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Windermere SA, Mehkri Y, Yan SC, Grady C, Christie C, Goutnik M, Galochkina Z, Roy A, Vaziri S, Rahman M. Risk factors and outcomes associated with external ventricular drain related hemorrhage. Clin Neurol Neurosurg 2024; 243:108386. [PMID: 38901374 DOI: 10.1016/j.clineuro.2024.108386] [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: 01/28/2024] [Revised: 06/07/2024] [Accepted: 06/08/2024] [Indexed: 06/22/2024]
Abstract
OBJECTIVE The objective of this study was to determine risk factors predictive of external ventricular drain (EVD)-related hemorrhage and the association of such hemorrhages with mortality, discharge disposition, length of stay (LOS), and total cost. METHODS After Institutional Review Board approval, data was collected retrospectively for adult patients requiring EVD placement from 2015 to 2018 at the authors' institution. Collected data included demographic patient information, peri-procedural factors, and relevant post-procedural measures. Computerized tomography (CT) images and associated radiologic reports were independently reviewed, identifying hemorrhages accompanying EVD placement. RESULTS From this 487-patient sample, 85 (17.5 %) patients had hemorrhages, including asymptomatic hemorrhages identified on imaging alone. A univariable analysis of patient parameters in the overall cohort was performed to identify possible predictors of hemorrhage. Age (p = 0.002), Charlson Comorbidity Index (CCI) (p < 0.001), platelet count (p = 0.002), presence of uremia (p = 0.035), and the number of times the EVD was replaced (p < 0.001) were associated with hemorrhage in univariable models. The experience of the resident surgeon based on post-graduate year (PGY level) and the number of attempts/passes needed for EVD placement were not associated with hemorrhage risk. Significant predictor of hemorrhage confirmed in a multivariable analysis only included the number of times the EVD was replaced (OR = 2.78, adjusted p < 0.001). Outcomes between EVD-related hemorrhage versus no hemorrhage groups, including mortality, discharge disposition, LOS, and cost, were compared. EVD-related hemorrhage was found to be associated with increased mortality (OR = 3.58, adjusted p < 0.001) and decreased likelihood of discharge home (OR = 0.13, adjusted p = 0.030) in the associated multivariable regressions. CONCLUSION The number of times an EVD was replaced was associated with EVD-related hemorrhage outcome. EVD-related hemorrhage is associated with increased mortality and a decreased likelihood of being discharged home.
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Affiliation(s)
- Sonora Andromeda Windermere
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA; Department of General Surgery, University of Florida, Gainesville, FL, USA.
| | - Yusuf Mehkri
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Sandra C Yan
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Clare Grady
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Carlton Christie
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Michael Goutnik
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Zhanna Galochkina
- Division of Quantitative Sciences, University of Florida Health Cancer Center, Gainesville, FL, USA
| | - Arkaprava Roy
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Sasha Vaziri
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Maryam Rahman
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
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2
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Dannhoff G, Chibbaro S, Mallereau CH, Ganau M, Agbo-Ponzo M, Santin MDN, Ollivier I, Pop R, Proust F, Todeschi J. Delayed Intracerebral Hematoma after Ventriculoperitoneal Shunt in the Context of Ruptured Brain Arteriovenous Malformation: A Literature Review. Brain Sci 2023; 13:1159. [PMID: 37626515 PMCID: PMC10452536 DOI: 10.3390/brainsci13081159] [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: 07/16/2023] [Revised: 07/29/2023] [Accepted: 08/01/2023] [Indexed: 08/27/2023] Open
Abstract
Hemorrhagic complications arising from ventricular drainage procedures are typically asymptomatic and of low volume. A particular subset of these complications, known as delayed intracranial hemorrhage (DICH), is however recognized for its particularly poor prognosis. We primarily aimed to identify epidemiological characteristics associated with DICH, to shed light on its occurrence and potential risk factors. To do so, we performed a retrospective analysis of a series of ten patients who presented with DICH in the context of a ruptured brain arteriovenous malformation (bAVM) and a systematic literature review of all DICH cases reported in the literature. Our ten patients showed delayed neurological deterioration after a ventriculoperitoneal shunt (VPS) procedure, with a computed tomography (CT) scan revealing a DICH surrounding the ventricular catheter, distinct and away from the nidus of their previously ruptured bAVM. Four patients (40%) rapidly declined and passed away, three (30%) required surgical management and the remaining three (30%) demonstrated gradual clinical improvement with conservative management. In the literature, most patients presenting with DICH had hydrocephalus associated with neurovascular disorders (47% of cases), such as bAVM rupture in our present series. These constatations point out the significance of the underlying pathologies potentially being predisposed to these unusual complications.
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Affiliation(s)
- Guillaume Dannhoff
- Department of Neurosurgery, Strasbourg University Hospital, 67000 Strasbourg, France
| | - Salvatore Chibbaro
- Department of Neurosurgery, Strasbourg University Hospital, 67000 Strasbourg, France
| | | | - Mario Ganau
- Department of Neurosurgery, Strasbourg University Hospital, 67000 Strasbourg, France
| | - Martial Agbo-Ponzo
- Department of Neurosurgery, Strasbourg University Hospital, 67000 Strasbourg, France
| | | | - Irène Ollivier
- Department of Neurosurgery, Strasbourg University Hospital, 67000 Strasbourg, France
| | - Raoul Pop
- Department of Interventional Radiology, Strasbourg University Hospital, 67000 Strasbourg, France
| | - François Proust
- Department of Neurosurgery, Strasbourg University Hospital, 67000 Strasbourg, France
| | - Julien Todeschi
- Department of Neurosurgery, Strasbourg University Hospital, 67000 Strasbourg, France
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3
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Zhou J, Zhong Y, Li X, Li H, Wang J, Yang S, Chen G. Risk Factors for External Ventricular Drainage-Related Infection: A Systematic Review and Meta-analysis. Neurol Clin Pract 2023; 13:e200156. [PMID: 37529300 PMCID: PMC10238084 DOI: 10.1212/cpj.0000000000200156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 02/21/2023] [Indexed: 08/03/2023]
Abstract
Background and Objectives External ventricular drainage (EVD) is one of the most commonly performed neurosurgical procedures, but EVD-related infection constitutes a significant health concern. Yet, little consensus identifies the risk factors for the development of EVD-related infection. Therefore, we performed a meta-analysis to systematically summarize existing evidence on the incidence and risk factors for EVD-related infection. Methods PubMed, Embase, and the Cochrane Library databases from database inception to February 28, 2022, were searched for all studies investigating the incidence and risk factors for EVD-related infection. Data were assessed by R-4.2.0 software. The meta-analysis was used to calculate pooled odds ratios (OR) and 95% confidence intervals (CI). Results A total of 48 studies were included. Among the 29 factors analyzed, statistically significant risk factors were subarachnoid hemorrhage(SAH)/intraventricular hemorrhage(IVH) (OR = 1.48, 95% CI = 1.20-1.82, p < 0.001), concomitant systemic infection (OR = 1.90, 95% CI = 1.34-2.70, p < 0.001), other neurosurgical procedures (OR = 1.76, 95% CI = 1.02-3.04, p = 0.041), change of catheter (OR = 5.05, 95% CI = 3.67-6.96, p < 0.001), bilateral EVDs (OR = 2.25, 95% CI = 1.03-4.89, p = 0.041), (cerebrospinal fluid) CSF leak (OR = 3.19, 95% CI = 2.12-4.81, p < 0.001) and duration of EVD >7 days (OR = 4.62, 95% CI = 2.26-9.43, p < 0.001). The use of silver-coated catheters (OR = 0.57, 95% CI = 0.38-0.87, p = 0.008) and antibiotic-impregnated catheters (OR = 0.60, 95% CI = 0.41-0.88, p = 0.009) might help reduce the risk of infection. No significant difference was indicated in studies evaluating factors like diabetes mellitus (OR = 1.25, 95% CI = 0.90-1.75, p = 0.178), steroids used (OR = 1.52, 95% CI = 0.96-2.4, p = 0.074), prophylactic antibiotics(OR = 0.87, 95% CI = 0.66-1.14, p = 0.308). Discussion The meta-analysis of various relevant factors in the onset of EVD-related infection in patients submitted to EVD enabled us to establish a more probable profile of the patients who are more likely to develop it during the treatment.
