1
|
Hallenberger TJ, Tharmagulasingam T, Licci M, Mariani L, Guzman R, Soleman J. Management of external ventricular drain: to wean or not to wean? Acta Neurochir (Wien) 2024; 166:279. [PMID: 38954061 PMCID: PMC11219415 DOI: 10.1007/s00701-024-06166-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 06/09/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE External ventricular drain (EVD) is one of the most frequent procedures in neurosurgery and around 15 to 30% of these patients require a permanent cerebrospinal fluid (CSF) diversion. The optimal EVD weaning strategy is still unclear. Whether gradual weaning compared to rapid closure, reduces the rate of permanent CSF diversion remains controversial. The aim of this trial is to compare the rates of permanent CSF diversion between gradual weaning and rapid closure of an EVD. METHODS This was a single-center, retrospective cohort study including patients between 2010 to 2020. Patients were divided into a weaning (WG) and non-weaning (NWG) group. The primary outcome was permanent CSF diversion rates, secondary outcomes included hospitalization time, EVD-related morbidity, and clinical outcome. RESULTS Out of 412 patients, 123 (29.9%) patients were excluded due to early death or palliative treatment. We registered 178 (61.6%) patients in the WG and 111 (38.4%) in the NWG. Baseline characteristics were comparable between groups. The VPS rate was comparable in both groups (NWG 37.8%; WG 39.9%, p = 0.728). EVD related infection (13.5% vs 1.8%, p < 0.001), as well as non-EVD related infection rates (2.8% vs 0%, p < 0.001), were significantly higher in the WG. Hospitalization time was significantly shorter in the NWG (WG 24.93 ± 9.50 days; NWG 23.66 ± 14.51 days, p = 0.039). CONCLUSION Gradual EVD weaning does not seem to reduce the need for permanent CSF diversion, while infection rates and hospitalization time were significantly higher/longer. Therefore, direct closure should be considered in the clinical setting.
Collapse
Affiliation(s)
- Tim Jonas Hallenberger
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | | | - Maria Licci
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
- Faculty of Medicine, University of Basel, Basel, Switzerland.
| |
Collapse
|
2
|
Park S. Emergent Management of Spontaneous Subarachnoid Hemorrhage. Continuum (Minneap Minn) 2024; 30:662-681. [PMID: 38830067 DOI: 10.1212/con.0000000000001428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE Spontaneous subarachnoid hemorrhage (SAH) carries high morbidity and mortality rates, and the emergent management of this disease can make a large impact on patient outcome. The purpose of this article is to provide a pragmatic overview of the emergent management of SAH. LATEST DEVELOPMENTS Recent trials have influenced practice around the use of antifibrinolytics, the timing of aneurysm securement, the recognition of cerebral edema and focus on avoiding a lower limit of perfusion, and the detection and prevention of delayed cerebral ischemia. Much of the acute management of SAH can be protocolized, as demonstrated by two updated guidelines published by the American Heart Association/American Stroke Association and the Neurocritical Care Society in 2023. However, the gaps in evidence lead to clinical equipoise in some aspects of critical care management. ESSENTIAL POINTS In acute management, there is an urgency to differentiate the etiology of SAH and take key emergent actions including blood pressure management and coagulopathy reversal. The critical care management of SAH is similar to that of other acute brain injuries, with the addition of detecting and treating delayed cerebral ischemia. Strategies for the detection and treatment of delayed cerebral ischemia are limited by disordered consciousness and may be augmented by monitoring and imaging technology.
Collapse
|
3
|
Garavaglia J, Hardigan T, Turner R, Monachello G, Khan MB, Hodge JO, Brandmeir NJ. Continuous Intrathecal Medication Delivery With the IRRA flow Catheter: Pearls and Early Experience. Oper Neurosurg (Hagerstown) 2024; 26:293-300. [PMID: 37819074 DOI: 10.1227/ons.0000000000000940] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/10/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Intrathecal (IT) medications are routinely introduced through catheterization of the intraventricular space or subarachnoid space. There has been sporadic use of IT medications delivered directly to the ventricle either by intermittent injection through an external ventricular drain (EVD) or by an Ommaya reservoir with a ventricular catheter. IT medication delivery through EVD has many drawbacks, including the necessary opening of a sterile system, delivery of medication in a bolus form, and requirements to clamp the EVD after medication delivery. Despite these setbacks, IT medications delivered through EVD have been used across a wide range of applications, including antibiotic delivery treatment of vasospasm with nicardipine and delivery of tissue plasminogen activator. METHODS We used a newly developed active fluid exchange device to treat various severe conditions involved in the cerebral ventricles. Here, we present our treatment protocols and advice on the techniques related to successful active fluid exchange therapy. RESULTS Seventy patients have been treated with our system with various conditions, including subarachnoid hemorrhage, intraventricular hemorrhage, ventriculitis, and cerebral abscess. Total complication rate was 14% with only 1 catheter occlusion and low rates of hemorrhage, infection, and spinal fluid leak. CONCLUSION Current continuous IT medication dosages and protocols are based on reports and consensus statements evaluating intermittent instillation of medication boluses. The pharmacokinetics of continuous dosing and the therapeutic and safety profiles of the medications need to be studied in a prospective manner to evaluate the true optimal dosing standards. Furthermore, the ability to deliver continuous, sterile medications directly through an IT route will open new avenues of pharmacotherapy that were previously closed. This report serves as a basic guide for the safe and effective use of the IRRA flow active fluid exchange catheter to deliver IT medications.
Collapse
Affiliation(s)
- Jeffrey Garavaglia
- Department of Pharmacy, Ruby Memorial Hospital, West Virginia University, Morgantown , West Virginia, USA
| | - Trevor Hardigan
- Department of Neurosurgery, Mt. Sinai Hospital, New York City , New York , USA
| | - Ryan Turner
- Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University, Morgantown , West Virginia , USA
| | - Gracie Monachello
- Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University, Morgantown , West Virginia , USA
| | - Muhammad Babar Khan
- Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University, Morgantown , West Virginia , USA
| | - Johnie O Hodge
- Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University, Morgantown , West Virginia , USA
| | - Nicholas J Brandmeir
- Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University, Morgantown , West Virginia , USA
| |
Collapse
|
4
|
Wu B, Zhou Y, Fan H, Liu Z, Wu W, Chen Z, Yan Y, Yuan W, Luo W. Cerebrospinal fluid drainage and chronic hydrocephalus in aneurysmal subarachnoid hemorrhage patients with intraventricular hemorrhage. Front Neurol 2023; 14:1302622. [PMID: 38164202 PMCID: PMC10758233 DOI: 10.3389/fneur.2023.1302622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/28/2023] [Indexed: 01/03/2024] Open
Abstract
Background Patients with intraventricular hemorrhage (IVH) are at a higher risk of developing hydrocephalus and often require external ventricular drainage or long-term ventriculoperitoneal shunt surgery. Objective To investigate whether cerebrospinal fluid drainage in patients with IVH due to aneurysmal subarachnoid hemorrhage (aSAH) reduces the incidence of chronic hydrocephalus. Method A retrospective analysis was conducted on patients with aSAH treated at our hospital between January 2020 and December 2022. The first analysis compared patients with and without IVH, while the second analysis compared IVH patients with and without chronic hydrocephalus. The third analysis compared IVH patients who underwent in different drainage methods which is lumbar drainage (LD) or external ventricular drainage (EVD). The primary outcome measure was the incidence of chronic hydrocephalus. Result Of the 296 patients hospitalized with aSAH, 108 (36.5%) had IVH, which was associated with a significantly higher incidence of chronic hydrocephalus compared to patients without IVH (49.1% vs. 16.5%, p < 0.001). Multivariate logistic regression analysis showed that IVH was independently associated with the formation of chronic hydrocephalus (OR: 3.530, 95% CI: 1.958-6.362, p < 0.001). Among the 108 IVH patients, 53 (49.1%) developed chronic hydrocephalus. Multivariate logistic regression analysis revealed that the Hunt Hess grade at admission (OR: 3.362, 95% CI: 1.146-9.863, p = 0.027) and postoperative cerebrospinal fluid drainage (OR: 0.110, 95% CI: 0.036-0.336, p < 0.001) were independent risk factors for the development of chronic hydrocephalus in IVH patients. Among all IVH patients who underwent cerebrospinal fluid drainage, 45 (75%) received continuous lumbar puncture drainage, and 15 (25%) received external ventricular drainage. Univariate analysis did not show a statistically significant difference between the two groups in terms of postoperative chronic hydrocephalus (p = 0.283). However, multivariate logistic regression analysis suggested that the drainage methods of LD and EVD might be associated with the development of chronic hydrocephalus. Conclusion The presence of IVH increases the risk of chronic hydrocephalus in patients with aSAH, and postoperative cerebrospinal fluid drainage appears to reduce this risk. The specific effects of lumbar puncture drainage and ventricular drainage on the incidence of chronic hydrocephalus require further investigation.
