Long-Term Safety and Efficacy of Pipeline Embolization Device in Anterior and Posterior Circulation Aneurysms: A Systematic Review and Meta-Analysis

BACKGROUND

Flow diversion using the pipeline embolization device (PED) has been a paradigm shift for anterior circulation (AC) aneurysms. However, only a few studies report the long-term (≥1 year) angiographic and clinical outcomes for posterior circulation (PC) aneurysms. This study aims to compare the long-term safety and efficacy of treatment of AC and PC aneurysms with PED.

METHODS

The databases included Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane, and Scopus. Studies with at least 10 patients and 1-year follow-up were included. Twenty-four studies met our inclusion criteria. A random effect meta-analysis was performed to estimate the ischemic and hemorrhagic complications. A meta-analysis of proportions was performed to estimate the pooled rates of long-term complete aneurysmal occlusion, symptomatic stroke, aneurysmal rupture, and intracranial hemorrhage.

RESULTS

There were 1952 aneurysms, of which 1547 (79.25%) were in the AC and 405 (20.75%) in the PC. The 1-year occlusion rate was 78% in AC compared to 73% in PC aneurysms (P < 0.01). The symptomatic infarct rate was 5% in AC compared to 13% in PC (P < 0.01). While the rupture rate was 1% in AC compared to 4% in PC (P = 0.01), the rate of intracranial hemorrhage was 2% for both (P = 0.99).

CONCLUSIONS

The long-term occlusion rate after PED was higher in AC aneurysms, and the cumulative incidence of stroke and aneurysm rupture was higher in PC aneurysms.

Mesenchymal Stem Cell Therapy in Acute Intracerebral Hemorrhage: A Dose-Escalation Safety and Tolerability Trial

BACKGROUND

We conducted a preliminary phase I, dose-escalating, safety, and tolerability trial in the population of patients with acute intracerebral hemorrhage (ICH) by using human allogeneic bone marrow-derived mesenchymal stem/stromal cells.

METHODS

Eligibility criteria included nontraumatic supratentorial hematoma less than 60 mL and Glasgow Coma Scale score greater than 5. All patients were monitored in the neurosciences intensive care unit for safety and tolerability of mesenchymal stem/stromal cell infusion and adverse events. We also explored the use of cytokines as biomarkers to assess responsiveness to the cell therapy. We screened 140 patients, enrolling 9 who met eligibility criteria into three dose groups: 0.5 million cells/kg, 1 million cells/kg, and 2 million cells/kg.

RESULTS

Intravenous administration of allogeneic bone marrow-derived mesenchymal stem/stromal cells to treat patients with acute ICH is feasible and safe.

CONCLUSIONS

Future larger randomized, placebo-controlled ICH studies are necessary to validate this study and establish the effectiveness of this therapeutic approach in the treatment of patients with ICH.

Artificial intelligence and machine learning in aneurysmal subarachnoid hemorrhage: Future promises, perils, and practicalities

INTRODUCTION

Aneurysmal subarachnoid hemorrhage (SAH) is a subtype of hemorrhagic stroke with thirty-day mortality as high as 40%. Given the expansion of Machine Learning (ML) and Artificial intelligence (AI) methods in health care, SAH patients desperately need an integrated AI system that detects, segments, and supports clinical decisions based on presentation and severity.

OBJECTIVES

This review aims to synthesize the current state of the art of AI and ML tools for the management of SAH patients alongside providing an up-to-date account of future horizons in patient care.

METHODS

We performed a systematic review through various databases such as Cochrane Central Register of Controlled Trials, MEDLINE, Scopus, Cochrane Database of Systematic Reviews, and Embase.

RESULTS

A total of 507 articles were identified. Following extensive revision, only 21 articles were relevant. Two studies reported improved mortality prediction using Glasgow Coma Scale and biomarkers such as Neutrophil to Lymphocyte Ratio and glucose. One study reported that ffANN is equal to the SAHIT and VASOGRADE scores. One study reported that metabolic biomarkers Ornithine, Symmetric Dimethylarginine, and Dimethylguanidine Valeric acid were associated with poor outcomes. Nine studies reported improved prediction of complications and reduction in latency until intervention using clinical scores and imaging. Four studies reported accurate prediction of aneurysmal rupture based on size, shape, and CNN. One study reported AI-assisted Robotic Transcranial Doppler as a substitute for clinicians.

CONCLUSION

AI/ML technologies possess tremendous potential in accelerating SAH systems-of-care. Keeping abreast of developments is vital in advancing timely interventions for critical diseases.

