understanding of the extensive pathophysiology, the options in diagnostics and therapy and the complications of the disease are essential. Anesthesiologists are decisively involved in the therapy of the primary and secondary damages and subsequently in the outcome as well. This article provides an overview of the perioperative and intensive care management of patients with SAH.
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