Collapse
Affiliation(s)
- Botao Wu
- Department of Neurosurgery, The Affiliated Zhuzhou Hospital of Xiangya Medical College, Central South University, Zhuzhou, Hunan, China
| | - Yang Zhou
- Department of Neurosurgery, The Affiliated Zhuzhou Hospital of Xiangya Medical College, Central South University, Zhuzhou, Hunan, China
| | - Hongjun Fan
- Department of Neurosurgery, The Affiliated Zhuzhou Hospital of Xiangya Medical College, Central South University, Zhuzhou, Hunan, China
| | - Zhimin Liu
- Department of Neurosurgery, The Affiliated Zhuzhou Hospital of Xiangya Medical College, Central South University, Zhuzhou, Hunan, China
| | - Wanyun Wu
- Loudi Vocational and Technical College, Loudi, Hunan, China
| | - Zebo Chen
- Department of Neurosurgery, The Affiliated Zhuzhou Hospital of Xiangya Medical College, Central South University, Zhuzhou, Hunan, China
| | - Yong Yan
- Department of Neurosurgery, The Affiliated Zhuzhou Hospital of Xiangya Medical College, Central South University, Zhuzhou, Hunan, China
| | - Wen Yuan
- Department of Neurosurgery, The Affiliated Zhuzhou Hospital of Xiangya Medical College, Central South University, Zhuzhou, Hunan, China
| | - Wei Luo
- Department of Neurosurgery, The Affiliated Zhuzhou Hospital of Xiangya Medical College, Central South University, Zhuzhou, Hunan, China
| |
Collapse
|
5
|
Solou M, Ydreos I, Papadopoulos EK, Demetriades AK, Boviatsis EJ. Management of neurological complications related to aneurysmal subarachnoid hemorrhage: A comparison of the bedside therapeutic algorithms. Surgeon 2023; 21:e328-e345. [PMID: 37451887 DOI: 10.1016/j.surge.2023.06.006] [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: 02/17/2023] [Revised: 04/09/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is of the most serious emergencies in neurosurgical practice and continues to be associated with high morbidity and mortality. Beyond securing the ruptured aneurysm to prevent a rebleed, physicians continue to be concerned about potential complications such as cerebral vasospasm-delayed cerebral ischemia (DCI), an area where management remains highly variable. This study aimed at reviewing the most recent literature and assessing any up-to-date schemes for treating the most common aSAH neurological complications in adults that can be applied in daily clinical practice towards optimising outcomes. METHODS A systematic review was performed according to PRISMA guidelines on the management of aSAH neurological complications in adults. The literature surveyed was between 2016 and 2022 inclusive, using the Pubmed search engine. Comparisons between the methods suggested by existing therapeutic algorithms were discussed. RESULTS Six stepwise algorithms assisting the decision-making for treating cerebral vasospasm-DCI were recognised and compared. No algorithm was found for the management of any other neurological complications of aSAH. Despite differences in the algorithms, induced hypertension and endovascular therapy were common treatments in all approaches. Controversy in the therapeutic process of these complications surrounds not only the variability of methods but also their optimal application towards clinical outcome optimisation. CONCLUSIONS A universal approach to managing aSAH complications is lacking. Despite advances in the techniques to secure a ruptured aneurysm, there persist a high rate of neurological deficit and mortality, and several unanswered questions. More research is required towards stratification of current treatment algorithms as per the quality of their evidence.
Collapse
Affiliation(s)
- Mary Solou
- Department of Neurosurgery, "Attikon" University General Hospital, National and Kapodistrian University, Athens Medical School, Greece.
| | - Ioannis Ydreos
- Department of Neurosurgery, "Attikon" University General Hospital, National and Kapodistrian University, Athens Medical School, Greece
| | - Evangelos K Papadopoulos
- Department of Neurosurgery, "Attikon" University General Hospital, National and Kapodistrian University, Athens Medical School, Greece
| | - Andreas K Demetriades
- Department of Neurosurgery, Royal Infirmary Edinburgh, UK; Department of Neurosurgery, Leiden University Medical Centre, the Netherlands
| | - Efstathios J Boviatsis
- Department of Neurosurgery, "Attikon" University General Hospital, National and Kapodistrian University, Athens Medical School, Greece
| |
Collapse
|
6
|
Azeem S, Ashraf M, Kamboh UA, Raza MA, Farooq M, Cheema HA, Tariq S, Choudhary N, Hussain SS, Ashraf N. Association of ABO Blood Group with Delayed Cerebral Ischemia and Clinical Outcomes Following Aneurysmal Subarachnoid Hemorrhage in Pakistan. Asian J Neurosurg 2023; 18:108-116. [PMID: 37056873 PMCID: PMC10089742 DOI: 10.1055/s-0043-1760859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
Abstract
Abstract
Background The ABO blood type, due to its various hemostaseologic properties, has been associated with several vascular diseases, including aneurysmal subarachnoid hemorrhage (aSAH). However, the role of ABO blood type in delayed cerebral ischemia (DCI) onset and other clinical outcomes after aSAH is largely unexplored. This study aimed to investigate the association between ABO blood type and outcomes after aSAH, primarily DCI.
Methods A retrospective analysis was made on the data collected from 175 aSAH patients at a tertiary supraregional neurosurgery department over 5 years. Socio-demographic factors, clinical variables (DCI, mFG, WFNS grade, and Glasgow Outcome Scale at discharge), EVD placement, and aneurysm size were analyzed for their association with ABO blood type.
Results DCI was reported in 25% of patients with ‘O’ blood type and 9.6% with ‘non-O’ blood type. A stepwise logistic regression model showed that after adjusting for BMI, mFG, WFNS grade, and EVD placement, ‘O’ type blood group was an independent risk factor for DCI, greatly increasing the risk of DCI as compared to ‘non-O’ type groups (OR = 3.27, 95% CI: 1.21–8.82).
Conclusion This study provides evidence that individuals with ‘O’ blood type may have a higher risk of DCI onset after aSAH. However, further studies are essential to address the limitations of our work and confirm our findings.
Collapse
Affiliation(s)
- Saleha Azeem
- King Edward Medical University, Lahore, Pakistan
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| | - Mohammad Ashraf
- Wolfson School of Medicine, University of Glasgow, Scotland, United Kingdom
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| | - Usman Ahmad Kamboh
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| | - Muhammad Asif Raza
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| | - Minaam Farooq
- King Edward Medical University, Lahore, Pakistan
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| | - Huzaifa Ahmad Cheema
- King Edward Medical University, Lahore, Pakistan
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| | - Simra Tariq
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| | - Nabeel Choudhary
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| | - Syed Shahzad Hussain
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
- Department of Neurosurgery, Gujranwala Medical College, Gujranwala, Pakistan
| | - Naveed Ashraf
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| |
Collapse
|
7
|
External Ventricular Drainage: A Practical Guide for Neuro-Anesthesiologists. Clin Pract 2023; 13:219-229. [PMID: 36826162 PMCID: PMC9955739 DOI: 10.3390/clinpract13010020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 02/05/2023] Open
Abstract
External ventricular drainage is often considered a life-saving treatment in acute hydrocephalus. Given the large number of discussion points, the ideal management of EVD has not been completely clarified. The objective of this study was to review the most relevant scientific evidence about the management of EVD in its main clinical scenarios. We reviewed the most recent and relevant articles about indications, timing, management, and complications of EVD in neurocritical care, with particular interest in patients with subarachnoid hemorrhage (SAH), severe traumatic brain injury (TBI), and intraventricular hemorrhage (IVH) using the following keywords alone or matching with one another: intracranial pressure, subarachnoid hemorrhage, traumatic brain injury, intraventricular hemorrhage, external ventricular drainage, cerebrospinal shunt, intracranial pressure monitoring, and ventriculoperitoneal shunt. In the management of EVD in SAH, the intermittent drainage strategy is burdened with an elevated risk of complications (e.g., clogged catheter, hemorrhage, and need for replacement). There seems to be more ventriculoperitoneal shunt dependency in rapid weaning approach-managed patients than in those treated with the gradual weaning approach. Although there is no evidence in favor of either strategy, it is conventionally accepted to adopt a continuous drainage approach in TBI patients. Less scientific evidence is available in the literature regarding the management of EVD in patients with severe TBI and intraparenchymal/intraventricular hemorrhage. EVD placement is a necessary treatment in several clinical scenarios. However, further randomized clinical trials are needed to clarify precisely how EVD should be managed in different clinical scenarios.