TeleNeuroICU: Expanding the Reach of Subspecialty Neurocritical Care

Telemedicine is a rapidly growing field of medicine due to a combination of high-speed global telecommunication systems and accessibility of small, fast mobile computing platforms with bidirectional audiovisual camera capabilities. Teleneurology is a subset of telemedicine. TeleNeuroICU, one form of teleneurology, is the practice of virtually consulting on patients in the ICU setting with neurological and neurosurgical conditions. Given the current and future shortage of neurologists and neurointensivists, there is a high demand for TeleNeuroICU services around the globe and this is expected to increase in the future. This review summarizes the state of the art around the TeleNeuroICU practice for practitioners in the field, emerging research in this area, and new technologies and integrations that enhance the value of TeleNeuroICU to health care systems.

Colistin neurotoxicity mimicking Guillain-Barré syndrome in a patient with cystic fibrosis: case report and review

Guillain-Barré syndrome (GBS) is an immune-mediated polyneuropathy, which is characterized by areflexia and ascending paresthesia which can progress to a respiratory failure. Certain conditions, such as vasculitis and heavy metal and drug toxicity, may have misleadingly similar clinical presentation to GBS. We describe a case of a patient with cystic fibrosis and intravenous colistin-induced neurotoxicity mimicking GBS. The patient had used inhaled colistin on five occasions with no adverse effects, however, developed symptoms on the second day of intravenous treatment. Overlapping findings between immune-mediated polyneuropathy and drug-induced neurotoxicity include limb paresthesia and decreased reflexes. Perioral tingling, however, is a common presentation of colistin-induced neurotoxicity, and therefore, is an important differentiating factor. Early diagnosis prevents further neurologic decline, extensive unnecessary workup and potentially harmful incorrect management.

Intracerebral Hemorrhage: A Common yet Disproportionately Deadly Stroke Subtype

Spontaneous intracerebral hemorrhage (ICH) is a medical emergency and is disproportionately associated with higher mortality and long-term disability compared with ischemic stroke. The phrase "time is brain" was derived for patients with large vessel occlusion ischemic stroke in which approximately 1.9 million neurons are lost every minute. Similarly, this statement holds true for ICH patients due to a high volume of neurons that are damaged at initial onset and during hematoma expansion. Most cases of spontaneous ICH pathophysiologically stem from chronic hypertension and rupture of small perforating vessels off of larger cerebral arteries supplying deep brain structures, with cerebral amyloid angiopathy being another cause for lobar hemorrhages in older patients. Optimal ICH medical management strategies include timely diagnosis, aggressive blood pressure control, correction of underlying coagulopathy defects if present, treatment of cerebral edema, and continuous assessment for possible surgical intervention. Current strategies in the surgical management of ICH include newly developed minimally invasive techniques for hematoma evacuation, with the goal of mitigating injury to fiber tracts while accessing the clot. We review evidence-based medical and surgical management of spontaneous ICH with the overall goal of reducing neurologic injury and optimizing functional outcome.

Endotheliitis, endothelin, and endothelin receptor blockers in COVID-19

We summarize the role of endothelin as a potent vasoconstrictor, pro-inflammatory, pro-oxidative agent in the pathophysiologic effects and end-organ dysfunction of coronavirus disease 2019 (COVID-19). Endotheliitis is an under-recognized pathophysiologic process that causes various types of dysfunction in end organs, including heart, lung, kidney, and brain. Endothelin receptor blockers, such as bosentan and sitaxentan, can pave a path ahead in the realm of COVID-19 therapies. These agents have a potential role against COVID-19 and should be studied in research trials to determine their efficacy in treatment of this severe disease.

Platforms for Personalized Polytherapeutics Discovery in COVID-19

The COVID-19 pandemic entered its third and most intense to date wave of infections in November 2020. This perspective article describes how combination therapies (polytherapeutics) are a needed focus for helping battle the severity of complications from SARS-CoV-2 infection. It outlines the types of systems that are needed for fast and efficient combinatorial assessment of therapeutic candidates. Proposed are micro-physiological systems using human iPSC as a format for tissue-specific modeling of infection, the use of gene-humanized zebrafish and C. elegans for combinatorial drug screens due to the animals being addressable in liquid multi-well formats, and the use of engineered pseudo-typing systems to safely model infection in the transgenic animals and engineered tissue systems.

