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Case records of the Massachusetts General Hospital. Case 8-2009. A 36-year-old woman with headache, hypertension, and seizure 2 weeks post partum.

Dr. W. Taylor Kimberly: A 36-year-old woman was admitted to the hospital because of headaches, hypertension, and seizures. Nineteen days before the current admission, she delivered healthy twins at 35.6 weeks of gestation by cesarean section (for breech presentation) at another hospital. She was discharged on the fifth day. Nine days before the current admission, she began to have intermittent, throbbing, bifrontal headaches, and 2 days later she saw her gynecologist. She rated the pain as 8 (on a scale of 0 to 10, with 10 being the most severe pain). The blood pressure was 150/72 mm Hg. She was referred to an internist the same day, but she did not see the internist because the headache resolved while she was in the waiting room, and she returned home. Headache recurred that evening, and she went to the emergency department of a second hospital, where the blood pressure was 190/80 mm Hg. Computed tomography (CT) and magnetic resonance imaging (MRI) of the brain and the results of laboratory tests were reportedly normal. Oxycodone–acetaminophen was given for pain; the blood pressure decreased to 168/70 mm Hg, and she was sent home. Four days before admission, the patient saw the internist. She reported that the headaches were sudden in onset and were usually worse in the early morning, when they awakened her from sleep, and in the late afternoon. She described her current headache as dull and rated the severity of the pain as 2 out of 10. The blood pressure was 142/78 mm Hg; trace peripheral edema was present. The remainder of the examination was normal. Furosemide and potassium chloride were prescribed. Two days before admission, a severe headache (10 out of 10 in severity) occurred, with nausea and photophobia. The patient returned to the emergency room of the second hospital; the blood pressure was 204/96 mm Hg. The hematocrit was 34.7%; the results of the remainder of the complete blood count were normal, as were the results of other laboratory tests, including measurements of serum electrolytes, magnesium, calcium, and phosphorus and tests of renal and liver function. A urinalysis revealed that the specific gravity was 1.020, the pH 6.0, and the Case 8-2009: A 36-Year-Old Woman with Headache, Hypertension, and Seizure 2 Weeks Post Partum

Postoperative Intensive Care Unit Requirements After Elective Craniotomy

OBJECTIVE Commonly, patients undergoing craniotomy are admitted to an intensive care setting postoperatively to allow for close monitoring. We aim to determine the frequency with which patients who have undergone elective craniotomies require intensive care unit (ICU)-level interventions or experience significant complications during the postoperative period to identify a subset of patients for whom an alternative to ICU-level care may be appropriate. METHODS Following Institutional Review Board approval, a prospective, consecutive cohort of adult patients undergoing elective craniotomy was established at the Massachusetts General Hospital between the dates of April 2010 and March 2011. Inclusion criteria were intradural operations requiring craniotomy performed on adults (18 years of age or older). Exclusion criteria were cases of an urgent or emergent nature, patients who remained intubated postoperatively, and patients who had a ventriculostomy drain in place at the conclusion of the case. RESULTS Four hundred patients were analyzed. Univariate analysis revealed that patients with diabetes (P = 0.00047), those who required intraoperative blood product administration (P = 0.032), older patients (P < 0.0001), those with higher intraoperative blood losses (P = 0.041), and those who underwent longer surgical procedures (P = 0.021) were more likely to require ICU-level interventions or experience significant postoperative complications. Multivariate analysis only found diabetes (P = 0.0005) and age (P = 0.0091) to be predictive of a patients need for postoperative ICU admission. CONCLUSIONS Diabetes and older age predict the need for ICU-level intervention after elective craniotomy. Properly selected patients may not require postcraniotomy ICU monitoring. Further study of resource utilization is necessary to validate these preliminary findings, particularly in different hospital types.

Rate of Perihematomal Edema Expansion Predicts Outcome After Intracerebral Hemorrhage.