Collapse
|
8
|
Nelson SE, Suarez JI, Sigmon A, Hua J, Weiner C, Sair HI, Stevens RD. External ventricular drain use is associated with functional outcome in aneurysmal subarachnoid hemorrhage. Neurol Res Pract 2022; 4:25. [PMID: 35754049 PMCID: PMC9235272 DOI: 10.1186/s42466-022-00189-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 05/08/2022] [Indexed: 12/01/2022] Open
Abstract
Purpose External ventricular drains (EVD) are commonly used in aneurysmal subarachnoid hemorrhage (aSAH) patients and can be life-saving by diverting cerebrospinal fluid. However, the overall relationship between EVD use and outcome is poorly understood. Methods In an exploratory analysis of an aSAH patient cohort, we examined EVD use in relation to modified Rankin Scale (mRS) at hospital discharge and at 6 months (unfavorable outcome = mRS > 2) using univariable and multivariable analyses. Results EVDs were placed in 31 of 56 (55.4%) patients and more often in women than men (66.7% vs 35.0%, p = 0.022) despite similar rates of hydrocephalus. Women had greater ICU [18 (13.5–25) vs 11.5 (6.5–18.5) days, p = 0.014] and hospital lengths of stay (LOS) [20.5 (16.5–34) vs 13.5 (10.5–27) days, p = 0.015] than men and greater mRS at discharge [4 (3–5) vs 3 (2–3.5), p = 0.011] although mRS at 6 months was similar. Patients with EVDs had longer ICU and hospital LOS and greater mRS at discharge [5 (3–6) vs 2 (2–3), p < 0.001] and at 6 months [4 (2–6) vs 1 (0–2), p = 0.001] than those without an EVD. In multivariable models, EVD use was associated with unfavorable 6-month outcome accounting for age, sex, and admission modified Fisher scale, but not in models adjusting for Hunt and Hess scale and World Federation of Neurological Surgeons scale. Conclusion In an aSAH cohort, the use of EVDs was associated with female sex and longer LOS, and may be linked to functional outcomes at discharge and at 6 months, although these associations warrant further investigation.
Collapse
|
9
|
Rubinos C, Kwon SB, Megjhani M, Terilli K, Wong B, Cespedes L, Ford J, Reyes R, Kirsch H, Alkhachroum A, Velazquez A, Roh D, Agarwal S, Claassen J, Connolly ES, Park S. Predicting Shunt Dependency from the Effect of Cerebrospinal Fluid Drainage on Ventricular Size. Neurocrit Care 2022; 37:670-677. [PMID: 35750930 PMCID: PMC9847349 DOI: 10.1007/s12028-022-01538-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 05/19/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Prolonged external ventricular drainage (EVD) in patients with subarachnoid hemorrhage (SAH) leads to morbidity, whereas early removal can have untoward effects related to recurrent hydrocephalus. A metric to help determine the optimal time for EVD removal or ventriculoperitoneal shunt (VPS) placement would be beneficial in preventing the prolonged, unnecessary use of EVD. This study aimed to identify whether dynamics of cerebrospinal fluid (CSF) biometrics can temporally predict VPS dependency after SAH. METHODS This was a retrospective analysis of a prospective, single-center, observational study of patients with aneurysmal SAH who required EVD placement for hydrocephalus. Patients were divided into VPS-dependent (VPS+) and non-VPS dependent groups. We measured the bicaudate index (BCI) on all available computed tomography scans and calculated the change over time (ΔBCI). We analyzed the relationship of ΔBCI with CSF output by using Pearson's correlation. A k-nearest neighbor model of the relationship between ΔBCI and CSF output was computed to classify VPS. RESULTS Fifty-eight patients met inclusion criteria. CSF output was significantly higher in the VPS+ group in the 7 days post EVD placement. There was a negative correlation between delta BCI and CSF output in the VPS+ group (negative delta BCI means ventricles become smaller) and a positive correlation in the VPS- group starting from days four to six after EVD placement (p < 0.05). A weighted k-nearest neighbor model for classification had a sensitivity of 0.75, a specificity of 0.70, and an area under the receiver operating characteristic curve of 0.80. CONCLUSIONS The correlation of ΔBCI and CSF output is a reliable intraindividual biometric for VPS dependency after SAH as early as days four to six after EVD placement. Our machine learning model leverages this relationship between ΔBCI and cumulative CSF output to predict VPS dependency. Early knowledge of VPS dependency could be studied to reduce EVD duration in many centers (intensive care unit length of stay).
Collapse
Affiliation(s)
- Clio Rubinos
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Neurology, Columbia University, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Soon Bin Kwon
- Department of Neurology, Columbia University, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University, New York, NY, USA
| | - Murad Megjhani
- Department of Neurology, Columbia University, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University, New York, NY, USA
| | - Kalijah Terilli
- Department of Neurology, Columbia University, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University, New York, NY, USA
| | - Brenda Wong
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Lizbeth Cespedes
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Jenna Ford
- Department of Neurology, Columbia University, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Renz Reyes
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Hannah Kirsch
- Department of Neurology, Columbia University, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Ayham Alkhachroum
- Department of Neurology, Columbia University, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Angela Velazquez
- Department of Neurology, Columbia University, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - David Roh
- Department of Neurology, Columbia University, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Sachin Agarwal
- Department of Neurology, Columbia University, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Columbia University, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - E Sander Connolly
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
- Department of Neurosurgery, Columbia University, New York, NY, USA
| | - Soojin Park
- Department of Neurology, Columbia University, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA.
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University, New York, NY, USA.
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA.
- Department of Biomedical Informatics, Columbia University, New York, NY, USA.
| |
Collapse
|
10
|
Wang B, Gao L, Zhang Y, Su MM, Shi W, Wang Y, Ge SN, Zhu G, Guo H, Gao F, Shi YW, Cui WX, Li ZH, Qu Y, Wang XL. Pre-operative external ventricle drainage improves neurological outcomes for patients with traumatic intracerebellar hematomas. Front Neurol 2022; 13:1006227. [DOI: 10.3389/fneur.2022.1006227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/02/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesTraumatic intracerebellar hematoma (TICH) is a very rare entity with a high morbidity and mortality rate, and there is no consensus on its optimal surgical management. In particular, whether and when to place external ventricle drainage in TICH patients without acute hydrocephalus pre-operation is still controversial.MethodsA single-institutional, retrospective analysis of total of 47 TICH patients with craniectomy hematoma evacuation in a tertiary medical center from January 2009 to October 2020 was performed. Primary outcomes were mortality in hospital and neurological function evaluated by GOS at discharge and 6 months after the ictus. Special attention was paid to the significance of external ventricular drainage (EVD) in TICH patients without acute hydrocephalus on admission.ResultsAnalysis of the clinical characteristics of the TICH patients revealed that the odds of use of EVD were seen in patients with IVH, fourth ventricle compression, and acute hydrocephalus. Placement of EVD at the bedside can significantly improve the GCS score before craniotomy, as well as the neurological score at discharge and 6 months. Compared with the only hematoma evacuation (HE) group, there is a trend that EVD can reduce hospital mortality and decrease the occurrence of delayed hydrocephalus, although the difference is not statistically significant. In addition, EVD can reduce the average NICU stay time, but has no effect on the total length of stay. Moreover, our data showed that EVD did not increase the risk of associated bleeding and intracranial infection. Interestingly, in terms of neurological function at discharge and 6 month after the ictus, even though without acute hydrocephalus on admission, the TICH patients can still benefit from EVD insertion.ConclusionFor TICH patients, perioperative EVD is safe and can significantly improve neurological prognosis. Especially for patients whose GCS dropped by more than 2 points before the operation, EVD can significantly improve the patient's GCS score, reduce the risk of herniation, and gain more time for surgical preparation. Even for TICH patients without acute hydrocephalus on admission CT scan, EVD placement still has positive clinical significance.
Collapse
|
11
|
Siddique HH, Elkambergy H, Bayrlee A, Abulhasan YB, Roser F, Dibu JR. Management of External Ventricular Drains and Related Complications: a Narrative Review. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00725-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
12
|
Predictive Values for Time from Transducer Stopcock Closure to Accurate Intracranial Pressure Reading. Neurocrit Care 2022; 38:422-428. [PMID: 35999410 DOI: 10.1007/s12028-022-01581-5] [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: 05/25/2022] [Accepted: 07/29/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND When using an external ventricular drain (EVD) to monitor intracranial pressure (ICP), nurses need to know how long to wait after each manipulation of the transducer before the displayed ICP value represents an accurate signal. This study explores ICP signal equilibration time (EqT) under clinical conditions. METHODS This was a prospective ex vivo study using a simulated skull, standard EVD tubing, and a strain gauge transducer. All 270 trials simulating 90 combinations of different pressures and common clinical conditions were completed in August 2021. Each trial was recorded on video. Videos were scored using video editing software to obtain the exact start and stop time for each trial. RESULTS The mean EqT was 44.90 (18.77) seconds. One hundred fifty (55.56%) observations did not reach their expected value within 60 s. The longest mean EqTs were noted when blood was present in the EVD tubing (57.67 [8.91] seconds), when air bubbles were in the tubing (57.41 [8.73] seconds), and when EVD tubing was not flat (level) (50.77 [15.43] seconds). An omnibus test comparing mean EqT for conditions with no variables manipulated (30.08 [16.07] seconds) against mean EqT for all others (47.18 [18.13] seconds) found that mean EqTs were significantly different (P < 0.001). CONCLUSIONS Even when no additional variables were introduced, the mean EqTs were ~ 30 s. Common clinical variables increase the length of time before a transducer connected to an EVD will provide an accurate reading. Nurses should wait at least 30 s after turning the EVD stopcock before assuming ICP value reflects accurate ICP.