Robotics in Simulated COVID-19 Patient Room for Health Care Worker Effector Tasks: Preliminary, Feasibility Experiments

The coronavirus disease 2019 (COVID-19) pandemic has strained health care systems and personal protective equipment (PPE) supplies globally. We hypothesized that a collaborative robot system could perform health care worker effector tasks inside a simulated intensive care unit (ICU) patient room, which could theoretically reduce both PPE use and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) exposures. We planned a prospective proof-of-concept feasibility and design pilot study to test 5 discrete medical tasks in a simulated ICU room of a COVID-19 patient using a collaborative robot: push a button on intravenous pole machine when alert occurs for downstream occlusion, adjust ventilator knob, push button on ICU monitor to silence false alerts, increase oxygen flow on wall-mounted flow meter to allow the patient to walk to the bathroom and back (dial-up and dial-down oxygen flow), and push wall-mounted nurse call button. Feasibility was defined as task completion robotically. A training period of 45 minutes to 1 hour was needed to program the system de novo for each task. In less than 30 days, the team completed 5 simple effector task experiments robotically. Selected collaborative robotic effector tasks appear feasible in a simulated ICU room of the COVID-19 patient. Theoretically, this robotic approach could reduce PPE use and staff SARS-CoV-2 exposure. It requires future validation and health care worker learning similar to other ICU device training.

Value of Broad Range 16S Ribosomal RNA Gene PCR / Sequencing (Br-PCR) of CSF in the Diagnosis of Bacterial Meningitis

Bacterial meningitis is a life-threatening condition that requires quick and definitive diagnosis. Bacterial cultures from cerebrospinal fluid (CSF) return with a negative result as treatment with antimicrobials are sometimes started before sampling of CSF can be obtained which makes isolating the causative bacteria challenging. The value of Broad Range 16S Ribosomal RNA Gene Polymerase Chain Reaction / Sequencing of CSF (Br-PCR) can address this problem by amplifying and identifying any bacterial DNA present in a clinical sample. A 65-year-old female presented with rapid onset of high fevers, headache, chills and right hip pain. She had blood cultures drawn, unremarkable CSF analysis in the emergency department, and was discharged home. Ten hours later, she developed vomiting and altered mental status, returned to hospital and started on antimicrobials for gram negative bacteremia and emergently intubated with repeat lumbar puncture showed evidence of bacterial meningitis with pleocytosis and elevated opening pressures. Empiric antimicrobial therapy was started. All subsequent CSF microbiological stains, cultures, and molecular analyses were negative. The blood cultures grew Haemophilus influenzae and H. influenzae meningitis was presumed to be the cause. Therefore, Br-PCR on CSF was sent which detected Haemophilus species DNA. She received a 3-week course of ceftriaxone. After rehabilitation, she returned home without any significant neurological deficits. No relapse of meningitis at 4 months was noted. The application for Br-PCR in the setting of suspected bacterial meningitis with negative stains and cultures could improve a diagnostic algorithm for bacterial meningitis.

Can Baseline Computed Tomography Scans Be Used to Identify Patients at High Risk of Vision Loss due to Terson Syndrome?

PURPOSE

To determine if routinely performed computed tomographic (CT) scanning in patients with aneurysmal subarachnoid hemorrhages (aSAHs) is sufficient to identify patients at high risk of vision loss due to Terson syndrome (TS).

METHODS

Consecutive patients with a diagnosis of aSAH admitted to the neurologic intensive care unit of a regional referral hospital over a 3-year period were prospectively evaluated. Head CT scans performed in the emergency department were assessed for the presence of a "crescent sign" (evidence of significant subinternal limiting membrane hemorrhage). Dilated funduscopic examinations were performed by an ophthalmologist, masked to the results of the CT scan, to identify retinal and vitreous hemorrhages consistent with TS. Retinal hemorrhages were categorized according to size-those smaller than 2 mm in diameter were deemed low risk (lrTS) for vision loss and those larger than 2 mm in diameter were deemed high risk (hrTS) for vision loss.

RESULTS

One hundred seventeen patients with aSAH were enrolled in the study. The overall incidence of TS was 24.9% (29 of 117 patients; 12 were bilateral). Compared to patients without TS, those with TS had a higher Fisher Hemorrhage Grade and a lower mean (±standard deviation) GCS score (8.66 ± 4.97 vs 12.09 ± 1.10; P < 0.001). The CT crescent sign was positive in 7 patients (6.0%), 6 (5.1%; 2 were bilateral) of whom were found to have hrTS. Of the 110 patients without a CT crescent sign, 88 (75.1%) patients did not have TS, 21 had lrTS, and 1 patient had hrTS in one eye. The CT crescent sign was highly sensitive (85.7%) and specific (99.1%) for diagnosing hrTS.