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Affiliation(s)
- Jialei Zhou
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University Suzhou, Jiangsu Province, China
| | - Yi Zhong
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University Suzhou, Jiangsu Province, China
| | - Xiang Li
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University Suzhou, Jiangsu Province, China
| | - Hang Li
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University Suzhou, Jiangsu Province, China
| | - Jiahe Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University Suzhou, Jiangsu Province, China
| | - Siyuan Yang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University Suzhou, Jiangsu Province, China
| | - Gang Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University Suzhou, Jiangsu Province, China
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4
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Roethlisberger M, Eberhard NE, Rychen J, Al-Zahid S, Jayapalan RR, Zweifel C, Karuppiah R, Waran V. Supratentorial cerebrospinal fluid diversion using image-guided trigonal ventriculostomy during retrosigmoid craniotomy for cerebellopontine angle tumors. Front Surg 2023; 10:1198837. [PMID: 37288135 PMCID: PMC10242017 DOI: 10.3389/fsurg.2023.1198837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 04/24/2023] [Indexed: 06/09/2023] Open
Abstract
Background Cerebellar contusion, swelling and herniation is frequently encoutered upon durotomy in patients undergoing retrosigmoid craniotomy for cerebellopontine angle (CPA) tumors, despite using standard methods to obtain adequate cerebellar relaxation. Objective The aim of this study is to report an alternative cerebrospinal fluid (CSF)-diversion method using image-guided ipsilateral trigonal ventriculostomy. Methods Single-center retro- and prospective cohort study of n = 62 patients undergoing above-mentioned technique. Prior durotomy, CSF-diversion was performed to the point where the posterior fossa dura was visibly pulsatile. Outcome assessment consisted of the surgeon's intra- and postoperative clinical observations, and postoperative radiological imaging. Results Fifty-two out of n = 62 (84%) cases were eligible for analysis. The surgeons consistently reported successful ventricular puncture and a pulsatile dura prior durotomy without cerebellar contusion, swelling or herniation through the dural incision in n = 51/52 (98%) cases. Forty-nine out of n = 52 (94%) catheters were placed correctly within the first attempt, with the majority of catheter tips (n = 50, 96%) located intraventricularly (grade 1 or 2). In n = 4/52 (8%) patients, postoperative imaging revealed evidence of a ventriculostomy-related hemorrhage (VRH) associated with an intracerebral hemorrhage [n = 2/52 (4%)] or an isolated intraventricular hemorrhage [n = 2/52 (4%)]. However, these hemorrhagic complications were not associated with neurological symptoms, surgical interventions or postoperative hydrocephalus. None of the evaluated patients demonstrated radiological signs of upward transtentorial herniation. Conclusion The method described above efficiently allows CSF-diversion prior durotomy to reduce cerebellar pressure during retrosigmoid approach for CPA tumors. However, there is an inherent risk of subclinical supratentorial hemorrhagic complications.
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Affiliation(s)
- Michel Roethlisberger
- Department of Neurosurgery, University Hospital Basel, University of Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Department of Surgery, Division of Neurosurgery, University Malaya, Jalan Universiti, Kuala Lumpur, Malaysia
- Department of Otorhinolaryngology (ORL), University Malaya Specialist Centre, University of Malaya, Jalan Universiti, Kuala Lumpur, Malaysia
| | | | - Jonathan Rychen
- Department of Neurosurgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Saif Al-Zahid
- Department of Otorhinolaryngology (ORL), University Malaya Specialist Centre, University of Malaya, Jalan Universiti, Kuala Lumpur, Malaysia
- Department of Otorhinolaryngology, Hereford County Hospital, Hereford, United Kingdom
| | - Ronie Romelean Jayapalan
- Department of Surgery, Division of Neurosurgery, University Malaya, Jalan Universiti, Kuala Lumpur, Malaysia
| | - Christian Zweifel
- Department of Neurosurgery, University Hospital Basel, University of Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Department of Neurosurgery, Cantonal Hospital Graubuenden, Chur, Graubuenden, Switzerland
| | - Ravindran Karuppiah
- Department of Surgery, Division of Neurosurgery, University Malaya, Jalan Universiti, Kuala Lumpur, Malaysia
| | - Vicknes Waran
- Department of Surgery, Division of Neurosurgery, University Malaya, Jalan Universiti, Kuala Lumpur, Malaysia
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5
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Wolthers SA, Engelholm CP, Uslu B, Brandt CT. Noninvasive intracranial pressure monitoring in central nervous system infections. Minerva Anestesiol 2023; 89:206-216. [PMID: 36422116 DOI: 10.23736/s0375-9393.22.16863-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Intracranial pressure (ICP) monitoring constitutes an important part of the management of traumatic brain injury. However, its application in other brain pathologies such as neuroinfections like acute bacterial meningitis is unclear. Despite focus on aggressive, prompt treatment, morbidity and mortality from acute bacterial meningitis remain high. Increased ICP is well-known to occur in severe neuroinfections. The increased ICP compromise cerebral perfusion pressure and may ultimately lead to brain stem herniation. Therefore, controlling the ICP could also be important in acute bacterial meningitis. However, risk factors for complications due to invasive monitoring among these patients may be significantly increased due to higher age and levels of comorbidity compared to the traumatic brain injury patient from which the ICP treatment algorithms are developed. This narrative review evaluates the different modalities of ICP monitoring with the aim to elucidate current status of non-invasive alternatives to invasive monitoring as a decision tool and eventually monitoring. Non-invasive screening using ultrasound of the optical nerve sheath, transcranial doppler, magnetic resonance imaging or preferably a combination of these modalities, provides measurements that can be used as a decision guidance for invasive ICP measurement. The available data do not support the replacement of invasive techniques for continuous ICP measurement in patients with increased ICP. Non-invasive modalities should be taken into consideration in patients with neuroinfections at low risk of increased ICP.
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Affiliation(s)
- Signe A Wolthers
- Department of Anesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark -
| | - Cecilie P Engelholm
- Department of Anesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Bülent Uslu
- Department of Anesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Christian T Brandt
- Unit of Infectious Diseases, Department of Internal Medicine, Zealand University Hospital, Roskilde, Denmark
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6
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Dakson A, Kameda-Smith M, Staudt MD, Lavergne P, Makarenko S, Eagles ME, Ghayur H, Guo RC, Althagafi A, Chainey J, Touchette CJ, Elliott C, Iorio-Morin C, Tso MK, Greene R, Bargone L, Christie SD. A nationwide prospective multicenter study of external ventricular drainage: accuracy, safety, and related complications. J Neurosurg 2022; 137:249-257. [PMID: 34826821 DOI: 10.3171/2021.7.jns21421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 07/07/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE External ventricular drainage (EVD) catheters are associated with complications such as EVD catheter infection (ECI), intracranial hemorrhage (ICH), and suboptimal placement. The aim of this study was to investigate the rates of EVD catheter complications and their associated risk factor profiles in order to optimize the safety and accuracy of catheter insertion. METHODS A total of 348 patients with urgently placed EVD catheters were included as a part of a prospective multicenter observational cohort. Strict definitions were applied for each complication category. RESULTS The rates of misplacement, ECI/ventriculitis, and ICH were 38.6%, 12.2%, and 9.2%, respectively. Catheter misplacement was associated with midline shift (p = 0.002), operator experience (p = 0.031), and intracranial length (p < 0.001). Although mostly asymptomatic, ICH occurred more often in patients receiving prophylactic low-molecular-weight heparin (LMWH) (p = 0.002) and those who required catheter replacement (p = 0.026). Infectious complications (ECI/ventriculitis and suspected ECI) occurred more commonly in patients whose catheters were inserted at the bedside (p = 0.004) and those with smaller incisions (≤ 1 cm) (p < 0.001). ECI/ventriculitis was not associated with preinsertion antibiotic prophylaxis (p = 0.421), catheter replacement (p = 0.118), and catheter tunneling length (p = 0.782). CONCLUSIONS EVD-associated complications are common. These results suggest that the operating room setting can help reduce the risk of infection, but not the use of preoperative antibiotic prophylaxis. Although EVD-related ICH was associated with LMWH prophylaxis for deep vein thrombosis, there were no significant clinical manifestations in the majority of patients. Catheter misplacement was associated with operator level of training and midline shift. Information from this multicenter prospective cohort can be utilized to increase the safety profile of this common neurosurgical procedure.