Collapse
|
13
|
Fu P, Zhang Y, Zhang J, Hu J, Sun Y. Prediction of Intracranial Infection in Patients under External Ventricular Drainage and Neurological Intensive Care: A Multicenter Retrospective Cohort Study. J Clin Med 2022; 11:jcm11143973. [PMID: 35887741 PMCID: PMC9317602 DOI: 10.3390/jcm11143973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/23/2022] [Accepted: 07/05/2022] [Indexed: 12/02/2022] Open
Abstract
Objective: To generate an optimal prediction model along with identifying major contributors to intracranial infection among patients under external ventricular drainage and neurological intensive care. Methods: A retrospective cohort study was conducted among patients admitted into neurointensive care units between 1 January 2015 and 31 December 2020 who underwent external ventricular drainage due to traumatic brain injury, hydrocephalus, and nonaneurysmal spontaneous intracranial hemorrhage. Multivariate logistic regression in combination with the least absolute shrinkage and selection operator regression was applied to derive prediction models and optimize variable selections. Other machine-learning algorithms, including the support vector machine and K-nearest neighbor, were also applied to derive alternative prediction models. Five-fold cross-validation was used to train and validate each model. Model performance was assessed by calibration plots, receiver operating characteristic curves, and decision curves. A nomogram analysis was developed to explicate the weights of selected features for the optimal model. Results: Multivariate logistic regression showed the best performance among the three tested models with an area under curve of 0.846 ± 0.006. Six variables, including hemoglobin, albumin, length of operation time, American Society of Anesthesiologists grades, presence of traumatic subarachnoid hemorrhage, and a history of diabetes, were selected from 37 variable candidates as the top-weighted prediction features. The decision curve analysis showed that the nomogram could be applied clinically when the risk threshold is between 20% and 100%. Conclusions: The occurrence of external ventricular-drainage-associated intracranial infections could be predicted using optimal models and feature-selection approaches, which would be helpful for the prevention and treatment of this complication in neurointensive care units.
Collapse
Affiliation(s)
- Pengfei Fu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai 200040, China; (P.F.); (J.Z.)
| | - Yi Zhang
- Engineering Research Center of Traditional Chinese Medicine Intelligent Rehabilitation Ministry of Education, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China;
| | - Jun Zhang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai 200040, China; (P.F.); (J.Z.)
| | - Jin Hu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai 200040, China; (P.F.); (J.Z.)
- Correspondence: (J.H.); (Y.S.); Tel.: +86-173-1782-1354 (J.H.); +86-134-7275-5168 (Y.S.)
| | - Yirui Sun
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai 200040, China; (P.F.); (J.Z.)
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China
- National Center for Neurological Disorders, Shanghai 200031, China
- Correspondence: (J.H.); (Y.S.); Tel.: +86-173-1782-1354 (J.H.); +86-134-7275-5168 (Y.S.)
| |
Collapse
|
14
|
Khan MM, Shaikh N, Yousaf Z, Sultan H, Sadek G, Khan A, Kamran S, Ahmed AZ, Albanna W, Belkhair S, Ayyad A. Risk Factors for Cerebral Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage: A Tertiary Care Center Experience. Asian J Neurosurg 2022; 17:242-247. [PMID: 36120624 PMCID: PMC9473800 DOI: 10.1055/s-0042-1750838] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objectives
Cerebral vasospasm in subarachnoid hemorrhage (SAH) is associated with high morbidity and mortality. There is a lack of consensus on the risk factors leading to cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage (aSAH). In this retrospective study, our objective was to determine the association of risk factors for cerebral vasospasm aSAH.
Methods
A total of 259 charts of aSAH patients consecutively admitted to the surgical intensive care unit of Hamad General Hospital from January 2007 to December 2016 were reviewed and included. The patient's demographic data, including comorbidities like hypertension (HTN), was recorded. Variables of interest included measurements of the neurological deficit on admission, the severity of SAH, treatment modality, and the initial computerized tomography scan of the head for intraventricular hemorrhage, intracerebral hemorrhage, or hydrocephalus. Multivariate analysis and multiple logistic regression analyzed the relationship to identify the association of independent variables.
Results
Out of the 259 patients, 34% (
n
= 87) suffered from cerebral vasospasm. The severity of SAH was associated with the development of cerebral vasospasm (
p
< 0.05). The presence of HTN and neurological deficits on admission were associated with an increased risk of cerebral vasospasm (
p
< 0.05,
p
< 0.01, respectively). Hydrocephalus requiring treatment using external ventricular drains decreased the risk of cerebral vasospasm (
p
< 0.05). Intraventricular and intracerebral hemorrhage were not associated with cerebral vasospasm (
p
= 0.25,
p
= 0.16). The endovascular treatment of cerebral aneurysms was associated with an increased risk of cerebral vasospasm (
p
< 0.05).
Conclusion
Cerebral vasospasm is common among patients admitted with aSAH. It is significantly associated with the history of HTN, the neurological deficit on admission that corelates more strongly to the motor deficit on admission, the severity of hemorrhage (modified Fischer score), and endovascular treatment. External ventricular drainage was associated with a decrease in cerebral vasospasm. The present study's findings shed light on cerebral vasospasm's risk factors in the country and the region.
Collapse
Affiliation(s)
| | - Nissar Shaikh
- Surgical Intensive Care Unit, Hamad Medical Corporation, Doha, Qatar
| | - Zohaib Yousaf
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Hussain Sultan
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | - George Sadek
- Weill Cornell Medicine, Education City, Al Luqta St, Ar-Rayyan, Qatar
| | - Adnan Khan
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | - Saadat Kamran
- Weill Cornell Medicine, Education City, Al Luqta St, Ar-Rayyan, Qatar
- Department of Neurology, Hamad Medical Corporation, Doha, Qatar
| | - Ayman Z. Ahmed
- Department of Neurology, Hamad Medical Corporation, Doha, Qatar
- Department of Neurosurgery, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Walid Albanna
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Sirajeddin Belkhair
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
- Department of Neurosurgery, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Ali Ayyad
- Department of Neurosurgery, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
- Department of Neurosurgery, Saarland University Hospital, Homburg, Germany
| |
Collapse
|
15
|
Bibu S, Iliceto A, Chukwuneke F, Munier S, Stecy M, Green B, Lee K. Predicting Ventriculoperitoneal Shunt Dependence in High Grade Aneurysmal Subarachnoid Hemorrhage. J Intensive Care Med 2022; 37:1460-1466. [PMID: 35171726 DOI: 10.1177/08850666221080073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Aneurysmal subarachnoid hemorrhage (aSAH) commonly presents with hydrocephalus due to obstruction of cerebrospinal fluid (CSF) passage across the ventricular system in the brain. Placement of an external ventricular device (EVD) and in some cases ventriculoperitoneal shunt (VPS) are often necessary for patients requiring prolonged CSF diversion. The study aimed at evaluating critical factors that play a role in determining the need for extended extraventricular drainage. METHODS We performed a retrospective observational cohort study of two groups of patients with radiological imaging confirmed high grade aSAH (Hunt & Hess grades 3-5) who required VPS placement, shunt-dependent group, and who did not require long term CSF diversion, non-shunt-dependent group. We collected and analyzed data regarding the daily CSF output for 10 days following EVD placement, daily EVD height, intracranial pressure (ICP) and cerebral perfusion pressure (CPP), indicators of hydrocephalus, and CSF characteristics. RESULTS The cohort, comprising of 8 patients in the shunt-dependent group and 32 patients in the non-shunt-dependent group, displayed median daily CSF output of 275.1 mL/day and 193.4 mL/day, respectively (P = .0005). ROC curve for CSF drainage for the two groups showed an area under the curve (AUC) of 0.71 with a 95% confidence interval (CI) 0.65 to 0.77. Qualitative analysis of CSF characteristics revealed that the shunt-dependent group had more proteinaceous, darker red color, and greater proportion of red blood cells (RBCs) although not statistically significant. CONCLUSIONS Determinants of prolonged CSF drainage requirements in patients with high grade aSAH are not fully elucidated to this date and there is no standardized protocol for CSF diversion. Our study revealed potential markers that can be used in the assessment for the need for long term CSF diversion. Our limited sample size necessitates further research to establish clear correlations and cutoffs of these parameters in predicting long term CSF diversion requirements.