CONCLUSION

The CT crescent sign is a highly sensitive and specific marker for hrTS. CT scanning may replace routine ophthalmologic examinations to identify patients at risk of vision loss due to aSAH.

The Incidence of Catheter Tract Hemorrhage and Catheter Placement Accuracy in the CLEAR III Trial

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.

Minimally invasive surgery and transsulcal parafascicular approach in the evacuation of intracerebral haemorrhage

Intracerebral haemorrhage (ICH) describes haemorrhage into the brain parenchyma that may result in a decline of the patient’s neurological function. ICH is a common cause of morbidity and mortality worldwide. Aggressive surgical treatment for ICH has remained controversial as clinical trials have failed to demonstrate substantial improvement in patient outcome and mortality. Recently, promising mechanical and pharmacological minimally invasive surgery (MIS) techniques for the treatment of ICH have been described. MIS was designed with the objective of reducing morbidity due to complications of surgical manipulation. Mechanical MIS includes the use of tubular retractors and small diameter instruments for ICH removal. Pharmacological methods consist of catheter placement inside the haematoma cavity for the passive drainage of the haematoma over the course of several days. One of the most favourable approaches for MIS is the use of natural corridors for reaching the lesion, such as the transsulcal parafascicular approach. This approach provides an anatomical dissection of the subjacent white matter tracts, causing the least amount of damage while evacuating the haematoma. A detailed description of the currently known MIS techniques and devices is presented in this review. Special attention is given to the transsulcal parafascicular approach, which has particular benefits to provide a less traumatic MIS with promising overall patient outcome.

Update on Neurocritical Care of Stroke

PURPOSE OF REVIEW

This review will highlight the recent advancements in acute ischemic stroke diagnosis and treatment, with special attention to new features and recommendations of stroke care in the neurocritical care unit.

RECENT FINDINGS

New studies suggest that pre-hospital treatment of stroke with mobile stroke units and telestroke technology may lead to earlier stroke therapy with intravenous tissue plasminogen activator (tPA), and recent studies show tPA can be given in previously contraindicated situations. More rapid automated CT perfusion and angiography may demonstrate a vascular penumbra for neuroendovascular intervention. Further, the greatest advance in acute stroke treatment since 2014 is the demonstration that neuroendovascular catheter-based thrombectomy with stent retrievers recanalizing intracranial large vessel occlusion (LVO) improves both recanalization and long-term outcomes in several trials. Hemorrhagic transformation and severe large infarct cerebral edema remain serious post-stroke challenges, with new guidelines describing who and when patients should get medical or surgical intervention. The adage "time is brain" directs the most evidence-based approach for rapid stroke diagnosis for tPA eligible and LVO recanalization using an orchestrated team approach. The neurocritical care unit is the appropriate location to optimize stroke outcomes for the most severely affected stroke patients.

Management of Intracranial Pressure

PURPOSE OF REVIEW

Intracranial pressure (ICP) can be elevated in traumatic brain injury, large artery acute ischemic stroke, intracranial hemorrhage, intracranial neoplasms, and diffuse cerebral disorders such as meningitis, encephalitis, and acute hepatic failure. Raised ICP is also known as intracranial hypertension and is defined as a sustained ICP of greater than 20 mm Hg.

RECENT FINDINGS

ICP must be measured through an invasive brain catheter, typically an external ventricular catheter that can drain CSF and measure ICP, or through an intraparenchymal ICP probe. Proper recognition of the clinical signs of elevated ICP is essential for timely diagnosis and treatment to prevent cerebral hypoperfusion and possible brain death. Clinical signs of elevated ICP include headache, papilledema, nausea, and vomiting in the early phases, followed by stupor and coma, pupillary changes, hemiparesis or quadriparesis, posturing and respiratory abnormalities, and eventually cardiopulmonary arrest.

SUMMARY

Management of elevated ICP is, in part, dependent on the underlying cause. Medical options for treating elevated ICP include head of bed elevation, IV mannitol, hypertonic saline, transient hyperventilation, barbiturates, and, if ICP remains refractory, sedation, endotracheal intubation, mechanical ventilation, and neuromuscular paralysis. Surgical options include CSF drainage if hydrocephalus is present and decompression of a surgical lesion, such as an intracranial hematoma/large infarct or tumor, if the patient's condition is deemed salvageable. Future research should continue investigating medical and surgical options for the treatment of raised ICP, such as hypothermia, drugs that reduce cerebral edema, and operations aimed at reducing intracranial mass effect.

