Laxmi P. Dhakal

Role of Anesthesia for Endovascular Treatment of Ischemic Stroke Do We Need Neurophysiological Monitoring

The use of acute endovascular stroke intervention was called into question after the results of 2 negative stroke endovascular trials (Interventional Management of Stroke 3 [IMS-3] and Systemic Thrombolysis for Acute Ischemic Stroke per the Stroke Center registry [SYNTHESIS]).1,2 However, the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) trial3 compared patients with acute stroke with proximal anterior circulation artery occlusions with usual stroke care, including intravenous tissue-type plasminogen activator (tPA). The study demonstrated a favorable shift in outcomes in the interventional group by modified Rankin Scale (mRS) by 90 days (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.21–2.30). Improvement in mRS was noted for all categories except for death. General anesthesia (GA) was used in 38% of the patients in the interventional group of MR CLEAN. In contrast, 9% of the patients in the Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE)4 trial received GA. The rate of functional independence (mRS, 0–2 by 90 days) was higher in the intervention group (53.0% versus 29.3%; P <0.01). Furthermore, lower mortality rate was seen in intervention group (10.4 versus 19.0; P =0.04). A recent meta-analysis by Fargen5,6 included MR CLEAN and the prior endovascular stroke trials and suggested a favorable shift outcome (mRS, 0–2; good outcome by 90 days; OR, 1.67; 95% CI, 1.29–1.16; P =0.0001) for patients with large-vessel occlusions who receive interventional therapy. In a post hoc analysis of MR CLEAN for use of GA, Berkhemer reported at the International Stroke Conference in Nashville, TN, a favorable effect when non-GA was used instead of GA (mRS, 0–2 at 90 days 38% versus 23%; P =0.013).7 Also, GA was associated with delayed initiation of interventional therapy in comparison with …

Early Absent Pupillary Light Reflexes After Cardiac Arrest in Patients Treated with Therapeutic Hypothermia

Loss of pupillary light reactivity is one recognized indicator of poor prognosis after cardiopulmonary resuscitation (CPR). However, drug overdose, low cardiac output, and/or resuscitation drugs can lead to impaired pupillary light reflex. To investigate pupillary light reflex status before therapeutic hypothermia (TH) in relation to neurological outcome, we retrospectively reviewed the data of a prospectively implemented TH protocol in patients with cardiac arrest (CA) at Mayo Clinic in Jacksonville, Florida (January 2006-January 2012), and Mayo Clinic in Scottsdale, Arizona (August 2010-March 2014). During this period, all CA patients who underwent hypothermia were included. These patients were selected from an institutional database and hypothermia data set. The Cerebral Performance Category (CPC) at time of discharge was our primary outcome measure. A CPC of 1 to 2 was defined as good outcome and a CPC from 3 to 5 was defined as poor outcome. We identified 99 patients who had CA treated with TH. Twenty-nine patients (29%) had pupils that were nonreactive to light on admission examination before TH, eight of whom later had return of pupil reactivity by day 3. Two of these 29 patients (6.9%) had good outcome, compared to 24 of 70 patients (34.3%) with pupils that were reactive to light (p = 0.005). Both of these patients had CA after illicit drug overdose. Early nonreactive pupils occurred in almost a third of patients after CPR and before TH in our patient population. Recovery of pupillary light reactivity is possible, and in a small minority of those cases (particularly when CA is preceded by the use of illicit drugs), a good outcome can be achieved.

The “Starfield” Pattern of Cerebral Fat Embolism From Bone Marrow Necrosis in Sickle Cell Crisis

Sickle cell disease may manifest with cerebrovascular and systemic complications. Sickle crisis that results in avascular necrosis of long bones with resultant cerebral fat embolism syndrome is rare and has a characteristic “starfield” pattern on MRI. This “starfield” MRI pattern should raise suspicion for sickle cell crisis in patients without a known history of the disease, which can lead to earlier sickle cell red blood cell exchange transfusion and treatment. We present a case of a male who presented emergently with acute seizure, coma with a characteristic MRI pattern, which lead to the diagnosis of avascular bone marrow necrosis and cerebral fat embolism syndrome from sickle cell crisis

Train of four stimulation artifact mimicking a seizure during computerized automated ICU EEG monitoring

A 54-year-old man was admitted to the intensive care unit with an aneurysmal subarachnoid hemorrhage and subsequently underwent mechanical ventilation and received neuromuscular blocking drugs to control refractory elevated intracranial pressure. During quantitative EEG monitoring, an automated alert was triggered by the train of four peripheral nerve stimulation artifacts. Real-time feedback was made possible due to remote monitoring. This case illustrates how computerized, automated artificial intelligence algorithms can be used beyond typical seizure detection in the intensive care unit for remote monitoring to benefit patient care.

Headache and Its Approach in Today's NeuroIntensive Care Unit.

Headache is a very common symptom in the neurointensive care unit (neuroICU). While headache in the neuroICU can be caused by worsening of a pre-existing primary headache disorder, most are secondary to another condition. Additionally, headache can be the presenting symptom of a number of conditions requiring prompt recognition and treatment including subarachnoid hemorrhage, ischemic and hemorrhagic stroke, central nervous system infection, pituitary apoplexy, and cerebral vasoconstriction. The neuroICU also has a unique postoperative population in which postcraniectomy and postcraniotomy headache, postintravascular intervention headache, hyperperfusion syndrome, ventriculitis, medication overuse or withdrawal headache, and hypercapnia may be encountered. Management varies dramatically depending on the etiology of the headache. Overreliance on opiate analgesics may produce significant adverse effects and lengthen ICU stays. However, nonnarcotic medications are increasingly being recognized as helpful in reducing the pain among various postsurgical and headache patients. Taken together, a multimodal approach targeting the underlying pathology and choosing appropriate systemic and local analgesic medications may be the best way to manage headache in critically ill patients.