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Affiliation(s)
- Ayoub Dakson
- 1Division of Neurosurgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Michael D Staudt
- 3Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada
| | - Pascal Lavergne
- 4Université de Laval, CHU de Québec Hôpital-Enfant-Jésus, Laval, Québec, Canada
| | - Serge Makarenko
- 5Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Matthew E Eagles
- 6Division of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
| | - Huphy Ghayur
- 2Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Ru Chen Guo
- 5Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alwalaa Althagafi
- 1Division of Neurosurgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jonathan Chainey
- 7Division of Neurosurgery, University of Alberta, Edmonton, Alberta, Canada; and
| | - Charles J Touchette
- 8Division of Neurosurgery, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Cameron Elliott
- 7Division of Neurosurgery, University of Alberta, Edmonton, Alberta, Canada; and
| | | | - Michael K Tso
- 6Division of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
| | - Ryan Greene
- 1Division of Neurosurgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Laurence Bargone
- 4Université de Laval, CHU de Québec Hôpital-Enfant-Jésus, Laval, Québec, Canada
| | - Sean D Christie
- 1Division of Neurosurgery, Dalhousie University, Halifax, Nova Scotia, Canada
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7
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Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN, Hemphill JC, Johnson R, Keigher KM, Mack WJ, Mocco J, Newton EJ, Ruff IM, Sansing LH, Schulman S, Selim MH, Sheth KN, Sprigg N, Sunnerhagen KS. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2022; 53:e282-e361. [PMID: 35579034 DOI: 10.1161/str.0000000000000407] [Citation(s) in RCA: 355] [Impact Index Per Article: 177.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | - William J Mack
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison
| | | | | | - Ilana M Ruff
- AHA Stroke Council Stroke Performance Measures Oversight Committee liaison
| | | | | | | | - Kevin N Sheth
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison.,AAN representative
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8
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Updates on techniques and technology to optimize external ventricular drain placement: A review of the literature. Clin Neurol Neurosurg 2022; 213:107126. [DOI: 10.1016/j.clineuro.2022.107126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 01/07/2022] [Accepted: 01/10/2022] [Indexed: 11/23/2022]
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9
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Yang J, Liu Y, Liu Q, Wang K, Mo S, Li M, Wu J, Jiang P, Yang S, Guo R, Yang Y, Zhang J, Cao Y, Wang S. A nomogram to predict the risk of postoperative intracranial rebleeding in patients with spontaneous intracranial hematoma. Neurosurg Rev 2021; 45:1571-1578. [PMID: 34714418 DOI: 10.1007/s10143-021-01682-3] [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: 07/21/2021] [Revised: 10/12/2021] [Accepted: 10/25/2021] [Indexed: 10/20/2022]
Abstract
The 30-day mortality rate of spontaneous cerebral hemorrhage (ICH) is approximately 30-50%. Surgery may improve the prognosis of patients with severe ICH. However, ICH survivors after surgery still face the risks of postoperative intracranial rebleeding (PIB), and clinical tools that accurately predict the risk of PIB occurrence are not available. Therefore, a retrospective study was performed. The population was divided into two groups according to the occurrence of PIB. Univariate and multivariate logistic regression analyses were performed to screen risk factors for PIB. Next, an early PIB risk nomogram prediction model was constructed. In addition, the impact of PIB on the prognosis of ICH was evaluated. In total, 150 ICH patients were continuously enrolled in this study; 21 patients suffered from PIB, and the overall incidence of PIB was 14.0% (21/150). Coronary heart disease history, a lower GCS score, and subarachnoid hemorrhage absence were screened as risk factors for early PIB. The early PIB risk nomogram showed good calibration and discrimination with a concordance index of 0.807 (95% confidence interval (CI), 0.715-0.899), which was confirmed to be 0.788 through bootstrapping validation. In addition, a significant difference in discharged GOS scores (P = 0.043) was observed between the PIB group and the n-PIB group. These results showed that a history of coronary heart disease, a lower GCS score, and absence of subarachnoid hemorrhage were risk factors for early PIB. In addition, the early PIB risk nomogram prediction model exhibits good discrimination and calibration. The occurrence of PIB could reduce the prognosis of ICH patients.
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Affiliation(s)
- Junhua Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, NO.119 Nansihuanxilu, Fengtai District, 100160, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Yang Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, NO.119 Nansihuanxilu, Fengtai District, 100160, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Qingyuan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, NO.119 Nansihuanxilu, Fengtai District, 100160, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Kaiwen Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, NO.119 Nansihuanxilu, Fengtai District, 100160, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Shaohua Mo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, NO.119 Nansihuanxilu, Fengtai District, 100160, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Maogui Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, NO.119 Nansihuanxilu, Fengtai District, 100160, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, NO.119 Nansihuanxilu, Fengtai District, 100160, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Pengjun Jiang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, NO.119 Nansihuanxilu, Fengtai District, 100160, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Shuzhe Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, NO.119 Nansihuanxilu, Fengtai District, 100160, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Rui Guo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, NO.119 Nansihuanxilu, Fengtai District, 100160, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Yi Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, NO.119 Nansihuanxilu, Fengtai District, 100160, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Jiaming Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, NO.119 Nansihuanxilu, Fengtai District, 100160, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, NO.119 Nansihuanxilu, Fengtai District, 100160, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, NO.119 Nansihuanxilu, Fengtai District, 100160, Beijing, People's Republic of China. .,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China. .,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China. .,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China.
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10
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Evans D, Flood R, Davies O, Wareham J, Mortimer A. Impact of Intravenous Aspirin Administration on Ventriculostomy-Associated Hemorrhage in Coiled Acute Subarachnoid Hemorrhage Patients. Neurointervention 2021; 16:141-148. [PMID: 34162195 PMCID: PMC8261103 DOI: 10.5469/neuroint.2021.00150] [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: 03/14/2021] [Accepted: 06/15/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose Aspirin has beneficial effects on coiling, even in acute subarachnoid hemorrhage, but there is also a perceived risk of increased bleeding and, importantly, a concern regarding ventriculostomy-associated hemorrhage (VAH) in those with complicating hydrocephalus. We aimed to assess the rate and extent of VAH in patients specifically treated with procedural intravenous aspirin during endovascular coiling of ruptured intracranial aneurysms. Materials and Methods This was a single neurovascular center retrospective observational study of consecutive patients treated over a three-year period. The rate of VAH assessed using computed tomography and clinical outcomes were compared in patients receiving intraprocedural intravenous aspirin loading (n=90) versus those that did not receive the drug (n=40). Results There was a significantly elevated rate of VAH in patients receiving intravenous aspirin (30% vs. 2.5%, odds ratio 16.7 [95% confidence interval: 2.2–128.0], P<0.0001). The majority of VAH was <10 mm in size (70%) with the largest bleed measuring 20 mm. No hematoma required surgical evacuation. No difference in favorable outcome at discharge was demonstrated. There was no difference in mortality between the 2 groups. Conclusion Loading with intravenous aspirin during endovascular treatment of ruptured intracranial aneurysms significantly increases the risk of VAH, but most are small with minimal impact on clinical outcome at discharge. Intravenous aspirin should probably be reserved for selected cases but should not be withheld based on risk of VAH.
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Affiliation(s)
- David Evans
- Department of Neuroradiology, North Bristol NHS Trust, Bristol, UK
| | - Richard Flood
- Department of Neuroradiology, North Bristol NHS Trust, Bristol, UK
| | - Owain Davies
- Department of Neurosurgery, North Bristol NHS Trust, Bristol, UK
| | - James Wareham
- Department of Neuroradiology, North Bristol NHS Trust, Bristol, UK
| | - Alex Mortimer
- Department of Neuroradiology, North Bristol NHS Trust, Bristol, UK
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11
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Arts S, van Lindert EJ, Aquarius R, Bartels RHMA, Boogaarts HD. Complications of external cerebrospinal fluid drainage in aneurysmal subarachnoid haemorrhage. Acta Neurochir (Wien) 2021; 163:1143-1151. [PMID: 33387044 PMCID: PMC7965850 DOI: 10.1007/s00701-020-04681-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/14/2020] [Indexed: 12/22/2022]
Abstract
Background The need for external cerebrospinal fluid (CSF) drains in aneurysmal subarachnoid haemorrhage (aSAH) patients is common and might lead to additional complications. Objective A relation between the presence of an external CSF drain and complication risk is investigated. Methods A prospective complication registry was analysed retrospectively. We included all adult aSAH patients admitted to our academic hospital between January 2016 and January 2018, treated with an external CSF drain. Demographic data, type of external drain used, the severity of the aSAH and complications, up to 30 days after drain placement, were registered. Complications were divided into (1) complications with a direct relation to the external CSF drain and (2) complications that could not be directly related to the use of an external CSF drain referred to as medical complications Results One hundred and forty drains were implanted in 100 aSAH patients. In total, 112 complications occurred in 59 patients. Thirty-six complications were drain related and 76 were medical complications. The most common complication was infection (n = 34). Drain dislodgement occurred 16 times, followed by meningitis (n = 11) and occlusion (n = 9). A Poisson model showed that the mean number of complications raised by 2.9% for each additional day of drainage (95% CI: 0.6–5.3% p = 0.01). Conclusion Complications are common in patients with aneurysmal subarachnoid haemorrhage of which 32% are drain-related. A correlation is present between drainage period and the number of complications. Therefore, reducing drainage period could be a target for further improvement of care.