Takotsubo cardiomyopathy in the setting of acute hydrocephalus secondary to neurocysticercosis

We report the case of a 45-year-old male who presented with transient neurogenic stunned myocardium, or takotsubo cardiomyopathy, secondary to acute hydrocephalus caused by obstruction of the third ventricle by neurocysticercosis.

A feasibility pilot using a mobile personal health assistant (PHA) app to assist stroke patient and caregiver communication after hospital discharge

BACKGROUND

Recent advancements have lowered national acute stroke mortality, yet posthospital care and readmission rates remain challenges. A personal health assistant (PHA) may help manage the spectrum of posthospital care. We hypothesized that a PHA application (app) would be associated with high poststroke patient care satisfaction and might prevent hospital readmission.

METHODS

This is a case series of acute stroke patients admitted to a single, tertiary care, comprehensive stroke center (Mayo Clinic, Jacksonville, Florida) who were offered a personal health assistance through a smart phone app. Patients were screened based on having a cerebrovascular event and the ability to use a necessary device. All patients received the standard poststroke discharge protocol, the PHA app, and the 30-day Likert scale survey.

RESULTS

We screened 21 patients and enrolled 3 (14%) before premature financial closure. Two of the 3 patients rated the app highly, and the third patient had not started using it. Of the ineligible patients, 4 had no device, 3 declined enrollment, and 2 were not able to use the device. One of the 2 patients who used the PHA app was readmitted for new stroke symptoms.

CONCLUSIONS

Both patients who used the app were very satisfied with the PHA and their posthospital care coordination. This study had an enrollment rate of about 14% due to various factors, including limited access or utilization of necessary technology. Though limited by final patient sample size and early termination from funding, this study provides useful information about developing future mobile health apps for acute stroke patients.

Teleneurosonology: a novel application of transcranial and carotid ultrasound

BACKGROUND

To demonstrate the technical feasibility of interfacing transcranial Doppler (TCD) and carotid "duplex" ultrasonography (CUS) peripherals with telemedicine end points to provide real-time spectral waveform and duplex imaging data for remote review and interpretation.

METHODS

We performed remote TCD and CUS examinations on a healthy, volunteer employee from our institution without known cerebrovascular disease. The telemedicine end point was stationed in our institution's hospital where the neurosonology examinations took place and the control station was in a dedicated telemedicine room in a separate building. The examinations were performed by a postgraduate level neurohospitalist trainee (M.N.R.) and interpreted by an attending vascular neurologist, both with experience in the performance and interpretation of TCD and CUS.

RESULTS

Spectral waveform and duplex ultrasound data were successfully transmitted from TCD and CUS instruments through a telemedicine end point to a remote reviewer at a control station. Image quality was preserved in all cases, and technical failures were not encountered.

CONCLUSIONS

This proof-of-concept study demonstrates the technical feasibility of interfacing TCD and CUS peripherals with a telemedicine end point to provide real-time spectral waveform and duplex imaging data for remote review and interpretation. Medical diagnostic and telemedicine devices should be equipped with interfaces that allow simple transmission of high-quality audio and video information from the medical devices to the telemedicine technology. Further study is encouraged to determine the clinical impact of teleneurosonology.

Nonconvulsive status with metronidazole

OBJECTIVE

To expand the adverse events associated with metronidazole to include nonconvulsive status epilepticus (NCSE).

DESIGN

Observational single case report of a rare association.

SETTING

Hospitalized lung transplant recipient treated with metronidazole for prevention of infection.

PATIENT

A 56-year-old man with systemic symptoms, peripheral neuropathy, generalized seizure, and a subsequent acute deterioration of mental status due to NCSE.

INTERVENTIONS

Administration of midazolam was successful in terminating status epilepticus.

MAIN OUTCOME MEASURES

Abrupt termination of NCSE was evident on continuous bedside electroencephalogam associated with clinical resolution of mental status.

RESULTS

Recovery occurred from NCSE eventually deteriorating to a fatal outcome.

CONCLUSIONS

Metronidazole may be associated with successfully treated NCSE.

Neurohospitalists reduce length of stay for patients with ischemic stroke

BACKGROUND

Neurohospitalists may improve the efficiency and quality of care delivered to hospitalized patients with neurological disease. However, there is limited systematic data to support this hypothesis. The primary purpose of this study was to compare length of stay (LOS) for patients with ischemic stroke cared for by either neurohospitalists or community-based neurologists at a single institution.