Objectives:Intracerebral hemorrhage is a devastating disorder with no current treatment. Whether perihematomal edema is an independent predictor of neurologic outcome is controversial. We sought to determine whether perihematomal edema expansion rate predicts outcome after intracerebral hemorrhage. Design:Retrospective cohort study. Setting:Tertiary medical center. Patients:One hundred thirty-nine consecutive supratentorial spontaneous intracerebral hemorrhage patients 18 years or older admitted between 2000 and 2013. Interventions:None. Measurements and Main Results:Intracerebral hemorrhage, intraventricular hemorrhage, and perihematomal edema volumes were measured from CT scans obtained at presentation, 24-hours, and 72-hours postintracerebral hemorrhage. Perihematomal edema expansion rate was the difference between initial and follow-up perihematomal edema volumes divided by the time interval. Logistic regression was performed to evaluate the relationship between 1) perihematomal edema expansion rate at 24 hours and 90-day mortality and 2) perihematomal edema expansion rate at 24 hours and 90-day modified Rankin Scale score. Perihematomal edema expansion rate between admission and 24-hours postintracerebral hemorrhage was a significant predictor of 90-day mortality (odds ratio, 2.97; 95% CI, 1.48–5.99; p = 0.002). This association persisted after adjusting for all components of the intracerebral hemorrhage score (odds ratio, 2.21; 95% CI, 1.05–4.64; p = 0.04). Similarly, higher 24-hour perihematomal edema expansion rate was associated with poorer modified Rankin Scale score in an ordinal shift analysis (odds ratio, 2.40; 95% CI, 1.37–4.21; p = 0.002). The association persisted after adjustment for all intracerebral hemorrhage score components (odds ratio, 2.07; 95% CI, 1.12–3.83; p = 0.02). Conclusions:Faster perihematomal edema expansion rate 24-hours postintracerebral hemorrhage is associated with worse outcome. Perihematomal edema may represent an attractive translational target for secondary injury after intracerebral hemorrhage.

Human Data Supporting Glyburide in Ischemic Stroke.

The SUR1-TRPM4 channel is a critical determinant of edema and hemorrhagic transformation after focal ischemia. Blockade of this channel by the small molecule glyburide results in improved survival and neurological outcome in multiple preclinical models of ischemic stroke. A robust, compelling body of evidence suggests that an intravenous formulation of glyburide, RP-1127, can prevent swelling and improve outcome in patients with stroke. Retrospective studies of diabetic stroke patients show improved outcomes in patients who are continued on sulfonylureas after stroke onset. An early phase II study using magnetic resonance imaging and plasma biomarkers supports the conclusion that RP-1127 may decrease swelling and hemorrhagic transformation. Finally, the ongoing phase II RP-1127 development program has demonstrated continued safety as well as feasibility of enrollment and tolerability of the intervention. Continued efforts to complete the ongoing phase II study and definitive efficacy studies are needed to bring a candidate pharmacotherapy to a population of severe stroke patients that currently have no alternative.

Novel Imaging Markers of Ischemic Cerebral Edema and Its Association with Neurological Outcome

Ischemic cerebral edema (ICE) is a recognized cause of secondary neurological deterioration after large hemispheric stroke, but little is known about the scope of its impact. To study edema in less severe stroke, our group has developed several markers of cerebral edema using brain magnetic resonance imaging (MRI). These tools, which are based on categorical and volumetric measurements in serial diffusion-weighted imaging (DWI), are applicable to a wide variety of stroke volumes. Further, these metrics provide distinct volumetric measurements attributable to ICE, infarct growth, and hemorrhagic transformation. We previously reported that ICE independently predicted neurological outcome after adjustment for known risk factors. We found that an ICE volume of 11 mL or greater was associated with worse neurological outcome.

Abstract WMP16: Elevated Cerebral Neurite Orientation Dispersion and Density Imaging and Diffusion Kurtosis Values Are Associated With Poor Neurologic Outcome in Comatose Cardiac Arrest Patients

Background: For cardiac arrest survivors initially comatose after restoration of spontaneous circulation (ROSC), the extent of brain injury and expected neurologic outcome are crucial for patient management decisions. Advanced diffusion imaging approaches such as neurite orientation dispersion and density imaging (NODDI) or diffusion kurtosis imaging may provide additional insight into tissue integrity and potential for recovery of consciousness complementary to standard diffusion tensor imaging (DTI). Methods: Multi-shell diffusion imaging was acquired in a prospective study of comatose cardiac arrest patients and in 5 controls. Neurite orientation dispersion (OD), intracellular volume fraction (ICVF), mean kurtosis (MK), axial kurtosis (AK), radial kurtosis (RK), mean diffusivity (MD), axial diffusivity (AD), radial diffusivity (RD) and fractional anisotropy (FA) were calculated. Median whole-brain values in patients with poor outcomes (no arousal recovery [AR] by discharge) were compared with those with AR and to controls (1-way ANOVA, post-hoc 1-sided Wilcoxon exact test). Results: 18 patients (mean ±SD 48±23 y, 39% men) and 5 controls (37±19 y, 40% men) were analyzed. Median (range) Glasgow Coma Scale was 3 [3-5]. 10 patients exhibited AR, 8 did not. Median [IQR] time-to-MRI was 5 [4-8] days. FA (P=0.009), MK (P=0.017), AK (P=0.026), RK (P=0.014), OD (P=0.018) and ICVF (P=0.0038) were significantly different (see Figure). FA control values were greater than AR and no AR (P Discussion: This is the first report investigating early NODDI and diffusional heterogeneity changes in post-cardiac arrest comatose patients. Patients who failed to recover arousal demonstrated greater values for all kurtosis and NODDI metrics compared to controls. Potential bias from early withdrawal of life sustaining treatment and small cohorts are limitations.