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Affiliation(s)
- Sebastian Arts
- Department of Neurosurgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Erik J van Lindert
- Department of Neurosurgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Rene Aquarius
- Department of Neurosurgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Ronald H M A Bartels
- Department of Neurosurgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Hieronymus D Boogaarts
- Department of Neurosurgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
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12
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Aboelela MA, Alrefaey AK. Brain-Relaxing Effect of Different Diuretic Regimens in Supratentorial Tumor Surgery: A Comparative Study Guided by Optic Nerve Sheath Diameter. Anesth Essays Res 2021; 14:531-535. [PMID: 34092871 PMCID: PMC8159040 DOI: 10.4103/aer.aer_15_21] [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: 02/05/2021] [Revised: 02/07/2021] [Accepted: 02/17/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Hyperosmolar therapy is a well-established method to approach brain relaxation during craniotomy. Mannitol is used with a wide range of dosing regimens, combination with loop diuretics exerts a synergistic effect resulting in both reduction of the dose and its complications. Ultrasound measurement of optic nerve sheath diameter (ONSD) gives reliable information about intracranial pressure (ICP) and avoids overdosing and complications of osmotherapy. Aims and Objectives: In this study, we compare the ordinary dose of mannitol with the low dose combined with furosemide and detect the effect on ICP by ONSD. Setting and Design: This is a prospective, randomized, double-blind study involving 60 patients undergoing supratentorial brain tumor surgery. Materials and Methods: Sixty patients were enrolled in this study, divided into two equal groups: Group M received mannitol 1 g.kg−1: while Group F received mannitol 0.25 g.kg−1 and furosemide 0.5 mg.kg−1. Reduction in ONSD measurement was the primary objective, while brain-relaxation score (BRS), hemodynamic changes, urine output, serum lactate, and changes in serum electrolyte were the secondary objectives. Statistical Analysis: Data collected were analyzed using SPSS software, IBM, USA, version 22. P value was considered significant if <0.05. Results: ONSD and BRS showed no statistically significant difference between the studied groups. After diuresis, Group M showed significant reduction in heart rate and mean arterial blood pressure, serum sodium, potassium, and lactate (P = 0.02, P = 0.02, P = 0.001, P = 0.001, P = 0.001, P = 0.001 respectively), with increased urine output (UOP) and fluids replacement (P = 0.00, P = 0.01, respectively). Conclusion: Compared to high dose, adding loop diuretics to low-dose mannitol during supratentorial brain tumor surgeries resulted in comparable BRSs with a lower incidence of hemodynamic and metabolic disturbances.
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Affiliation(s)
- Mohamed Adel Aboelela
- Department of Anesthesia and Surgical Intensive Care, Mansoura University, Mansoura, Egypt
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13
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Roa JA, Fakih R, Zanaty M, Pazour A, Howard MA, Hasan DM, Samaniego EA. Quantitative Assessment of Ventriculostomy-Related Hemorrhage: A Volume-Based Classification System to Predict New Neurological Symptoms. Oper Neurosurg (Hagerstown) 2021; 20:198-205. [PMID: 33047131 DOI: 10.1093/ons/opaa319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/02/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Hemorrhage is one of the most feared complications following ventriculostomy placement. Current studies have assessed factors associated with increased risk of ventriculostomy-related hemorrhage (VRH). However, the clinical significance of VRH has not been determined. OBJECTIVE To correlate quantitative volumetric measurements of VRH with new neurological symptoms. METHODS A retrospective review of our institutional database of ventriculostomy patients during the last decade was performed. Patients' demographics and procedural details such as indication, number of passes and position of the catheter were recorded. VRH volume was quantified on noncontrast head computed tomography using the Picture Archiving Communication System (Carestream Vue®, Rochester, New York) semi-automated livewire segmentation tool. Patients with new neurological symptoms within 48 h of VRH were considered symptomatic. Several clinical confounders were ruled out. Logistic regression analyses were performed. The best volumetric cut-offs in predicting symptomatic VRH were determined through receiver operating characteristic (ROC) curve analysis. RESULTS A total of 3090 patients underwent ventriculostomy procedures and 179 (∼6%) developed VRH. A total of 41 (1.06%) patients with VRH developed new neurological symptoms. Only 12 (0.39%) were attributable to a new VRH. Multivariable logistic regression showed that volume of the hemorrhage (OR 1.17, P = .006) is the only significant predictor of symptomatic VRH. ROC curve analysis demonstrated that VRH volume <1.10 cc has 91.7% sensitivity to rule out symptomatic VRH, whereas a volume >7.59 cc has 95.5% specificity to predict symptomatic VRH. CONCLUSION Approximately 6% of patients developed postprocedural VRH, but only 0.4% were symptomatic. VRH volumes <1 cc are extremely unlikely to become symptomatic, whereas volumes >7.5 cc may predict development of new neurological deficits.
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Affiliation(s)
- Jorge A Roa
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa.,Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Rami Fakih
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Mario Zanaty
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Avery Pazour
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - David M Hasan
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Edgar A Samaniego
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa.,Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa.,Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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14
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Belzberg M, Mahapatra S, Perdomo-Pantoja A, Chavez F, Morrison K, Xiong KT, Gamo NJ, Restaino S, Thakor N, Yazdi Y, Iyer R, Tyler B, Theodore N, Luciano MG, Brem H, Groves M, Cohen AR, Manbachi A. Minimally invasive therapeutic ultrasound: Ultrasound-guided ultrasound ablation in neuro-oncology. ULTRASONICS 2020; 108:106210. [PMID: 32619834 PMCID: PMC8895244 DOI: 10.1016/j.ultras.2020.106210] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 05/28/2020] [Accepted: 06/12/2020] [Indexed: 05/19/2023]
Abstract
INTRODUCTION To improve patient outcomes (eg, reducing blood loss and infection), practitioners have gravitated toward noninvasive and minimally invasive surgeries (MIS), which demand specialized toolkits. Focused ultrasound, for example, facilitates thermal ablation from a distance, thereby reducing injury to surrounding tissue. Focused ultrasound can often be performed noninvasively; however, it is more difficult to carry out in neuro-oncological tumors, as ultrasound is dramatically attenuated while propagating through the skull. This shortcoming has prompted exploration of MIS options for intracranial placement of focused ultrasound probes, such as within the BrainPath™ (NICO Corporation, Indianapolis, IN). Herein, we present the design, development, and in vitro testing of an image-guided, focused ultrasound prototype designed for use in MIS procedures. This probe can ablate neuro-oncological lesions despite its small size. MATERIALS & METHODS Preliminary prototypes were iteratively designed, built, and tested. The final prototype consisted of three 8-mm-diameter therapeutic elements guided by an imaging probe. Probe functionality was validated on a series of tissue-mimicking phantoms. RESULTS Lesions were created in tissue-mimicking phantoms with average dimensions of 2.5 × 1.2 × 6.5 mm and 3.4 × 3.25 × 9.36 mm after 10- and 30-second sonification, respectively. 30 s sonification with 118 W power at 50% duty cycle generated a peak temperature of 68 °C. Each ablation was visualized in real time by the built-in imaging probe. CONCLUSION We developed and validated an ultrasound-guided focused ultrasound probe for use in MIS procedures. The dimensional constraints of the prototype were designed to reflect those of BrainPath trocars, which are MIS tools used to create atraumatic access to deep-seated brain pathologies.
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Affiliation(s)
- Micah Belzberg
- Department of Dermatology, Johns Hopkins University, Baltimore, MD, USA
| | - Smruti Mahapatra
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | | | - Nao J Gamo
- Maryland Development Center, Baltimore, MD, USA
| | | | - Nitish Thakor
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Youseph Yazdi
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Rajiv Iyer
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | - Betty Tyler
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | - Nicholas Theodore
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA; Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | - Mark G Luciano
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA; Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | - Henry Brem
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA; Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | - Mari Groves
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | - Alan R Cohen
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | - Amir Manbachi
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA; Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA.