METHODS

A retrospective chart review was performed for all patients with ischemic stroke discharged from St. Luke's Hospital in Jacksonville, Florida, between January 2006 and December 2007. The LOS for patients cared for by neurohospitalists was compared to the LOS for patients cared for by community neurologists. Compliance with Joint Commission inpatient stroke quality metrics was also compared.

RESULTS

A total of 533 patients were discharged with a principal diagnosis of ischemic stroke over the 24-month study period. Neurohospitalists cared for 313 patients with mean (± SD) LOS of 4.9 (5.2) days (95% CI: 4.3-5.5 days), and community-based neurologists cared for 220 patients with a mean LOS of 6.5 (8.2) days (95% CI: 5.4-7.6 days). The mean LOS was significantly less for the neurohospitalists compared to the community-based neurologists (P = .005). Neurohospitalists achieved a higher compliance rate in 10 of 11 inpatient stroke quality metrics and achieved significantly higher compliance rate of smoking cessation education (P = .019).

CONCLUSIONS

Neurohospitalists achieved significantly shorter LOS for patients with ischemic stroke compared to community-based neurologists. These data suggest that neurohospitalists can also improve compliance with quality metrics necessary for Joint Commission Primary Stroke Center designation.

Survey of current neurohospitalist practice

Neurohospitalists represent a new approach to inpatient neurologic care. In order to characterize this practice, we surveyed both a general neurology sample as well as a sample of pertinent American Academy of Neurology sections. Of the section sample, 42% defined themselves as neurohospitalists, compared to 16% of the general sample. The majority of neurohospitalists are in an academic setting and share call responsibilities with non-neurohospitalists. Many are concerned about the possibility of burnout in their current practice setting. This representative sample of neurohospitalists reveals a diverse group facing a number of unanswered questions and challenges, including concerns for burnout, ideal practice setting, and defining the core curriculum for a neurohospitalist.

Hypoxic-ischemic brain injury and prognosis after cardiac arrest

PURPOSE OF REVIEW

: Cardiac death is the leading cause of death in the United States, and patients who have out-of-hospital cardiac arrest have only a 1% to 10% survival rate, despite improvements in advanced life support. The neurologic sequelae of hypoxic-ischemic brain injury after cardiac arrest vary from subtle cognitive impairment to coma, persistent vegetative state, and brain death. Neurologists are commonly asked to prognosticate neurologic outcome after cardiac arrest.

RECENT FINDINGS

: In 2002, two randomized controlled trials demonstrated that therapeutic hypothermia (32°C to 34°C [89.6°F to 93.2°F]) increases the odds of improved neurologic outcome and reduces the risk of death compared with normothermia when applied for the initial 12 to 24 hours after ventricular fibrillation or tachycardia cardiac arrest. Considerable research continues into neurologic prognostication after hypoxic-ischemic brain injury, especially with the advent of therapeutic hypothermia and its effects on the clinical examination, neurophysiologic studies, and serum biomarkers of brain injury. Recent reports indicate that poor motor response 72 hours after cardiac arrest, absent cortical responses on median nerve somatosensory-evoked potentials, and elevated neuron-specific enolase may not necessarily indicate poor prognosis in patients treated with therapeutic hypothermia compared with historical populations not treated with hypothermia, perhaps because of sedation and neuromuscular blockade.

SUMMARY

: Neurologic prognostication after cardiac arrest remains challenging because of the sedation and neuromuscular blocking agents given to patients who undergo therapeutic hypothermia. A multimodal algorithmic approach (clinical, electrophysiologic, and possibly serum biomarker testing) is suggested for cardiac arrest patients treated with hypothermia, but further research is needed to determine more accurate prognostic predictors.

Prediction of potential for organ donation after cardiac death in patients in neurocritical state: a prospective observational study

BACKGROUND

Successful donation of organs after cardiac death (DCD) requires identification of patients who will die within 60 min of withdrawal of life-sustaining treatment (WLST). We aimed to validate a straightforward model to predict the likelihood of death within 60 min of WLST in patients with irreversible brain injury.

METHODS

In this multicentre, observational study, we prospectively enrolled consecutive comatose patients with irreversible brain injury undergoing WLST at six medical centres in the USA and the Netherlands. We assessed four clinical characteristics (corneal reflex, cough reflex, best motor response, and oxygenation index) as predictor variables, which were selected on the basis of previous findings. We excluded patients who had brain death or were not intubated. The primary endpoint was death within 60 min of WLST. We used univariate and multivariable logistic regression analyses to assess associations with predictor variables. Points attributed to each variable were summed to create a predictive score for cardiac death in patients in neurocritical state (the DCD-N score). We assessed performance of the score using area under the curve analysis.

