Neha Dangayach

Ultra-early angiographic vasospasm associated with delayed cerebral ischemia and infarction following aneurysmal subarachnoid hemorrhage.

OBJECTIVE The clinical significance of cerebral ultra-early angiographic vasospasm (UEAV), defined as cerebral arterial narrowing within the first 48 hours of aneurysmal subarachnoid hemorrhage (aSAH), remains poorly characterized. The authors sought to determine its frequency, predictors, and impact on functional outcome. METHODS The authors prospectively studied UEAV in a cohort of 1286 consecutively admitted patients with aSAH between August 1996 and June 2013. Admission clinical, radiographic, and acute clinical course information was documented during patient hospitalization. Functional outcome was assessed at 3 months using the modified Rankin Scale. Logistic regression and Cox proportional hazards models were generated to assess predictors of UEAV and its relationship to delayed cerebral ischemia (DCI) and outcome. Multiple imputation methods were used to address data lost to follow-up. RESULTS The cohort incidence rate of UEAV was 4.6%. Multivariable logistic regression analysis revealed that younger age, sentinel bleed, and poor admission clinical grade were significantly associated with UEAV. Patients with UEAV had a 2-fold increased risk of DCI (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.4-3.9, p = 0.002) and cerebral infarction (OR 2.0, 95% CI 1.0-3.9, p = 0.04), after adjusting for known predictors. Excluding patients who experienced sentinel bleeding did not change this effect. Patients with UEAV also had a significantly higher hazard for DCI in a multivariable model. UEAV was not found to be significantly associated with poor functional outcome (OR 0.8, 95% CI 0.4-1.6, p = 0.5). CONCLUSIONS UEAV may be less frequent than has been reported previously. Patients who exhibit UEAV are at higher risk for refractory DCI that results in cerebral infarction. These patients may benefit from earlier monitoring for signs of DCI and more aggressive treatment. Further study is needed to determine the long-term functional significance of UEAV.

The impact of evidence: evolving therapy for acute ischemic stroke in a large healthcare system.

Background With a recent surge of clinical trials, the treatment of ischemic stroke has undergone dramatic changes. Objective To evaluate the impact of evidence and a revamped stroke protocol on a large healthcare system. Methods A retrospective review of 69 patients with ischemic stroke treated with intra-arterial therapy was carried out. Cohort 1 included patients treated before implementation of a new stroke protocol, and cohort 2 after implementation. Angiographic outcome was graded using the Thrombolysis in Cerebral Infarction (TICI) score. Clinical outcomes were assessed using the National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS). Results Primary outcomes comparing cohorts demonstrated decreased arrival-to-puncture time (cohort 2: 104 vs cohort 1: 181 min, p<0.001), similar TICI 2b/3 rates (86.5% vs 81.3%, p=0.5530), and similar percentage of patients with discharge mRS 0–2 (18.9% vs 21.9%, p=0.7740). Notable secondary outcomes for cohort 2 included decreased puncture-to-first pass time (34 vs 53 min, p <0.001), increased TICI 3 rates (37.8% vs 18.8%, p=0.0290), a trend toward greater improvements in NIHSS on postoperative day 1 (6.8 vs 2.6, p=0.0980) and discharge (9.5 vs 6.7, p=0.1130), and a trend toward increased percentage of patients discharged with mRS 0–3 (48.6% vs 34.4%, p=0.3280 NS). There were similar rates of symptomatic intracerebral hemorrhage (10.8% vs 9.4%, p=0.9570) and death (10.8% vs 15.6%, p=0.5530). Conclusions An interdisciplinary and rapid response to the emergence of strong clinical evidence can result in dramatic changes in a large healthcare system.

Emerging Markers of Early Brain Injury and Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage

BACKGROUND Delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage is characterized by a highly complex pathophysiology and results in neurologic deterioration after the inciting bleed. Despite its significant consequences, prompt diagnosis can be elusive and treatment is often administered too late. Early brain injury, which occurs within the first 72 hours after ictus, may be an important factor for delayed cerebral ischemia and poor overall outcome. Here, we explore the purported clinical and pathologic manifestations of early brain injury to identify biomarkers that could have prognostic value. METHODS We review the literature and discuss potential emerging markers of delayed cerebral ischemia in the context of early brain injury. RESULTS The following clinical features and biomarkers were examined: global cerebral edema, ictal loss of consciousness, ultra early angiographic vasospasm, continuous electroencephalogram monitoring, systemic inflammatory response syndrome, cellular mediators of the inflammatory response, and hematologic derangements. CONCLUSIONS Some of these markers possess independent value for determining the risk of complications after aneurysmal subarachnoid hemorrhage. However, their use is limited because of a variety of factors, but they do provide an avenue of further study to aid in diagnosis and management.