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15
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Mansoor N, Madsbu MA, Mansoor NM, Trønnes AN, Fredriksli OA, Salvesen Ø, Jakola AS, Solheim O, Gulati S. Accuracy and complication rates of external ventricular drain placement with twist drill and bolt system versus standard trephine and tunnelation: a retrospective population-based study. Acta Neurochir (Wien) 2020; 162:755-761. [PMID: 32020298 PMCID: PMC7066093 DOI: 10.1007/s00701-020-04247-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 01/23/2020] [Indexed: 11/10/2022]
Abstract
Background An external ventricular drain (EVD) is typically indicated in the presence of hydrocephalus and increased intracranial pressure (ICP). Procedural challenges have prompted the development of different methods to improve accuracy, safety, and logistics. Objectives EVD placement and complications rates were compared using two surgical techniques; the standard method (using a 14-mm trephine burrhole with the EVD tunnelated through the skin) was compared to a less invasive method (EVD placed through a 2.7–3.3-mm twist drill burrhole and fixed to the bone with a bolt system). Methods Retrospective observational study in a single-centre setting between 2008 and 2018. EVD placement was assessed using the Kakarla scoring system. We registered postoperative complications, surgery duration and number of attempts to place the EVD. Results Two hundred seventy-two patients received an EVD (61 bolt EVDs, 211 standard EVDs) in the study period. Significant differences between the bolt system and the standard method were observed in terms of revision surgeries (8.2% vs. 21.5%, p = 0.020), surgery duration (mean 16.5 vs. 28.8 min, 95% CI 7.64, 16.8, p < 0.001) and number of attempts to successfully place the first EVD (mean 1.72 ± 1.2 vs. 1.32 ± 0.8, p = 0.017). There were no differences in accuracy of placement or complication rates. Conclusions The two methods show similar accuracy and postoperative complication rates. Observed differences in both need for revisions and surgery duration favoured the bolt group. Slightly, more attempts were needed to place the initial EVD in the bolt group, perhaps reflecting lower flexibility for angle correction with a twist drill approach.
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16
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Müller A, Mould WA, Freeman WD, McBee N, Lane K, Dlugash R, Thompson R, Nekoovaght-Tak S, Madan V, Ali H, Stadnik A, Awad I, Hanley D, Ziai WC. The Incidence of Catheter Tract Hemorrhage and Catheter Placement Accuracy in the CLEAR III Trial. Neurocrit Care 2019; 29:23-32. [PMID: 29294223 DOI: 10.1007/s12028-017-0492-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Incidence of catheter tract hemorrhage (CTH) after initial ventriculostomy placement ranges from 10 to 34%. We investigated CTH incidence in the Clot Lysis: Evaluation of Accelerated Resolution of Intraventricular Hemorrhage Phase III trial. METHODS Prospective observational analysis of 1000 computer tomography (CT) scans from all 500 patients enrolled in the trial. All catheters were evaluated on first CT post-placement and on last CT prior to randomization for placement location and CTH size, location, and severity. Clinical variables were assessed for association with CTH with multivariable logistic regression. RESULTS Of 563 catheters, CTH was detected in 14 and 21% of patients on first and last CT (median 3.7 and 43.4 h after catheter placement, respectively). All, but one were asymptomatic. Majority of CTH (86%) occurred within 24 h after placement, were located within 1 cm of the skull, and had at least one diameter > 5 mm. Most catheters (71%) terminated in the third or lateral ventricle ipsilateral to insertion site. Factors significantly associated with CTH were pre-admission use of antiplatelet drugs, accuracy of catheter placement, non-operating room catheter placement, Asian race, and intraventricular hemorrhage expansion. CONCLUSIONS CTH incidence on initial catheter placement and during stabilization was relatively low, despite emergent placement in a high-risk population. Catheter placement accuracy was similar or better than convenience samples from the published literature. Decreasing risk of CTH may be achieved with attention to catheter placement accuracy and placement in the operating room. Antiplatelet agent use was an independent risk factor for CTH.
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Affiliation(s)
- Achim Müller
- Division of Brain Injury Outcomes, Departments of Neurology, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - W Andrew Mould
- Division of Brain Injury Outcomes, Departments of Neurology, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - W David Freeman
- Department of Neurology, Neurosurgery, and Critical Care, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Nichol McBee
- Division of Brain Injury Outcomes, Departments of Neurology, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karen Lane
- Division of Brain Injury Outcomes, Departments of Neurology, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rachel Dlugash
- Division of Brain Injury Outcomes, Departments of Neurology, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rick Thompson
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Saman Nekoovaght-Tak
- Division of Brain Injury Outcomes, Departments of Neurology, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vikram Madan
- Division of Brain Injury Outcomes, Departments of Neurology, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hasan Ali
- Division of Brain Injury Outcomes, Departments of Neurology, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Agnieszka Stadnik
- Department of Neurological Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Issam Awad
- Department of Neurological Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Daniel Hanley
- Division of Brain Injury Outcomes, Departments of Neurology, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Wendy C Ziai
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, 600 N. Wolfe St./Phipps 455, Baltimore, MD, 21287, USA.
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17
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Fam MD, Stadnik A, Zeineddine HA, Girard R, Mayo S, Dlugash R, McBee N, Lane K, Mould WA, Ziai W, Hanley D, Awad IA. Symptomatic Hemorrhagic Complications in Clot Lysis: Evaluation of Accelerated Resolution of Intraventricular Hemorrhage Phase III Clinical Trial (CLEAR III): A Posthoc Root-Cause Analysis. Neurosurgery 2019; 83:1260-1268. [PMID: 29294116 DOI: 10.1093/neuros/nyx587] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 11/16/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND As intraventricular thrombolysis for intraventricular hemorrhage (IVH) has developed over the last 2 decades, hemorrhagic complications have remained a concern despite general validation of its safety in controlled trials in the Clot Lysis: Evaluation of Accelerated Resolution of Intraventricular Hemorrhage Phase III (CLEAR-IVH) program. OBJECTIVE To analyze factors associated with symptomatic bleeding following IVH with and without thrombolysis in conjunction with the recently completed CLEAR III trial. METHODS We reviewed safety reports on symptomatic bleeding events reported during the first year after randomization among subjects enrolled in the CLEAR III trial. Clinical and imaging data were retrieved through the trial database as part of ongoing quality and safety monitoring. A posthoc root-cause analysis was performed to identify potential factors predisposing to rebleeding in each case. Cases were classified according to onset of rebleeding (during dosing, early after dosing and delayed), the pattern of bleeding, and treatment rendered (alteplase vs saline). RESULTS Twenty subjects developed a secondary symptomatic intracranial hemorrhage constituting 4% of subjects. Symptomatic rebleeding events occurred during the dosing protocol (n = 9, 67% alteplase), early after the protocol (n = 5, 40% alteplase), and late (n = 6, 0% alteplase). Catheter-related hemorrhages were the most common (n = 7, 35%) followed by expansion or new intraventricular (n = 6, 30%) and intracerebral (n = 5, 25%) hemorrhages. Symptomatic hemorrhages during therapy resulted from a combination of treatment- and patient-related factors and were at most partially attributable to alteplase. Rebleeding after the dosing protocol primarily reflected patients' risk factors. CONCLUSION Intraventricular thrombolysis marginally increases the overall risk of symptomatic hemorrhagic complications after IVH, and only during the treatment phase.