FINDINGS

We included 178 patients, 82 (46%) of whom died within 60 min of WLST. Absent corneal reflexes (odds ratio [OR] 2·67, 95% CI 1·19-6·01; p=0·0173; 1 point), absent cough reflex (4·16, 1·79-9·70; p=0·0009; 2 points), extensor or absent motor responses (2·99, 1·22-7·34; p=0·0168; 1 point), and an oxygenation index score of more than 3·0 (2·31, 1·10-4·88; p=0·0276; 1 point) were predictive of death within 60 min of WLST. 59 of 82 patients who died within 60 min of WLST had DCD-N scores of 3 or more (72% sensitivity), and 75 of 96 of those who did not die within this interval had scores of 0-2 (78% specificity); taking into account the prevalence of death within 60 min in this population, a score of 3 or more was translated into a 74% chance of death within 60 min (positive predictive value) and a score of 0-2 translated into a 77% chance of survival beyond 60 min (negative predictive value).

INTERPRETATION

The DCD-N score can be used to predict potential candidates for DCD in patients with non-survivable brain injury. However, this score needs to be tested specifically in a cohort of potential donors participating in DCD protocols.

FUNDING

None.

Gender differences in presenting signs and symptoms of acute ischemic stroke: a population-based study

BACKGROUND

There are few population-based data regarding gender differences in signs and symptoms of acute ischemic stroke, and previously reported data have been inconsistent and conflicting.

OBJECTIVE

The goal of this study was to address the gender differences of the presenting signs and symptoms of acute ischemic stroke in a population-based study.

METHODS

All patients with first ischemic stroke occurring between 1985 and 1989 were identified; subjects were residents of Rochester, Minnesota. Signs and symptoms were collected via review of comprehensive medical records. Differences were identified using the Pearson χ(2) test.

RESULTS

A total of 449 cases of first ischemic stroke were identified; 268 (60%) were women. Symptoms at ischemic stroke presentation differed between men and women. Women more commonly presented with generalized weakness (P = 0.005) and mental status change (P = 0.0001). Men more commonly presented with paresthesia (P = 0.003), ataxia (P = 0.006), and double vision (P = 0.005). Signs at ischemic stroke presentation differed between men and women. Men more commonly presented with nystagmus (P = 0.002) on examination. Significant trends were that women more commonly presented with fatigue (P = 0.02), disorientation (P = 0.04), and fever (P = 0.02), whereas men more commonly presented with sensory abnormalities (P = 0.02).

CONCLUSIONS

There were gender differences in signs and symptoms at presentation of ischemic stroke in these study patients. In addition to selected focal symptoms, women more commonly presented with diffuse symptoms of generalized weakness, fatigue, disorientation, and mental status change.

Emergent, controlled lumbar drainage for intracranial pressure monitoring during orthotopic liver transplantation

BACKGROUND

Measurement of intracranial pressure (ICP) is recommended in comatose acute liver failure (ALF) patients due to risk of rapid global cerebral edema. External ventricular drains (EVD) can be placed to drain cerebrospinal fluid and monitor ICP simultaneously although this remains controversial in the neurosurgical community given the risk of hemorrhagic complications. We describe a patient with ALF and global cerebral edema whose EVD failed immediately before orthotopic liver transplantation (OLT) in which a lumbar drain (LD) was used temporarily to monitor ICP.

METHODS

We describe a 36 year old patient with ALF and brain edema from acetaminophen overdose who had an EVD placed for ICP monitoring and management. The EVD failed repeatedly (i.e., lost CSF drainage and ICP waveform) despite several saline irrigations and three doses intraventricular tissue plasminogen activator (1 mg) in the hours that immediately preceded her planned emergency OLT. An LD was placed emergently and controlled cerebrospinal fluid (CSF) drainage and ICP measurement was performed by setting the LD at 20 mmHg and leveling at the ear level (foramen of Monro). The LD was removed once the EVD flow was re-established post-OLT.

RESULTS

The EVD and LD ICP measurements were reported to be the same just prior to removing the LD.

CONCLUSIONS

Controlled CSF drainage using a lumbar drain can be used to monitor ICP when leveled at the foramen of Monro if EVD failure occurs perioperatively. The LD can temporarily guide ICP management until the EVD flow can be re-established after OLT.

