Neil F. Rosenberg

Delayed intraventricular hemorrhage is common and worsens outcomes in intracerebral hemorrhage

Objective: To evaluate the incidence, characteristics, and clinical consequences of delayed intraventricular hemorrhage (dIVH). Methods: Patients with primary intracerebral hemorrhage (ICH) were enrolled into a prospective registry between December 2006 and February 2012. Patients were managed, and serial neuroimaging obtained, per a structured protocol. Initial and delayed IVH were identified on imaging, along with ICH volumes, with outcomes blinded. Multivariate models were developed to test whether the occurrence of dIVH was a predictor of functional outcomes independent of known predictors, including the ICH score elements and ICH growth. Results: A total of 216 patients were studied, and 104 (48%) had IVH on initial imaging. Of the 112 with no IVH, 23 (21%) subsequently developed IVH. Emergent surgical intervention, mostly ventriculostomy placement, was required after discovery of dIVH in 10 (43%) of these 23. In multivariate models adjusting for all elements of the ICH score and hematoma growth, dIVH was an independent predictor of death at 14 days (p = 0.015) and higher modified Rankin Scale scores at 3 months (all p = 0.037). The effect of dIVH remained significant in a secondary analysis that adjusted for all other variables significant in the univariate analysis. Conclusions: Similar to hematoma expansion dIVH is independently associated with death and poor outcomes. Because IVH is easily detected by serial neuroimaging and often requires emergent surgical intervention, monitoring for dIVH is recommended.

Surveillance neuroimaging and neurologic examinations affect care for intracerebral hemorrhage

Objective: We tested the hypothesis that surveillance neuroimaging and neurologic examinations identified changes requiring emergent surgical interventions in patients with intracerebral hemorrhage (ICH). Methods: Patients with primary ICH were enrolled into a prospective registry between December 2006 and July 2012. Patients were managed in a neuroscience intensive care unit with a protocol that included serial neuroimaging at 6, 24, and 48 hours, and hourly neurologic examinations using the Glasgow Coma Scale and NIH Stroke Scale. We evaluated all cases of craniotomy and ventriculostomy to determine whether the procedure was part of the initial management plan or occurred subsequently. For those that occurred subsequently, we determined whether worsening on neurologic examination or worsened neuroimaging findings initiated the process leading to intervention. Results: There were 88 surgical interventions in 84 (35%) of the 239 patients studied, including ventriculostomy in 52 (59%), craniotomy in 21 (24%), and both in 11 (13%). Of the 88 interventions, 24 (27%) occurred subsequently and distinctly from initial management, a median of 15.9 hours (8.9–27.0 hours) after symptom onset. Thirteen (54%) were instigated by findings on neurologic examination and 11 (46%) by neuroimaging. Demographics, severity of hemorrhage, and hemorrhage location were not associated with delayed intervention. Conclusions: More than 25% of surgical interventions performed after ICH were prompted by delayed imaging or clinical findings. Serial neurologic examinations and neuroimaging are important and effective surveillance techniques for monitoring patients with ICH.

Predictors of 30-day readmission after intracerebral hemorrhage: a single-center approach for identifying potentially modifiable associations with readmission.

Objective:To determine whether patient’s demographics or severity of illness predict hospital readmission within 30 days following spontaneous intracerebral hemorrhage, to identify readmission associations that may be modifiable at the single-center level, and to determine the impact of readmission on outcomes. Design:We collected demographic, clinical, and hospital course data for consecutive patients with spontaneous intracerebral hemorrhage enrolled in an observational study. Readmission within 30 days was determined retrospectively by an automated query with manual confirmation. We identified the reason for readmission and tested for associations between readmission and functional outcomes using modified Rankin Scale (a validated functional outcome measure from 0, no symptoms, to 6, death) scores before intracerebral hemorrhage and at 14 days, 28 days, and 3 months after intracerebral hemorrhage. Setting:Neurologic ICU of a tertiary care hospital. Patients:Critically ill patients with spontaneous intracerebral hemorrhage. Interventions:Patients received standard critical care management for intracerebral hemorrhage. Measurements and Main Results:Of 246 patients (mean age, 65 yr; 51% female), 193 patients (78%) survived to discharge. Of these, 22 patients (11%) were readmitted at a median of 9 days (interquartile range, 4–15 d). The most common readmission diagnoses were infections after discharge (n = 10) and vascular events (n = 6). Age, history of stroke and hypertension, severity of neurologic deficit at admission, Acute Physiology and Chronic Health Evaluation score, ICU and hospital length of stay, ventilator-free days, days febrile, and surgical procedures were not predictors of readmission. History of coronary artery disease was associated with readmission (p = 0.03). Readmitted patients had similar modified Rankin Scale and severity of neurologic deficit at 14 days but higher (worse) modified Rankin Scale scores at 3 months (median [interquartile range], 5 [3–6] vs 3 [1–4]; p = 0.01). Conclusions:Severity of illness and hospital complications were not associated with 30-day readmission. The most common indication for readmission was infection after discharge, and readmission was associated with worse functional outcomes at 3 months. Preventing readmission after intracerebral hemorrhage may depend primarily on optimizing care after discharge and may improve functional outcomes at 3 months.