Collapse
Affiliation(s)
- Steve Bibu
- 12287Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | | | | | - Sean Munier
- 12287Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Madeline Stecy
- 12287Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Bryan Green
- 12287Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Kiwon Lee
- 12287Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| |
Collapse
|
16
|
Chang H, Silva MA, Giner A, Ancheta S, Romano JG, Komotar R, Cajigas I. Effects of an external ventricular drain alert protocol on venticulostomy placement time in the emergency department. Neurosurg Focus 2021; 51:E4. [PMID: 34724637 DOI: 10.3171/2021.8.focus21378] [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: 06/26/2021] [Accepted: 08/23/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Timely ventriculostomy placement is critical in the management of neurosurgical emergencies. Prompt external ventricular drain (EVD) placement has been shown to improve long-term patient outcomes and decrease the length of ICU and hospital stays. Successful and efficient EVD placement requires seamless coordination among multiple healthcare teams. In this study, the authors sought to identify factors favoring delayed ventriculostomy via a quality improvement initiative and to implement changes to expedite EVD placement. METHODS Through process mapping, root cause analysis, and interviews with staff, the authors identified the lack of a standardized mechanism for alerting necessary healthcare teams as a major contributor to delays in EVD placement. In December 2019, an EVD alert system was developed to automatically initiate an EVD placement protocol and to alert the neurosurgery department, pharmacy, core laboratory, and nursing staff to prepare for EVD placement. The time to EVD placement was tracked prospectively using time stamps in the electronic medical record. RESULTS A total of 20 patients who underwent EVD placement between December 2019 and April 2021, during the EVD alert protocol initiation, and 18 preprotocol control patients (January 2018 to December 2019) met study inclusion criteria and were included in the analysis. The mean time to EVD placement in the control group was 71.88 minutes compared with 50.3 minutes in the EVD alert group (two-tailed t-test, p = 0.025). The median time to EVD placement was 64 minutes in the control group compared with 52 minutes in the EVD alert group (rank-sum test, p = 0.0184). All patients from each cohort exhibited behavior typical of stable processes, with no violation of Shewhart rules and no special cause variations on statistical process control charts. CONCLUSIONS A quality improvement framework helped identify sources of delays to EVD placement in the emergency department. An automated EVD alert system was a simple intervention that significantly reduced the time to EVD placement in the emergency department and can be easily implemented at other institutions to improve patient care.
Collapse
Affiliation(s)
- Henry Chang
- 1University of Miami Miller School of Medicine, Miami; and
| | - Michael A Silva
- 1University of Miami Miller School of Medicine, Miami; and.,Departments of2Neurosurgery
| | | | - Selina Ancheta
- 5Quality and Patient Safety, Jackson Memorial Hospital, Miami, Florida
| | | | - Ricardo Komotar
- 1University of Miami Miller School of Medicine, Miami; and.,Departments of2Neurosurgery
| | - Iahn Cajigas
- 1University of Miami Miller School of Medicine, Miami; and.,Departments of2Neurosurgery
| |
Collapse
|
17
|
Chung DY, Thompson BB, Kumar MA, Mahta A, Rao SS, Lai JH, Tadevosyan A, Kessler K, Locascio JJ, Patel AB, Mohamed W, Olson DM, John S, Rordorf GA. Association of External Ventricular Drain Wean Strategy with Shunt Placement and Length of Stay in Subarachnoid Hemorrhage: A Prospective Multicenter Study. Neurocrit Care 2021; 36:536-545. [PMID: 34498207 DOI: 10.1007/s12028-021-01343-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 08/26/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Survivors of aneurysmal subarachnoid hemorrhage (SAH) face a protracted intensive care unit (ICU) course and are at risk for developing refractory hydrocephalus with the need for a permanent ventriculoperitoneal shunt (VPS). Management of the external ventricular drain (EVD) used to provide temporary cerebrospinal fluid diversion may influence the need for a VPS, ICU length of stay (LOS), and drain complications, but the optimal EVD management approach is unknown. Therefore, we sought to determine the effect of EVD discontinuation strategy on VPS rate. METHODS This was a prospective multicenter observational study at six neurocritical care units in the United States. The target population included adults with suspected aneurysmal SAH who required an EVD. Patients were preassigned to rapid or gradual EVD weans based on their treating center. The primary outcome was the rate of VPS placement. Secondary outcomes were EVD duration, ICU LOS, hospital LOS, and drain complications. RESULTS A rapid EVD wean protocol was associated with a lower rate of VPS placement, including a delayed posthospitalization shunt, in an adjusted Cox proportional analysis (hazard ratio 0.52 [p = 0.041]) and adjusted logistic regression model (odds ratio 0.43 [95% confidence interval 0.18-1.03], p = 0.057). A rapid wean was also associated with 2.1 fewer EVD days (p = 0.007) and saved an estimated 2.5 ICU days (p = 0.049), as compared with a gradual wean protocol. There were fewer nonfunctioning EVDs in the rapid group (odds ratio 0.32 [95% confidence interval 0.11-0.92]). Furthermore, we found that the time to first wean and the number of weaning attempts were important independent covariates that affected the likelihood of receiving a VPS and the duration of ICU admission. CONCLUSIONS A rapid EVD wean was associated with decreased rates of VPS placement, decreased ICU LOS, and decreased drain complications in survivors of aneurysmal SAH. These findings suggest that a randomized multicentered controlled study comparing rapid vs. gradual EVD weaning protocols is justified.
Collapse
Affiliation(s)
- David Y Chung
- Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA. .,Neurovascular Research Unit, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA.
| | - Bradford B Thompson
- Departments of Neurology and Neurosurgery, Alpert Medical School, Rhode Island Hospital, Brown University, Providence, RI, USA
| | - Monisha A Kumar
- Department of Neurology, Perelman School of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA, USA
| | - Ali Mahta
- Departments of Neurology and Neurosurgery, Alpert Medical School, Rhode Island Hospital, Brown University, Providence, RI, USA
| | - Shyam S Rao
- Departments of Neurology and Neurosurgery, Alpert Medical School, Rhode Island Hospital, Brown University, Providence, RI, USA
| | - James H Lai
- Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA.,Neurovascular Research Unit, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Aleksey Tadevosyan
- Department of Neurology, Perelman School of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA, USA
| | - Kathryn Kessler
- Department of Neurology, Perelman School of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph J Locascio
- Biostatistics Center, Division of Clinical Research, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Wazim Mohamed
- Department of Neurology, Detroit Medical Center, Wayne State University, Detroit, MI, USA
| | - DaiWai M Olson
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sayona John
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Guy A Rordorf
- Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA
| |
Collapse
|
18
|
Dodd WS, Laurent D, Dumont AS, Hasan DM, Jabbour PM, Starke RM, Hosaka K, Polifka AJ, Hoh BL, Chalouhi N. Pathophysiology of Delayed Cerebral Ischemia After Subarachnoid Hemorrhage: A Review. J Am Heart Assoc 2021; 10:e021845. [PMID: 34325514 PMCID: PMC8475656 DOI: 10.1161/jaha.121.021845] [Citation(s) in RCA: 98] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/09/2021] [Indexed: 01/23/2023]
Abstract
Delayed cerebral ischemia is a major predictor of poor outcomes in patients who suffer subarachnoid hemorrhage. Treatment options are limited and often ineffective despite many years of investigation and clinical trials. Modern advances in basic science have produced a much more complex, multifactorial framework in which delayed cerebral ischemia is better understood and novel treatments can be developed. Leveraging this knowledge to improve outcomes, however, depends on a holistic understanding of the disease process. We conducted a review of the literature to analyze the current state of investigation into delayed cerebral ischemia with emphasis on the major themes that have emerged over the past decades. Specifically, we discuss microcirculatory dysfunction, glymphatic impairment, inflammation, and neuroelectric disruption as pathological factors in addition to the canonical focus on cerebral vasospasm. This review intends to give clinicians and researchers a summary of the foundations of delayed cerebral ischemia pathophysiology while also underscoring the interactions and interdependencies between pathological factors. Through this overview, we also highlight the advances in translational studies and potential future therapeutic opportunities.