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Affiliation(s)
- Maged D Fam
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine, Chicago, Illinois
| | - Agnieszka Stadnik
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine, Chicago, Illinois
| | - Hussein A Zeineddine
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine, Chicago, Illinois
| | - Romuald Girard
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine, Chicago, Illinois
| | | | - Rachel Dlugash
- Brain Injury Outcomes Unit, Johns Hopkins University, Baltimore, Maryland
| | - Nichol McBee
- Brain Injury Outcomes Unit, Johns Hopkins University, Baltimore, Maryland
| | - Karen Lane
- Brain Injury Outcomes Unit, Johns Hopkins University, Baltimore, Maryland
| | - W Andrew Mould
- Brain Injury Outcomes Unit, Johns Hopkins University, Baltimore, Maryland
| | - Wendy Ziai
- Brain Injury Outcomes Unit, Johns Hopkins University, Baltimore, Maryland
| | - Daniel Hanley
- Brain Injury Outcomes Unit, Johns Hopkins University, Baltimore, Maryland
| | - Issam A Awad
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine, Chicago, Illinois
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18
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Woo PYM, Ng BCF, Xiao JX, Wong D, Seto A, Lam S, Yim C, Lo HY, Po YC, Wong LYW, Lee MWY, Yam KY, Pu JKS, Chan KY, Poon WS. The importance of aspirin, catheterization accuracy, and catheter design in external ventricular drainage-related hemorrhage: a multicenter study of 1002 procedures. Acta Neurochir (Wien) 2019; 161:1623-1632. [PMID: 31222516 DOI: 10.1007/s00701-019-03978-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 06/05/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND External ventricular drainage (EVD) is the commonest neurosurgical procedure performed in daily neurosurgical practice, but relatively few studies have investigated the incidence and risk factors of its related hemorrhagic complications. METHODS This was a multicenter retrospective review of consecutive EVD procedures. Patients 18 years or older who underwent EVD and had a routine postoperative computed tomography (CT) scan performed within 24 hours were included. EVD-related hemorrhage was defined as new intracranial hemorrhage immediately adjacent or within the ventricular catheter trajectory. The volume of hemorrhage and the position of the catheter tip were assessed. A review of patient-, disease-, and surgery-related factors including the ventricular catheter design utilized was conducted. The Bonferroni correction was applied to the alpha level of significance (0.05) for multivariable analysis. RESULTS Nine hundred sixty-two patients underwent 1002 EVD performed by neurosurgeons in the operating theater. Sixteen percent (154) of patients were on aspirin before the procedure. Thirty-four percent (333) of patients had intracerebral hemorrhage, 25% (251) had aneurysmal subarachnoid hemorrhage and 16% (158) had traumatic brain injury. The mean duration from EVD to the first postoperative CT scan was 20 ± 4 h. EVD-related hematomas were detected after 81 procedures with a per-catheter risk of 8.1%. Mean hematoma volume was 1.2 ± 3.3 ml. Most were less than 1 ml (grade I, 79%, 64), 1 to 15 ml (grade II) in 20% (16) and a single clot larger than 15 ml (grade III, 1%) were detected. Clinically significant hemorrhage that resulted in catheter occlusion occurred in 1.7% (17) of procedures. Most catheters (62%, 625) were optimally placed, i.e., its tip being within the ipsilateral frontal horn or third ventricle. Three non-antibiotic-impregnated ventricular catheter designs were used with 55% (550) being the 2.2-mm Integra™ catheter, 14% (137) being the 2.8-mm Medtronic™ catheter, and 31% (315) being the 3.1-mm Codman™ catheter. Independent significant predictors for EVD-related hemorrhage were the preoperative prescription of aspirin (adjusted OR 1.94; 95% CI 1.10-3.44), catheter malposition (aOR 1.99; 95% CI 1.22-3.23), and use of the 2.8-mm Medtronic™ catheter (aOR 4.22; 95% CI 2.39-7.41). CONCLUSIONS The per-catheter risk of hemorrhage was 8.1%, but the incidence of symptomatic hemorrhage was low. The only patient risk factor was aspirin intake. This is the first study to evaluate and establish an association between catheter malposition and catheter design with EVD-related hemorrhage.
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Affiliation(s)
- Peter Y M Woo
- Department of Neurosurgery, Kwong Wah Hospital, Hong Kong, China.
| | - Ben C F Ng
- Department of Neurosurgery, Queen Elizabeth Hospital, Hong Kong, China
| | - Jacob X Xiao
- Department of Neurosurgery, Kwong Wah Hospital, Hong Kong, China
| | - Daniel Wong
- Department of Neurosurgery, Kwong Wah Hospital, Hong Kong, China
| | - Andrew Seto
- Department of Neurosurgery, Kwong Wah Hospital, Hong Kong, China
| | - Sandy Lam
- Department of Neurosurgery, Kwong Wah Hospital, Hong Kong, China
| | - Carmen Yim
- Department of Neurosurgery, Kwong Wah Hospital, Hong Kong, China
| | - Hong-Yip Lo
- Department of Neurosurgery, Kwong Wah Hospital, Hong Kong, China
| | - Yin-Chung Po
- Department of Neurosurgery, Princess Margaret Hospital, Hong Kong, China
| | - Larry Y W Wong
- Department of Neurosurgery, Queen Elizabeth Hospital, Hong Kong, China
| | - Michael W Y Lee
- Department of Neurosurgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
| | - Kwong-Yui Yam
- Department of Neurosurgery, Tuen Mun Hospital, Hong Kong, China
| | - Jenny K S Pu
- Division of Neurosurgery, Department of Surgery, Queen Mary Hospital, Hong Kong, China
| | - Kwong-Yau Chan
- Department of Neurosurgery, Kwong Wah Hospital, Hong Kong, China
| | - Wai-Sang Poon
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, Hong Kong, China
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Intracranial Monitoring in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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20
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Catapano JS, Lee M, Veljanoski D, Whiting AC, Brigeman S, Morgan CD, Labib MA, Ducruet AF, Nakaji P. Iatrogenic pseudoaneurysm rupture of the anterior cerebral artery after placement of an external ventricular drain, treated with clip-wrapping: a case report and review of the literature. Acta Neurochir (Wien) 2019; 161:1371-1376. [PMID: 31102006 DOI: 10.1007/s00701-019-03935-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 04/29/2019] [Indexed: 10/26/2022]
Abstract
External ventricular drains (EVDs) are often placed emergently for patients with hydrocephalus, which carries a risk of hemorrhage. Rarely, rupture of a pseudoaneurysm originating from an EVD placement precipitates such a hemorrhage. An EVD was placed in a patient with a ruptured left posterior communicating artery aneurysm who later underwent endovascular coil embolization. On post-bleed day 20, a distal right anterior cerebral artery pseudoaneurysm along the EVD tract ruptured, which was successfully treated via clip-wrapping. Although EVD-associated pseudoaneurysms are rare, they have a high propensity for rupture. Early treatment of these lesions should be considered to prevent neurologic deterioration.
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21
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Haber MA, Abd-El-Barr M, Gormley W, Mukundan S, Sodickson AD, Potter CA. Neurosurgical complications: what the radiologist needs to know. Emerg Radiol 2019; 26:331-340. [PMID: 30761443 DOI: 10.1007/s10140-019-01672-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 01/08/2019] [Indexed: 10/27/2022]
Abstract
Visits to the emergency department by patients who have recently undergone neurosurgery are a common occurrence, and these patients frequently receive emergent cross-sectional head imaging in order to evaluate for complications. Different neurosurgical approaches may have typical postoperative imaging findings that can be confused with pathology. Furthermore, particular abnormal postoperative imaging findings may signal an evolving complication. It is essential for the radiologist to understand common neurosurgical procedures and their potential complications in order to provide proper diagnostic evaluation of the postoperative neurosurgical patient. The purpose of this review is to assist radiologists in the evaluation of the postoperative neurosurgical patient and educate them on associated complications. Familiarity with common neurosurgical techniques and postoperative complications will help radiologists make the correct diagnosis, communicate effectively with the neurosurgeon, and expedite patient care.
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Affiliation(s)
- Matthew A Haber
- Department of Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Harvard Medical School, Boston, MA, USA.
| | - Muhammad Abd-El-Barr
- Department of Neurosurgery, Duke University Medical Center, 40 Duke Medicine Circle, Durham, NC, 27710, USA
| | - William Gormley
- Harvard Medical School, Boston, MA, USA.,Department of Neurosurgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Srinivasan Mukundan
- Harvard Medical School, Boston, MA, USA.,Division of Neuroradiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Aaron D Sodickson
- Harvard Medical School, Boston, MA, USA.,Division of Emergency Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Christopher A Potter
- Harvard Medical School, Boston, MA, USA.,Division of Neuroradiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Division of Emergency Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
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22
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Davies DJ, Clancy M, Dehghani H, Lucas SJE, Forcione M, Yakoub KM, Belli A. Cerebral Oxygenation in Traumatic Brain Injury: Can a Non-Invasive Frequency Domain Near-Infrared Spectroscopy Device Detect Changes in Brain Tissue Oxygen Tension as Well as the Established Invasive Monitor? J Neurotrauma 2018; 36:1175-1183. [PMID: 29877139 DOI: 10.1089/neu.2018.5667] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The cost and highly invasive nature of brain monitoring modality in traumatic brain injury patients currently restrict its utility to specialist neurological intensive care settings. We aim to test the abilities of a frequency domain near-infrared spectroscopy (FD-NIRS) device in predicting changes in invasively measured brain tissue oxygen tension. Individuals admitted to a United Kingdom specialist major trauma center were contemporaneously monitored with an FD-NIRS device and invasively measured brain tissue oxygen tension probe. Area under the curve receiver operating characteristic (AUROC) statistical analysis was utilized to assess the predictive power of FD-NIRS in detecting both moderate and severe hypoxia (20 and 10 mm Hg, respectively) as measured invasively. Sixteen individuals were prospectively recruited to the investigation. Severe hypoxic episodes were detected in nine of these individuals, with the NIRS demonstrating a broad range of predictive abilities (AUROC 0.68-0.88) from relatively poor to good. Moderate hypoxic episodes were detected in seven individuals with similar predictive performance (AUROC 0.576-0.905). A variable performance in the predictive powers of this FD-NIRS device to detect changes in brain tissue oxygen was demonstrated. Consequently, this enhanced NIRS technology has not demonstrated sufficient ability to replace the established invasive measurement.