Spontaneous intracerebral hemorrhage

Spontaneous intracerebral hemorrhage (sICH) is defined as bleeding within the brain parenchyma, and occurs twice as commonly as subarachnoid hemorrhage, but is equally as deadly. Risk factors for sICH include hypertension, advanced age, leukoaraiosis, prior ICH, renal failure, use of anticoagulant drugs, and cerebral amyloid angiopathy. When a patient is clinically suspected of having sICH, head computed tomography scan is the standard diagnostic tool. However, newer magnetic resonance neuroimaging techniques may aid in determining the underlying pathology and aid in prognosis. Supportive care and blood pressure management are important in the care of patients with sICH. Ongoing research is aimed at determining a safe blood pressure goal that may also prevent expansion of hemorrhage. Hemostatic medications and neuroprotectants have thus far not shown clinical improvement. Although several neurosurgical trials have failed to demonstrate benefit for surgical evacuation of sICH, multiple research trials are ongoing investigating acute blood pressure control, deep or basal ganglionic hemorrhage evacuation via minimally invasive approach (MISTIE; http://mistietrial.com/default.aspx), lobar ICH evacuation (STICH; II http://research.ncl.ac.uk/stich/), and intraventricular thrombolysis with tissue plasminogen activator (tPA) (CLEAR III; http://biosgroup-johnshopkinsmedicine.health.officelive.com/default.aspx).

Prolonged Mild-to-Moderate Hypothermia for Refractory Intracranial Hypertension

BACKGROUND

Therapeutic hypothermia is an emerging therapy for brain injury and cerebral edema. Hypothermia is known to reduce death and neurologic morbidity in survivors of cardiac arrest from ventricular fibrillation. Traumatic brain injury (TBI) trials studies of short-term hypothermia (24 to 48hours) have had conflicting results. Recent evidence however suggests prolonged hypothermia (48 hours to 14 days) may be beneficial for TBI and select cases of nontraumatic brain injury especially when the duration of cerebral edema and intracranial hypertension is expected to last longer than 24 hours.

CASE REPORT

A 43-year-old female presented with a Fisher grade 4 aneurysmal (anterior communicating artery) subarachnoid hemorrhage. The patient was comatose upon transfer to our hospital, was intubated, and had immediate aneurysm coiling. The patient had a right external ventricular drain (EVD) placed for acute hydrocephalus and intracranial pressure (ICP) monitoring. The patient developed severe vasospasm of several intracranial vessels requiring angioplasty on two consecutive days, and hypertensive, hypervolemic, hemodilution therapy (HHH). On the ninth day, ICP went above 20mmHg and computed tomography (CT) showed global cerebral edema. For the next 17 days, the patient had refractory intracranial hypertension, requiring sedation, neuromuscular blockade, hyperosmolar therapy (3% infusion, and 23.4% saline boluses), thiopental coma with burst suppression, and hypothermia (31 to 34C). Hypothermia continued for a total of 14 days before ICP and edema on CT normalized.

CONCLUSION

We report the first case of prolonged therapeutic hypothermia over a total of 14days to control nontraumatic brain injury-related refractory intracranial pressure and global cerebral edema. More studies are needed comparing clinical outcomes and complication rates between short duration and prolonged hypothermia for brain injury.

Repeated dosing of 23.4% hypertonic saline for refractory intracranial hypertension. A case report

BACKGROUND

Hypertonic saline (HTS) at a concentration of 23.4% is an emerging therapy for intracranial hypertension. Compared to mannitol which can be given as a single bolus or as repeated bolus dosing, little data exists regarding safety or efficacy of repeated dosing of 23.4% HTS. We report the first case of 16 doses of 23.4% HTS over a 5 day period in a patient with refractory intracranial hypertension.

CASE REPORT

A 43-year-old woman with Fisher 3 subarachnoid hemorrhage and hydrocephalus requiring an external ventricular drain developed global cerebral edema on computed tomography. Medically refractory intracranial hypertension ensued which required repeated dosing of 23.4% HTS. Reductions in intracranial pressure (ICP) occurred after each dose of 23.4% HTS. No central nervous system complications occurred. Anasarca was the only observed complication, which responded to furosemide diuresis.

CONCLUSION

Repeated dosing of 23.4% HTS was effective in reducing ICP in a case of medically refractory intracranial hypertension without major systemic complications. Prospective studies should address the safety and efficacy of repeat dose 23.4% HTS on serum sodium, intracranial pressure, and complications.