A step-down unit transfer protocol for low-risk aneurysmal subarachnoid hemorrhage

OBJECTIVE Patients who have experienced subarachnoid hemorrhage (SAH) often receive care in the setting of the ICU. However, SAH patients may not all require extended ICU admission. The authors established a protocol on January 1, 2015, to transfer select, low-risk patients to a step-down unit (SDU) to streamline care for SAH patients. This study describes the results of the implemented protocol. METHODS In this retrospective chart review, patients presenting with SAH between January 2011 and September 2016 were reviewed for inclusion. The control group consisted of patients admitted prior to establishment of the SDU transfer protocol, while the intervention group consisted of patients admitted afterward. RESULTS Of the patients in the intervention group, 79.2% (57/72) were transferred to the SDU during their admission. Of these transferred patients, 29.8% (17/57) required return to the neurosurgical ICU (NSICU). There were no instances of morbidity or mortality directly related to care in the SDU. Patients in the intervention group had a mean reduced NSICU length of stay, by 1.95 days, which trended toward significance, and a longer average hospitalization, by 2.7 days, which also trended toward significance. In-hospital mortality and 90-day readmission rate were not statistically different between the groups. In addition, early transfer timing prior to 7 days was associated with neither a higher return rate to the NSICU nor higher 90-day readmission rate. CONCLUSIONS In this retrospective study, the authors demonstrated that the transfer protocol was safe, feasible, and effective in reducing the ICU length of stay and was independent of transfer timing. Confirmation of these results is needed in a large, multicenter study.

Antiepileptics for Post-Traumatic Seizure Prophylaxis after Traumatic Brain Injury

Traumatic brain injury (TBI) is an important public health concern plagued by high rates of mortality and significant long-term disability in many survivors. Post-traumatic seizures (PTS) are not uncommon following TBI, both in the early (within 7 days post-injury) and late (after 7 days post-injury) period. Due to the potential of PTS to exacerbate secondary injury following TBI and the possibility of developing post-traumatic epilepsy (PTE), the medical community has explored preventative treatment strategies. Prophylactic antiepileptic drug (AED) administration has been proposed as a measure to reduce the incidence of PTS and the ultimate development of PTE in TBI patients. In this topical review, we discuss the pathophysiologic mechanisms of early and late PTS and the development of PTE following TBI, the pharmacodynamic and pharmacokinetic properties of AEDs commonly used to prevent post-traumatic seizures, and summarize the available clinical evidence for employing AEDs for seizure prophylaxis after TBI.

Bailout Strategies and Complications Associated with the Use of Flow-Diverting Stents for Treating Intracranial Aneurysms

Background: Flow-diverting stents (FDS) have revolutionized the endovascular management of unruptured, complex, wide-necked, and giant aneurysms. There is no consensus on management of complications associated with the placement of these devices. This review focuses on the management of complications of FDS for the treatment of intracranial aneurysms. Summary: We performed a systematic, qualitative review using electronic databases MEDLINE and Google Scholar. Complications of FDS placement generally occur during the perioperative period. Key Message: Complications associated with FDS may be divided into periprocedural complications, immediate postprocedural complications, and delayed complications. We sought to review these complications and novel management strategies that have been reported in the literature.

Novel management strategies for medically-refractory vasospasm following aneurysmal subarachnoid hemorrhage

Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH) is an important cause of further morbidity and mortality after an already devastating condition. Though traditionally attributed to vasospasm of large capacitance arteries and the resulting down-stream disruption of cerebral blood flow, the pathogenesis of DCI has proven to be more complex with early brain injury, blood-brain barrier disruption, microthrombosis, cortical spreading depolarizations, and the failure of cerebral autoregulation as newly elucidated factors. Vasospasm is a known consequence of SAH. The standard of care includes close monitoring for neurological deterioration, most often with serial clinical examinations, transcranial Doppler ultrasonography, and vascular imaging (crucial for early detection of DCI and allows for prompt intervention). Nimodipine continues to remain an important pharmacological strategy to improve functional outcomes in patients with SAH at risk for developing vasospasm. The paradigm for first line therapy in patients with vasospasm of induced hypertension, hypervolemia, and hemodilution has recently been challenged. Current American Heart Association guidelines recommend targeting euvolemia and judicious use of the pharmacologically induced hypertension component. Symptomatic vasospasm patients who do not improve with this first line therapy require rescue intervention with mechanical or chemical angioplasty and optimization of cardiac output and hemoglobin levels. This can be escalated in a step-wise fashion to include adjunct treatments such as intrathecal administration of vasodilators and sympatholytic or thrombolytic therapies. This review provides a general overview of the treatment modalities for DCI with a focus on novel management strategies that show promising results for treating vasospasm to prevent DCI.