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Affiliation(s)
- David James Davies
- 1 National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Michael Clancy
- 1 National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Hamid Dehghani
- 2 School of Computer Science, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Samuel John Edwin Lucas
- 3 School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Mario Forcione
- 1 National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Kamal Makram Yakoub
- 1 National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Antonio Belli
- 1 National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
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23
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Gard AP, Sayles BD, Robbins JW, Thorell WE, Surdell DL. Hemorrhage Rate After External Ventricular Drain Placement in Subarachnoid Hemorrhage: Time to Heparin Administration. Neurocrit Care 2018; 27:350-355. [PMID: 28612132 DOI: 10.1007/s12028-017-0417-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The use of antiplatelet or anticoagulants has previously been shown to increase hemorrhagic complications of ventricular catheterization. Although heparin use 24 h after ventriculostomy appears safe, the safety of heparin immediately (within 4 h) after ventriculostomy is unknown. The objective of this study was to assess the safety of heparin immediately (within 4 h) after ventriculostomy in subarachnoid hemorrhage (SAH) patients undergoing endovascular treatment. PATIENTS AND METHODS This is a retrospective cohort study of 46 patients with aneurysmal SAH secondary to aneurysm rupture who required ventriculostomy. Post-ventriculostomy imaging was carefully reviewed for tract hemorrhaging. Timing of heparinization was noted. Early heparinization was within 4 h after ventriculostomy, and intermediate heparinization was between 4 and 24 h after ventriculostomy. RESULTS Overall, the tract hemorrhage rate was 26.1% for the study cohort-mostly grade I tract hemorrhages-consistent with the existing literature. The tract hemorrhage rate in the early (<4 h) heparin group was a remarkable 58.8%. The hemorrhages were also notably larger in the early (<4 h) heparin group. CONCLUSION Although heparin appears to be safe after 4 h, immediate heparinization (within 4 h) after ventriculostomy significantly increases the odds of tract hemorrhage. Additional time should be afforded between ventriculostomy and heparinization to avoid potentially devastating external ventricular drain tract hemorrhage. It is advisable to wait a sufficient time (at least 4 h) after ventriculostomy before embarking on endovascular treatment of ruptured aneurysms.
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Affiliation(s)
- Andrew P Gard
- Division of Neurosurgery, University of Nebraska Medical Center, 982035 Nebraska Medical Center, Omaha, NE, 68198-2035, USA.
| | - Brian D Sayles
- Division of Neurosurgery, University of Nebraska Medical Center, 982035 Nebraska Medical Center, Omaha, NE, 68198-2035, USA
| | - J Will Robbins
- Division of Neurosurgery, University of Nebraska Medical Center, 982035 Nebraska Medical Center, Omaha, NE, 68198-2035, USA
| | - William E Thorell
- Division of Neurosurgery, University of Nebraska Medical Center, 982035 Nebraska Medical Center, Omaha, NE, 68198-2035, USA
| | - Daniel L Surdell
- Division of Neurosurgery, University of Nebraska Medical Center, 982035 Nebraska Medical Center, Omaha, NE, 68198-2035, USA
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24
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Tavakoli S, Peitz G, Ares W, Hafeez S, Grandhi R. Complications of invasive intracranial pressure monitoring devices in neurocritical care. Neurosurg Focus 2018; 43:E6. [PMID: 29088962 DOI: 10.3171/2017.8.focus17450] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intracranial pressure monitoring devices have become the standard of care for the management of patients with pathologies associated with intracranial hypertension. Given the importance of invasive intracranial monitoring devices in the modern neurointensive care setting, gaining a thorough understanding of the potential complications related to device placement-and misplacement-is crucial. The increased prevalence of intracranial pressure monitoring as a management tool for neurosurgical patients has led to the publication of a plethora of papers regarding their indications and complications. The authors aim to provide a concise review of key contemporary articles in the literature concerning important complications with the hope of elucidating practices that improve outcomes for neurocritically ill patients.
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Affiliation(s)
- Samon Tavakoli
- Department of Neurosurgery, University of Texas Health San Antonio, Texas; and
| | - Geoffrey Peitz
- Department of Neurosurgery, University of Texas Health San Antonio, Texas; and
| | - William Ares
- Department of Neurosurgery, University of Pittsburgh, Pennsylvania
| | - Shaheryar Hafeez
- Department of Neurosurgery, University of Texas Health San Antonio, Texas; and
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Texas Health San Antonio, Texas; and
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25
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Hemorrhagic Complications Associated with Ventriculostomy in Patients Undergoing Endovascular Treatment for Intracranial Aneurysms: A Single-Center Experience. Neurocrit Care 2018; 27:11-16. [PMID: 28000128 DOI: 10.1007/s12028-016-0350-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Currently, a complete understanding of post-ventriculostomy hemorrhagic complications in subarachnoid hemorrhage due to ruptured aneurysms remains unknown. The present study evaluates the impact of periprocedural risk factors on rates of external ventricular drain (EVD)-associated hemorrhage in the setting of endovascular treatment of intracranial aneurysms. METHODS A retrospective chart review of 107 patients who underwent EVD placement within 24 h of endovascular coiling was performed. CT of head without contrast was obtained after drain placement and before endovascular treatment. Post-procedural CT was also obtained within 48 h of embolization and was reviewed for new/worsened track hemorrhages. Chi-squared test was used in evaluation. RESULTS Ninety-three of the 107 patients reviewed met the inclusion criteria. Four (25%) of the 16 patients on antiplatelet medications at presentation experienced post-EVD hemorrhage compared to 11 (14.3%) of 77 that were not (p = 0.29). Of the 13 patients given intraprocedural antiplatelets, 3 (23.1%) demonstrated hemorrhage compared to 12 (15%) of 80 not administered these medications (p = 0.46). Further, of 36 patients with intraprocedural anticoagulation, 6 (16.7%) exhibited hemorrhage compared to 9 (15.8%) of 57 in those without (p = 0.91). In 17 patients who received DVT prophylaxis, 2 (11.8%) exhibited hemorrhage compared to 13 (17.1%) of 76 who did not (p = 0.59). No post-EVD hemorrhage had attributable neurologic morbidity. CONCLUSION Our results, demonstrating no significant risk factor related to EVD-associated hemorrhage rates, support the safety of EVD placement in the peri-endovascular treatment period.
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Rowe AS, Rinehart DR, Lezatte S, Langdon JR. Intracerebral hemorrhage after external ventricular drain placement: an evaluation of risk factors for post-procedural hemorrhagic complications. BMC Neurol 2018. [PMID: 29514640 PMCID: PMC5842631 DOI: 10.1186/s12883-018-1030-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background The objective of this study was to evaluate and identify the risk factors for developing a new or enlarged intracranial hemorrhage (ICH) after the placement of an external ventricular drain. Methods A single center, nested case-control study of individuals who received an external ventricular drain from June 1, 2011 to June 30, 2014 was conducted at a large academic medical center. A bivariate analysis was conducted to compare those individuals who experienced a post-procedural intracranial hemorrhage to those who did not experience a new bleed. The variables identified as having a p-value less than 0.15 in the bivariate analysis were then evaluated using a multivariate logistic regression model. Results Twenty-seven of the eighty-one study participants experienced a new or enlarged intracranial hemorrhage after the placement of an external ventricular drain. Of these twenty-seven patients, 6 individuals received an antiplatelet within ninety-six hours of external ventricular drain placement (p = 0.024). The multivariate logistic regression model identified antiplatelet use within 96 h of external ventricular drain insertion as an independent risk factor for post-EVD ICH (OR 13.1; 95% CI 1.95–88.6; p = 0.008). Conclusion Compared to those study participants who did not receive an antiplatelet within 96 h of external ventricular drain placement, those participants who did receive an antiplatelet were 13.1 times more likely to exhibit a new or enlarged intracranial hemorrhage.