Collapse
Affiliation(s)
- William S. Dodd
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
| | - Dimitri Laurent
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
| | - Aaron S. Dumont
- Department of Neurological SurgerySchool of MedicineTulane UniversityNew OrleansLA
| | - David M. Hasan
- Department of NeurosurgeryCarver College of MedicineUniversity of IowaIowa CityIA
| | - Pascal M. Jabbour
- Department of Neurological SurgerySidney Kimmel Medical CollegeThomas Jefferson UniversityPhiladelphiaPA
| | - Robert M. Starke
- Department of Neurological SurgeryMiller School of MedicineUniversity of MiamiFL
| | - Koji Hosaka
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
| | - Adam J. Polifka
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
| | - Brian L. Hoh
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
| | - Nohra Chalouhi
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
| |
Collapse
|
19
|
Chang H, Silva M, Giner A, Diaz Y, Sosa MA, Knudsen G, Mahavadi AK, Ellis J, Cameron A, Núñez CAQ, Wynter MA, O'Phelan K, Komotar RJ, Cajigas I. Ventriculostomy supply cart decreases time-to-external ventricular drain placement in the emergency department. Surg Neurol Int 2021; 12:362. [PMID: 34350056 PMCID: PMC8330128 DOI: 10.25259/sni_371_2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 05/18/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Minimizing time-to-external ventricular drain (EVD) placement in the emergency department (ED) is critical. We sought to understand factors affecting time-to-EVD placement through a quality improvement initiative. Methods: The use of process mapping, root cause analyses, and interviews with staff revealed decentralized supply storage as a major contributor to delays in EVD placement. We developed an EVD “crash cart” as a potential solution to this problem. Time-to-EVD placement was tracked prospectively using time stamps in the electronic medical record (EMR); precart control patients were reviewed retrospectively. Results: The final cohorts consisted of 33 precart and 18 postcart cases. The mean time-to-EVD in the precart group was 99.09 min compared to 71.88 min in the postcart group (two-tailed t-test, P = 0.023). Median time-to-EVD was 92 min in the precart group compared to 64 min in the postcart group (rank sum test, P = 0.0165). Postcart patients trended toward improved outcomes with lower modified Rankin score scores at 1 year, but this did not reach statistical significance (two-tailed t-test, P = 0.177). Conclusion: An EVD “crash cart” is a simple intervention that can significantly reduce time-to-EVD placement and may improve outcomes in patients requiring an EVD.
Collapse
Affiliation(s)
- Henry Chang
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Michael Silva
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Alexander Giner
- Department of Emergency, Jackson Memorial Hospital, Miami, Florida, United States
| | - Yvonne Diaz
- Department of Medicine, Jackson Memorial Hospital, Miami, Florida, United States
| | - Marie Ann Sosa
- Department of Medicine, Jackson Memorial Hospital, Miami, Florida, United States
| | - Grace Knudsen
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Anil K Mahavadi
- Department of Neurosurgery, University of Alabama Birmingham School of Medicine, Birmingham, Alabama, United States
| | - June Ellis
- Department of Medicine, Jackson Memorial Hospital, Miami, Florida, United States
| | - Arlene Cameron
- Department of Orthopedic, Division of Neurology and Surgery, Jackson Memorial Hospital, Miami, Florida, United States
| | | | - Millicent A Wynter
- Department of Nursing Education, Jackson Memorial Hospital, Miami, Florida, United States
| | - Kristine O'Phelan
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Ricardo J Komotar
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Iahn Cajigas
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, United States
| |
Collapse
|
20
|
Kuo LT, Huang APH. The Pathogenesis of Hydrocephalus Following Aneurysmal Subarachnoid Hemorrhage. Int J Mol Sci 2021; 22:ijms22095050. [PMID: 34068783 PMCID: PMC8126203 DOI: 10.3390/ijms22095050] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/29/2021] [Accepted: 04/29/2021] [Indexed: 12/11/2022] Open
Abstract
Hydrocephalus is a common complication of aneurysmal subarachnoid hemorrhage (aSAH) and reportedly contributes to poor neurological outcomes. In this review, we summarize the molecular and cellular mechanisms involved in the pathogenesis of hydrocephalus following aSAH and summarize its treatment strategies. Various mechanisms have been implicated for the development of chronic hydrocephalus following aSAH, including alterations in cerebral spinal fluid (CSF) dynamics, obstruction of the arachnoid granulations by blood products, and adhesions within the ventricular system. Regarding molecular mechanisms that cause chronic hydrocephalus following aSAH, we carried out an extensive review of animal studies and clinical trials about the transforming growth factor-β/SMAD signaling pathway, upregulation of tenascin-C, inflammation-dependent hypersecretion of CSF, systemic inflammatory response syndrome, and immune dysregulation. To identify the ideal treatment strategy, we discuss the predictive factors of shunt-dependent hydrocephalus between surgical clipping and endovascular coiling groups. The efficacy and safety of other surgical interventions including the endoscopic removal of an intraventricular hemorrhage, placement of an external ventricular drain, the use of intraventricular or cisternal fibrinolysis, and an endoscopic third ventriculostomy on shunt dependency following aSAH were also assessed. However, the optimal treatment is still controversial, and it necessitates further investigations. A better understanding of the pathogenesis of acute and chronic hydrocephalus following aSAH would facilitate the development of treatments and improve the outcome.
Collapse
|
21
|
Abstract
Aneurysmal subarachnoid hemorrhage is a neurologic emergency that requires immediate patient stabilization and prompt diagnosis and treatment. Early measures should focus on principles of advanced cardiovascular life support. The aneurysm should be evaluated and treated in a comprehensive stroke center by a multidisciplinary team capable of endovascular and, operative approaches. Once the aneurysm is secured, the patient is best managed by a dedicated neurocritical care service to prevent and manage complications, including a syndrome of delayed neurologic decline. The goal of such specialized care is to prevent secondary injury, reduce length of stay, and improve outcomes for survivors of the disease.
Collapse
Affiliation(s)
- David Y Chung
- Division of Neurocritical Care, Department of Neurology, Boston Medical Center, Boston, MA, USA; Division of Neurocritical Care, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA; Neurovascular Research Unit, Department of Radiology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA.
| | - Mohamad Abdalkader
- Department of Neurology, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA; Department of Neurosurgery, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA; Department of Radiology, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Thanh N Nguyen
- Department of Neurology, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA; Department of Neurosurgery, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA; Department of Radiology, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
| |
Collapse
|
22
|
Esteban Garcia JM, Mato Mañas D, Marco De Lucas E, Garcia Catalan G, Lopez Gomez P, Santos Jimenez C, Laez RM. Invisible compression, anterior fossa tumor causing trigeminal neuralgia. Surg Neurol Int 2021; 12:106. [PMID: 33880211 PMCID: PMC8053474 DOI: 10.25259/sni_371_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 02/20/2021] [Indexed: 11/29/2022] Open
Abstract
Background: Trigeminal neuralgia secondary to posterior and middle fossae tumors, whether ipsilateral or contralateral, has been well described. However, this disabling disease has never been reported in the context of anterior fossa neoplasms. Case Description: A 75-year-old female with right hemifacial pain was diagnosed with an anterior clinoid meningioma. Despite neuroimaging did not show any apparent anatomical or neurovascular conflict, a detailed MRI analysis revealed a V3 hyperintensity. Not only symptoms completely resolved after surgical resection but also this radiological sign disappeared. Nowadays, the patient remains asymptomatic and V3 hyperintensity has not reappeared during her follow-up. Conclusion: A surgical definitive treatment can be offered to patients suffering from trigeminal neuralgia secondary to lesions adjacent to Gasserian ganglion or trigeminal branches. In this respect, posterior and middle fossae tumors are well-reported etiologies. Nevertheless, in the absence of evident compression, other neoplasms located in the vicinity of these critical structures and considered as radiological findings may be involved in trigeminal pain. Microvascular and pressure gradient changes could be an underlying cause of these symptoms in anterior skull base lesions. Here, we report the case of a patient with uncontrollable hemifacial pain resolved after anterior clinoid meningioma removal.
Collapse
Affiliation(s)
| | - David Mato Mañas
- Department of Neurosurgery, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Enrique Marco De Lucas
- Department of Neurosurgery, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Guillermo Garcia Catalan
- Department of Neurosurgery, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Patricia Lopez Gomez
- Department of Neurosurgery, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Carlos Santos Jimenez
- Department of Neurosurgery, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Ruben Martin Laez
- Department of Neurosurgery, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| |
Collapse
|
23
|
Capion T, Lilja-Cyron A, Juhler M, Mathiesen TI, Wetterslev J. Prompt closure versus gradual weaning of external ventricular drainage for hydrocephalus in adult patients with aneurysmal subarachnoid haemorrhage: a systematic review. BMJ Open 2020; 10:e040722. [PMID: 33243807 PMCID: PMC7692827 DOI: 10.1136/bmjopen-2020-040722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES To summarise the evidence on benefits and harms of prompt closure versus gradual weaning of external ventricular drainage (EVD) in patients with hydrocephalus following aneurysmal subarachnoid haemorrhage (aSAH) based on randomised clinical trials (RCTs) in humans. SETTING RCTs comparing prompt closure versus gradual weaning of EVD in adult patients with hydrocephalus following aSAH were included. PARTICIPANTS Patients aged equal to or greater than 18 years with an EVD due to hydrocephalus following aSAH were eligible for inclusion. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcomes were all-cause mortality, any serious adverse event, rate of ventriculoperitoneal (VP) shunt placement and quality of life. Secondary outcomes were patients with shunt failure, hospital and neuro intensive care unit (NICU) length of stay (LOS) and complications related to treatment with an EVD. Data permitted report of rate of VP shunt placement, and hospital and NICU LOS. RESULTS Six studies were assessed in full text. One RCT with 81 patients was included. Rate of VP shunt placement was 63.4% in the rapid weaning group (ie, prompt closure of the EVD; 41 patients) and 62.5% in the gradual weaning group (40 patients; p=0.932). LOS in hospital and NICU was significantly shorter in the rapidly weaned group compared with the gradually weaned group (mean 19.1 vs 21.5 days in hospital (p=0.03); and mean 14.1 vs 16.9 days in NICU (p=0.0002)). Data were insufficient to conduct meta-analysis, trial sequential analysis or subgroup analysis of heterogeneity and sensitivity. One RCT is currently ongoing. CONCLUSIONS We found insufficient evidence to favour any of the two strategies for EVD discontinuation in patients with hydrocephalus following aSAH. PROSPERO REGISTRATION NUMBER CRD42018108801.