Addressing spirituality during critical illness: A review of current literature

Objectives: The purpose of this review is to provide an overview of research on spirituality and religiosity in the intensive care setting that has been published since the 2004–2005 American College of Critical Care Medicine (ACCM) Clinical Practice Guidelines for the Support of Family in the Patient‐Centered Intensive Care Unit with an emphasis on its application beyond palliative and end‐of‐life care. Materials and methods: ACCM 2004–2005 guidelines emphasized the importance of spiritual and religious support in the form of four specific recommendations: [1] assessment and incorporation of spiritual needs in ICU care plan; [2] spiritual care training for doctors and nurses; [3] physician review of interdisciplinary spiritual need assessments; and [4] honoring the requests of patients to pray with them. We reviewed 26 studies published from 2006 to 2016 and identified whether studies strengthened the grade of these recommendations. We further categorized findings of these studies to understand the roles of spirituality and religiosity in surrogate perceptions and decision‐making and patient and family experience. Conclusions: Spiritual care has an essential role in the treatment of critically ill patients and families. Current literature offers few insights to support clinicians in navigating this often‐challenging aspect of patient care and more research is needed. HIGHLIGHTSOrganizations emphasize spiritual support for ICU patients and their surrogates.69–94% of surrogate decision‐makers report spirituality as important.Chaplains are specialist and clinicians are generalist in regards to spiritual care.Research is needed in addressing the spiritual needs of ICU patients and surrogates.

767: THE IMPACT OF PERCEIVED AGE ON PATIENT OUTCOMES IN NEUROCRITICAL CARE

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Perceived age, or how young or old individuals feel relative to their chronological age, is a crucial construct in geriatrics. A relatively lower perceived age has been associated with increased levels of physical activity, higher life satisfaction, and better psychological health and lower mortality. The purpose of this study was to understand whether perceived age affects mortality and recovery in neurocritical care. Methods: This study was conducted as part of an IRB approved longitudinal prospective cohort study at Mount Sinai Hospital Neurocritical Care (NCC) unit to understand the impact of resilience, reserve, and spirituality on recovery. Demographic, clinical, and outcomes data were recorded for patients expected to stay in the NCC unit for ≥ 48 hours. At baseline, patients, or their surrogates, were asked whether the patient felt older, the same, or younger than their biological age. We analyzed the correlation of subjects’ perceived age and outcomes as described by discharge destination and ICU length of stay (LoS). Good outcome was defined as a discharge destination of home, outpatient rehab, acute rehab, and subacute rehab. Poor outcome was defined as discharge to nursing home or in hospital mortality. Results: Good outcomes for those with younger perceived age, perceived age same as biological age and older perceived age were 24 (92%), 19 (90%), and 4 (80%) respectively, which was not statistically significant in an unadjusted analysis (P = 0.62). Length of stay for the younger, perceived age same as biological age and older perceived age groups were 13 ± 10 days, 9 ± 10 days, and 13 ± 13 days respectively, which was also not statistically significant (P = 0.72). We also found no impact of perceived age on these outcomes in a stratified analysis among older (age > 65) and younger patients. Conclusions: Perceived age, although an important determinant of health care outcomes in geriatrics, does not appear to influence LoS or functional outcome after neurocritical illness.

137: A CASE OF HYPERSENSITIVITY REACTION TO DEXAMETHASONE PRESENTING WITH SHOCK

Learning Objectives: Hypersensitivity reactions to steroids are exceedingly uncommon, with only few reports in the medical literature. We report a case of anaphylactic shock secondary to the administration of IV dexamethasone during spinal surgery. Methods: A 67-year-old female with past medical history of hypertension and kyphoscoliosis status post spinal fusion surgery performed a month before presenting with two weeks of progressively worsening paresis of the lower extremities associated with urinary and fecal incontinence and band-like distribution of pain in the T4 distribution. Her neurological examination was remarkable for a decreased tone and strength in the lower extremities with diminished sensation to pin-prick and vibration at the T4 spinal distribution. CT imaging revealed a T3-4 epidural hematoma and flexion distraction fracture of T3-4 vertebra causing cord compression. She underwent an emergent T3-4 decompressive laminectomy/facetectomy. Intraoperatively she received 10 mg of IV dexamethasone and two minutes later she developed acute circulatory failure requiring high doses of norepinephrine and epinephrine. An intra-op POCUS showed hyperdynamic LV function and normal RV:LV ratio; there was no evidence of a pericardial effusion and lung sliding was appreciated at the bilateral apices excluding cardiogenic or obstructive etiology of her shock from either massive pulmonary embolism, cardiac tamponade or tension pneumothorax. Hypovolemic shock was unlikely given minimal blood loss. Review of her medical history from a different hospital revealed prior episodes of urticarial skin rash with IV methylprednisolone. This clinical correlate in conjunction with the temporal relationship between administration of IV dexamethasone and the ensuing circulatory collapse prompted the diagnoses of anaphylactic shock secondary to steroids. Results: Hypersensitivity reactions related to steroids are uncommon and often misdiagnosed. It is unclear whether the triggering molecule is the steroid itself, or if the steroids or its metabolites act like a hapten bound to serum protein, creating an allergenic complex. Anaphylactic shock should be considered in a patient with previous IgE mediated hypersensitivity reaction to any class of glucocorticoids such as urticarial skin rash with our patient.