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Affiliation(s)
- A Shaun Rowe
- College of Pharmacy, Department of Clinical Pharmacy and Translational Science, The University of Tennessee Health Science Center, 1924 Alcoa Highway, Box 117, Knoxville, TN, 37920, USA.
| | | | - Stephanie Lezatte
- The University of Tennessee Medical Center, University Neurocritical Care, Knoxville, TN, USA
| | - J Russell Langdon
- Department of Anesthesiology, The University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
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27
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Perioperative Management of Adult Patients With External Ventricular and Lumbar Drains: Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care. J Neurosurg Anesthesiol 2017; 29:191-210. [DOI: 10.1097/ana.0000000000000407] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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28
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Miller C, Tummala RP. Risk factors for hemorrhage associated with external ventricular drain placement and removal. J Neurosurg 2017; 126:289-297. [DOI: 10.3171/2015.12.jns152341] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
External ventricular drains (EVDs) have an important role in the management of neurological disease, and their placement is a frequently performed neurosurgical procedure. Hemorrhage is a common complication of EVD placement and occurs more frequently than originally believed. There is also risk of hemorrhage with removal of an EVD, which has not been well described. The authors investigated the risk factors associated with placement and removal of EVDs at their institution.
METHODS
A database was created including patients who required EVD placement from March 2008 to June 2014 at the University of Minnesota. A retrospective chart review was completed, and data were collected for each patient. All cranial imaging studies during the index hospitalization were reviewed to identify hemorrhages associated with either EVD placement or removal. The study was performed using a research protocol approved by the University of Minnesota's institutional review board.
RESULTS
Four hundred eighty-two EVDs were placed during the designated time period. Among the cases in which patients underwent imaging after the placement procedure, hemorrhage was found in 94 (21.6%). The hemorrhage volume ranged from 0.003 cm3 to 45.9 cm3 (mean [± SD] 1.96 ± 6.48 cm3). Two of these hemorrhages resulted in additional interventions: 1 surgical evacuation and 1 contralateral EVD. In 55 (22.5%) of the 244 cases in which imaging was performed after EVD removal, hemorrhage associated with removal was identified. The mean volume of these hemorrhages was 8.25 ± 20.34 cm3 (range 0.012–82.08 cm3). Two EVDs were replaced, and 1 patient died as a result of a large hemorrhage. Large hemorrhages (> 30 cm3) occurred in 2 patients on placement (0.46%) and in 5 patients on removal (2.0%). In this series, decreased platelet levels on admission and an increasing number of EVD placement attempts correlated with an increased risk of hemorrhage on placement. Only those with an EVD placed at bedside were more likely to have hemorrhage on EVD removal.
CONCLUSIONS
Multiple studies have reported varying EVD hemorrhage rates while very few studies have described hemorrhage secondary to EVD removal. This is the first reported analysis of risk factors associated with hemorrhage on EVD removal. Hemorrhages occur relatively frequently following EVD placement and removal, though clinical significance of these events seems to be low.
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29
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Frameless, electromagnetic image-guided ventriculostomy for ventriculoperitoneal shunt and Ommaya reservoir placement. Clin Neurol Neurosurg 2016; 147:46-52. [DOI: 10.1016/j.clineuro.2016.05.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 05/24/2016] [Accepted: 05/28/2016] [Indexed: 11/20/2022]
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Fargen KM, Hoh BL, Neal D, O’connor T, Rivera-Zengotita M, Murad GJA. The burden and risk factors of ventriculostomy occlusion in a high-volume cerebrovascular practice: results of an ongoing prospective database. J Neurosurg 2016; 124:1805-12. [DOI: 10.3171/2015.5.jns15299] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Ventriculostomy occlusion is a known complication after external ventricular drain (EVD) placement. There have been no prospective published series that primarily evaluate the incidence of and risk factors for EVD occlusion. These phenomena are investigated using a prospective database.
METHODS
An ongoing prospective study of all patients undergoing frontal EVD placement in the Neurosurgery Intensive Care Unit at the University of Florida was accessed for the purposes of this analysis. Demographic, procedural, and radiographic data were recorded prospectively and retrospectively. The need for catheter irrigation or replacement was meticulously documented. Univariate and multivariate regression analyses were performed.
RESULTS
Ninety-eight of 101 total enrolled patients had accessible data, amounting to 131 total catheters and 1076 total catheter days. Nineteen percent of patients required at least 1 replacement. Forty-one percent of catheters developed at least 1 temporary occlusion, with an average of 2.4 irrigations per patient. Intracranial hemorrhage occurred in 28% of patients after the first EVD placement (2% resulting in new neurological deficit) and in 62% of patients after 1 replacement. The cost of occlusion is estimated at $615 per enrolled patient. Therapeutic anticoagulation and use of small EVD catheters were statistically significant predictors of permanent occlusion (p = 0.01 and 0.04, respectively).
CONCLUSIONS
EVD occlusion is frequent and imparts a significant burden in terms of patient morbidity, physician upkeep, and cost. This study suggests that developing strategies or devices to prevent EVD occlusion, such as the preferential use of larger diameter catheters, may be beneficial in reducing the burden associated with ventriculostomy malfunction.
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Affiliation(s)
| | | | - Dan Neal
- Departments of 1Neurosurgery and
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31
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Fried HI, Nathan BR, Rowe AS, Zabramski JM, Andaluz N, Bhimraj A, Guanci MM, Seder DB, Singh JM. The Insertion and Management of External Ventricular Drains: An Evidence-Based Consensus Statement. Neurocrit Care 2016; 24:61-81. [DOI: 10.1007/s12028-015-0224-8] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Bruder M, Schuss P, Konczalla J, El-Fiki A, Lescher S, Vatter H, Seifert V, Güresir E. Ventriculostomy-Related Hemorrhage After Treatment of Acutely Ruptured Aneurysms: The Influence of Anticoagulation and Antiplatelet Treatment. World Neurosurg 2015; 84:1653-9. [DOI: 10.1016/j.wneu.2015.07.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 07/01/2015] [Accepted: 07/02/2015] [Indexed: 11/30/2022]
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Chohan MO, Akbik OS, Ramos-Canseco J, Ramirez PM, Murray-Krezan C, Berlin T, Olin K, Taylor CL, Yonas H. A novel single twist-drill access device for multimodal intracranial monitoring: a 5-year single-institution experience. Neurosurgery 2015; 10 Suppl 3:400-11; discussion 411. [PMID: 24887290 DOI: 10.1227/neu.0000000000000451] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Multimodal intracranial monitoring in the neurosurgical patient requires insertion of probes through multiple craniostomies. OBJECTIVE To report our 5-year experience with a novel device allowing multimodal monitoring though a single twist-drill hole. METHODS All devices (Hummingbird Synergy, Innerspace) were placed at the Kocher point between 2008 and 2013 at our institution. An independent clinical research nurse prospectively collected data on all bedside placements. Placement accuracy was graded on computed tomography scan as grade 1 (ipsilateral frontal horn or third ventricle), grade 2 (contralateral lateral ventricle), and grade 3 (anywhere else). Infection was monitored with serial cerebrospinal fluid samples. RESULTS Two hundred seventy-five devices (198 at bedside, 77 in operating room) were placed in patients with spontaneous subarachnoid hemorrhage (49%), traumatic brain injury (47%), and others (4%) for a median duration of 6 days. A junior (postgraduate year 1-2), midlevel (postgraduate year 3-4), or senior resident (postgraduate year 5-6) placed 39%, 32%, and 29% of the devices, respectively. Ninety-two percent of all devices placed were draining cerebrospinal fluid, ie, were grade 1 (75%) or 2 (17%). Placement accuracy did not vary with level of training. Complications included hemorrhage (10%) and infection (4%), with 1 patient requiring intraparenchymal hematoma evacuation and a second requiring abscess drainage. These rates were lower than reported in the literature for standard external ventricular drains. CONCLUSION Hummingbird Synergy is a novel single-port access device for multimodal intracranial monitoring that can be placed safely at the bedside or in the operating room with placement accuracy and has a complication profile similar to or better than that for standard external ventricular drains.
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Affiliation(s)
- Muhammad Omar Chohan
- *Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico; ‡Division of Epidemiology, Biostatistics, and Preventive Medicine, Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
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34
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External ventricular drain placement in the intensive care unit versus operating room: Evaluation of complications and accuracy. Clin Neurol Neurosurg 2015; 128:94-100. [DOI: 10.1016/j.clineuro.2014.09.026] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 08/17/2014] [Accepted: 09/28/2014] [Indexed: 11/17/2022]
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35
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Naik BI, Keeley EC, Gress DR, Zuo Z. Case scenario: a patient on dual antiplatelet therapy with an intracranial hemorrhage after percutaneous coronary intervention. Anesthesiology 2014; 121:644-53. [PMID: 24950163 PMCID: PMC4165792 DOI: 10.1097/aln.0000000000000350] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Bhiken I Naik
- From the Department of Anesthesiology (B.I.N., Z.Z.), Division of Cardiovascular Medicine (E.C.K.), Department of Neurology (D.R.G.), University of Virginia, Charlottesville, Virginia
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