Collapse
Affiliation(s)
- Tenna Capion
- Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Alexander Lilja-Cyron
- Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Tiit Illimar Mathiesen
- Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Jørn Wetterslev
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen, Denmark
| |
Collapse
|
24
|
Intracranial Pressure Monitoring via External Ventricular Drain: Are We Waiting Long Enough Before Recording the Real Value? J Neurosci Nurs 2020; 52:37-42. [PMID: 31899715 DOI: 10.1097/jnn.0000000000000487] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND External ventricular drain (EVD) is a standard approach for both monitoring intracranial pressure (ICP) and draining cerebrospinal fluid (CSF) for patients with subarachnoid hemorrhage. Documenting an accurate ICP value is important to assess the status of the brain, which would require the EVD system to be leveled properly and closed to CSF drainage for an adequate period. It is suggested that a minimum period of 5-minute EVD closure is needed before documenting a true ICP; however, there is no commonly agreed upon standard for documenting ICP. To obtain an insight into how well the intermittent EVD clamping procedure is performed for ICP documentation, we conducted a retrospective analysis of ICP recordings obtained through EVD from 107 patients with subarachnoid hemorrhage. METHODS The EVD was kept open for continuous CSF drainage and then intermittently closed for ICP documentation. For each EVD closure, mean ICP, standard deviation of ICP, duration of EVD closure, and time interval between 2 adjacent EVD closures were studied. The total number of EVD closures was calculated for each patient. We developed an algorithm to evaluate whether ICP reached a new equilibrium before the EVD was reopened to drainage. The percentage of EVD closures that reach the equilibrium was calculated. RESULTS The 107 patients had 32 755 EVD closures in total, among which 65.9% instances lasted less than 1 minute and only 16.3% of all the EVD closure episodes lasted longer than 5 minutes. The median duration of each EVD closure was 25 seconds (interquartile range, 10.2 seconds to 2.33 minutes). Only 22.9% of the EVD closures reached ICP equilibrium before EVD reopening. CONCLUSION A standard guideline and proper training are needed for bedside nurses, and a potential tool that can render ICP trend at a proper scale at bedside would help clinicians correctly document ICP.
Collapse
|
25
|
Hofman M, Hajder N, Duda I, Krzych ŁJ. A Questionnaire Survey of Management of Patients with Aneurysmal Subarachnoid Haemorrhage in Poland. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E4161. [PMID: 32545225 PMCID: PMC7313024 DOI: 10.3390/ijerph17114161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/06/2020] [Accepted: 06/08/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid haemorrhage (aSAH) remains a potentially devastating threat to the brain with a serious impact on mortality and morbidity. We attempted to investigate correspondence between the current guidelines for aSAH management and real clinical practice in Poland. METHODS A web-based questionnaire was performed between 03.2019 and 06.2019. Centres performing neuro-interventional radiology procedures and neuro-critical care were included (n = 29). One response from each hospital was recorded. RESULTS In three (10.4%) centres, there was no clear protocol for an interventional treatment plan. Endovascular embolisation was predominantly used in 11 (37.9%) hospitals, and microsurgical clipping, in 10 (34.5%). A written protocol for standard anaesthetic management was established only in six (20.7%) centres for coiling and in five (17.2%) for microsurgical clipping. The diagnosis of cerebral vasospasm was based on transcranial Doppler as the first-choice method in seven (24.1%) units. "3-H therapy" was applied by 15 (51.8%) respondents, and "2-H therapy", by four (13.8%) respondents. In only eight (27.6%) centres were all patients with aSAH being admitted to the ICU. CONCLUSION Many discrepancies exist between the available guidelines and clinical practice in aSAH treatment in Poland. Peri-procedural management is poorly standardised. Means must be undertaken to improve patient-oriented treatment and care.
Collapse
Affiliation(s)
- Mariusz Hofman
- Department of Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-007 Katowice, Poland; (N.H.); (I.D.); (Ł.J.K.)
| | | | | | | |
Collapse
|
26
|
Anan M, Nagai Y, Fudaba H, Fujiki M. Lactate and Lactate Dehydrogenase in Cistern as Biomarkers of Early Brain Injury and Delayed Cerebral Ischemia of Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2020; 29:104765. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.104765] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/07/2020] [Accepted: 02/13/2020] [Indexed: 01/02/2023] Open
|
27
|
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.
Collapse
|
28
|
Rouanet C, Silva GS. Aneurysmal subarachnoid hemorrhage: current concepts and updates. ARQUIVOS DE NEURO-PSIQUIATRIA 2019; 77:806-814. [DOI: 10.1590/0004-282x20190112] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 05/13/2019] [Indexed: 11/21/2022]
Abstract
ABSTRACT Aneurysmal subarachnoid hemorrhage is a condition with a considerable incidence variation worldwide. In Brazil, the exact epidemiology of aneurysmal SAH is unknown. The most common presenting symptom is headache, usually described as the worst headache ever felt. Head computed tomography, when performed within six hours of the ictus, has a sensitivity of nearly 100%. It is important to classify the hemorrhage based on clinical and imaging features as a way to standardize communication. Classification also has prognostic value. In order to prevent rebleeding, there still is controversy regarding the ideal blood pressure levels and the use of antifibrinolytic therapy. The importance of definitely securing the aneurysm by endovascular coiling or surgical clipping cannot be overemphasized. Hydrocephalus, seizures, and intracranial pressure should also be managed. Delayed cerebral ischemia is a severe complication that should be prevented and treated aggressively. Systemic complications including cardiac and pulmonary issues, sodium abnormalities, fever, and thromboembolism frequently happen and may have na impact upon prognosis, requiring proper management.
Collapse
|
29
|
Capion T, Lilja-Cyron A, Juhler M, Mathiesen TI, Wetterslev J. Prompt closure versus gradual weaning of extraventricular drainage for hydrocephalus in adult patients with aneurysmal subarachnoid haemorrhage: a systematic review protocol with meta-analysis and trial sequential analysis. BMJ Open 2019; 9:e029719. [PMID: 31575534 PMCID: PMC6797380 DOI: 10.1136/bmjopen-2019-029719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 07/25/2019] [Accepted: 08/09/2019] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION In Neuro Intensive Care Units (NICU) and neurosurgical units, patients with an external ventricular drain (EVD) due to hydrocephalus following aneurysmal subarachnoid haemorrhage (SAH) are commonly seen. Cessation of the EVD involves the dilemma of either closing the EVD directly, or gradually weaning it before removal. Development of increased intracranial pressure (ICP) and acute hydrocephalus with subsequent need of a permanent shunt has been associated with prompt closure of theEVD, whereas increased risk of infection with possible spreading to the brain and subsequent patient fatality is suspected in connection to a longer treatment as seen in gradual weaning. Sparse data exist on the recommendation of cessation strategy and patients are currently being treated on the basis of personal experience and expert opinion. The objective of this systematic review is to assess the available evidence from clinical trials on the effects of prompt closure versus gradual weaning of EVD treatment for hydrocephalus in adult patients with SAH. METHODS AND ANALYSIS We will search for randomised clinical trials in major international databases. Two authors will independently screen and select references for inclusion, extract data and assess the methodological quality of the included randomised clinical trials using the Cochrane risk of bias tool. Any disagreement will be resolved by consensus. We will analyse the extracted data using Review Manager and trial sequential analysis. To assess the quality of the evidence, we will create a 'Summary of Findings' table containing our primary and secondary outcomes using the GRADE assessment. ETHICS AND DISSEMINATION Results will be published widely according to the interest of the society. No possible impact, harm or ethical concerns are expected doing this protocol. TRIAL REGISTRATION NUMBER PROSPERO CRD42018108801.
Collapse
Affiliation(s)
- Tenna Capion
- Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Alexander Lilja-Cyron
- Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Tiit Illimar Mathiesen
- Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Jørn Wetterslev
- Copenhagen Trial Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| |
Collapse
|
30
|
Chau CYC, Craven CL, Rubiano AM, Adams H, Tülü S, Czosnyka M, Servadei F, Ercole A, Hutchinson PJ, Kolias AG. The Evolution of the Role of External Ventricular Drainage in Traumatic Brain Injury. J Clin Med 2019; 8:E1422. [PMID: 31509945 PMCID: PMC6780113 DOI: 10.3390/jcm8091422] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 09/05/2019] [Accepted: 09/05/2019] [Indexed: 02/06/2023] Open
Abstract
External ventricular drains (EVDs) are commonly used in neurosurgery in different conditions but frequently in the management of traumatic brain injury (TBI) to monitor and/or control intracranial pressure (ICP) by diverting cerebrospinal fluid (CSF). Their clinical effectiveness, when used as a therapeutic ICP-lowering procedure in contemporary practice, remains unclear. No consensus has been reached regarding the drainage strategy and optimal timing of insertion. We review the literature on EVDs in the setting of TBI, discussing its clinical indications, surgical technique, complications, clinical outcomes, and economic considerations.
Collapse
Affiliation(s)
- Charlene Y C Chau
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
| | - Claudia L Craven
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N3BG, UK
| | - Andres M Rubiano
- Neurosciences Institute, INUB-MEDITECH Research Group, El Bosque University, 113033 Bogotá, Colombia
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge CB20QQ, UK
| | - Hadie Adams
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
| | - Selma Tülü
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
- Department of Neurosurgery, Innsbruck Medical University, 6020 Innsbruck, Austria
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
| | - Franco Servadei
- Department of Neurosurgery, Humanitas University and Research Hospital, 20090 Milan, Italy
| | - Ari Ercole
- Division of Anaesthesia, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge CB20QQ, UK
| | - Angelos G Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK.
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge CB20QQ, UK.
| |
Collapse
|
31
|
Shikata E, Tamura T, Shinno K, Okayama Y, Shinohara N, Shimada K, Kanematsu Y, Kitazato KT, Nagahiro S, Takagi Y. Importance of Managing the Water-Electrolyte Balance by Delivering the Optimal Minimum Amount of Water and Sodium After Subarachnoid Hemorrhage. World Neurosurg 2019; 129:e352-e360. [PMID: 31132492 DOI: 10.1016/j.wneu.2019.05.152] [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] [Received: 04/06/2019] [Revised: 05/15/2019] [Accepted: 05/16/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND After aneurysmal subarachnoid hemorrhage (aSAH), crystalloid fluids with a relatively high sodium concentration have been used to maintain the cerebral blood flow. However, the prophylactic delivery of water and sodium by intravenous (IV) infusion will not necessarily improve the prognosis of patients after aSAH, and the excessive supply of water and sodium can negatively affect the outcome. We hypothesized that the delivery of an optimal amount of water and sodium separately might improve the outcome after aSAH. METHODS We recruited 55 consecutive patients who had undergone clipping or endovascular coil embolization after aSAH. Group 1 (n = 33) received conventional therapy (i.e., prophylactic IV sodium and water [protocol 1]). Group 2 (n = 22) received the optimal amount of water and sodium separately (protocol 2). RESULTS The median total of water and sodium chloride supplied in group 1 was significantly greater than that supplied in group 2 (P < 0.01). The modified Rankin scale score at discharge was 0-2 in 15 patients (95%) in group 2 and 23 patients (55%) in group 1 (P < 0.001). On multivariate logistic regression analysis, the odds ratio for a discharge modified Rankin scale score of 0-2 or 3-6 was significantly associated with the treatment protocol (P < 0.05) and the net fluid balance on days 4-8 (P < 0.05). CONCLUSION The separate delivery of optimal amounts of water and sodium could be a promising therapeutic strategy to improve the prognosis after aSAH.
Collapse
Affiliation(s)
- Eiji Shikata
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Japan.
| | - Tetsuya Tamura
- Department of Neurosurgery, Tokushima Prefectural Central Hospital, Tokushima, Japan
| | - Kiyohito Shinno
- Department of Neurosurgery, Tokushima Prefectural Central Hospital, Tokushima, Japan
| | - Yoshihiro Okayama
- Clinical Trial Center for Developmental Therapeutics, Tokushima University Hospital, Tokushima, Japan
| | - Naoki Shinohara
- Department of Neurosurgery, HITO Medical Center, Ehime, Japan
| | - Kenji Shimada
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Japan
| | - Yasuhisa Kanematsu
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Japan
| | - Keiko T Kitazato
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Japan
| | - Shinji Nagahiro
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Japan
| | - Yasushi Takagi
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Japan
| |
Collapse
|
32
|
Rao SS, Chung DY, Wolcott Z, Sheriff F, Khawaja AM, Lee H, Guanci MM, Leslie-Mazwi TM, Kimberly WT, Patel AB, Rordorf GA. Intermittent CSF drainage and rapid EVD weaning approach after subarachnoid hemorrhage: association with fewer VP shunts and shorter length of stay. J Neurosurg 2019; 132:1583-1588. [PMID: 31026832 DOI: 10.3171/2019.1.jns182702] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 01/18/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There is variability and uncertainty about the optimal approach to the management and discontinuation of an external ventricular drain (EVD) after subarachnoid hemorrhage (SAH). Evidence from single-center randomized trials suggests that intermittent CSF drainage and rapid EVD weans are safe and associated with shorter ICU length of stay (LOS) and fewer EVD complications. However, a recent survey revealed that most neurocritical care units across the United States employ continuous CSF drainage with a gradual wean strategy. Therefore, the authors sought to determine the optimal EVD management approach at their institution. METHODS The authors reviewed records of 200 patients admitted to their institution from 2010 to 2016 with aneurysmal SAH requiring an EVD. In 2014, the neurocritical care unit of the authors' institution revised the internal EVD management guidelines from a continuous CSF drainage with gradual wean approach (continuous/gradual) to an intermittent CSF drainage with rapid EVD wean approach (intermittent/rapid). The authors performed a retrospective multivariable analysis to compare outcomes before and after the guideline change. RESULTS The authors observed a significant reduction in ventriculoperitoneal (VP) shunt rates after changing to an intermittent CSF drainage with rapid EVD wean approach (13% intermittent/rapid vs 35% continuous/gradual, OR 0.21, p = 0.001). There was no increase in delayed VP shunt placement at 3 months (9.3% vs 8.6%, univariate p = 0.41). The intermittent/rapid EVD approach was also associated with a shorter mean EVD duration (10.2 vs 15.6 days, p < 0.001), shorter ICU LOS (14.2 vs 16.9 days, p = 0.001), shorter hospital LOS (18.2 vs 23.7 days, p < 0.0001), and lower incidence of a nonfunctioning EVD (15% vs 30%, OR 0.29, p = 0.006). The authors found no significant differences in the rates of symptomatic vasospasm (24.6% vs 20.2%, p = 0.52) or ventriculostomy-associated infections (1.3% vs 8.8%, OR 0.30, p = 0.315) between the 2 groups. CONCLUSIONS An intermittent CSF drainage with rapid EVD wean approach is associated with fewer VP shunt placements, fewer complications, and shorter LOS compared to a continuous CSF drainage with gradual EVD wean approach. There is a critical need for prospective multicenter studies to determine if the authors' experience is generalizable to other centers.
Collapse
Affiliation(s)
- Shyam S Rao
- 1Division of Neurocritical Care and Emergency Neurology, Department of Neurology
| | - David Y Chung
- 1Division of Neurocritical Care and Emergency Neurology, Department of Neurology
| | - Zoe Wolcott
- 1Division of Neurocritical Care and Emergency Neurology, Department of Neurology
| | - Faheem Sheriff
- 1Division of Neurocritical Care and Emergency Neurology, Department of Neurology
| | - Ayaz M Khawaja
- 1Division of Neurocritical Care and Emergency Neurology, Department of Neurology
| | - Hang Lee
- 2Biostatistics Center, Division of Clinical Research, Department of Medicine; and
| | - Mary M Guanci
- 1Division of Neurocritical Care and Emergency Neurology, Department of Neurology
| | - Thabele M Leslie-Mazwi
- 1Division of Neurocritical Care and Emergency Neurology, Department of Neurology.,3Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - W Taylor Kimberly
- 1Division of Neurocritical Care and Emergency Neurology, Department of Neurology
| | - Aman B Patel
- 3Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Guy A Rordorf
- 1Division of Neurocritical Care and Emergency Neurology, Department of Neurology
| |
Collapse
|