Leukoaraiosis on magnetic resonance imaging correlates with worse outcomes after spontaneous intracerebral hemorrhage.

Background and Purpose— Leukoaraiosis (LA) is associated with dementia, ischemic stroke, and intracerebral hemorrhage (ICH), but there are few data on how LA might impact outcomes after acute ICH. We tested the hypothesis that the severity of LA on magnetic resonance imaging is related to worse functional outcomes after spontaneous ICH. Methods— We prospectively identified patients with spontaneous acute ICH. LA was identified on magnetic resonance imaging and its severity was graded using the Fazekas method to include a score for the deep white matter and periventricular regions. Outcomes were obtained at 14 days, 28 days, and 3 months with the modified Rankin Scale (mRS; a validated scale from 0 [no symptoms] to 6 [dead]) and analyzed with multivariate logistic regression. Results— Higher Fazekas total (periventricular plus deep white matter) score correlated with higher mRS score at 14 days (P=0.02) and 3 months (P=0.02). This relationship was driven by the periventricular score, for which higher score (more severe disease) correlated with higher National Institute of Health Stroke Scale at 14 days (P=0.03), and higher mRS score at 14 days (P<0.001), 28 days (P=0.004), and 3 months (P=0.005). A higher (more severe) Fazekas periventricular score was associated with dependence or death at 3 months (odds ratio, 1.8 per point; 95% confidence interval, 1.02–3.1; P=0.04) after correction for the ICH score. Conclusions— Increased LA is an independent predictor of worse functional outcomes in patients after spontaneous ICH. The pathophysiology associating LA with worse outcomes requires further study. These data may improve prognostication and selection for clinical trials.

Anemia and transfusion after aneurysmal subarachnoid hemorrhage.

Anemia is common in patients with aneurysmal subarachnoid hemorrhage (SAH), but these patients have constituted only a small fraction of those studied in large trials of anemia and transfusion. Unlike other critically ill patients, those with SAH face a well-defined risk of vasospasm and cerebral ischemia in the weeks after their hemorrhage. The risk of ongoing ischemia may make them less able to tolerate anemia and more likely to benefit from blood transfusion. The available data show that anemia is associated with poor outcomes after SAH but that blood transfusion does not consistently improve physiological markers, and it may be associated with poor outcomes. Most of these data are observational in nature, although 1 recent study demonstrated the safety and feasibility of maintaining relatively high transfusion thresholds in patients with SAH. Larger, randomized trials are needed to determine at what levels of anemia patients with SAH might benefit from transfusion, the optimal timing of transfusion, and how to identify those patients who are most likely to benefit.

Predictors of hemorrhage volume and disability after perimesencephalic subarachnoid hemorrhage

Objective: The determinants of subarachnoid hemorrhage (SAH) volume and an atypical pattern of blood are not clear. Our objective was to determine if reduced platelet activity on admission and abnormal venous drainage are associated with greater SAH volume. Methods: We prospectively identified noncomatose patients with SAH without an identifiable aneurysm. We routinely measured platelet activity on admission and recorded aspirin use. SAH volumes were calculated with a validated technique. CT angiograms were reviewed by a certified neuroradiologist for venous drainage. Patients were followed for clinical outcomes through 3 months with the modified Rankin Scale (mRS). Data are Q1–Q3. Results: There were 31 patients in the cohort. Thirty (97%) underwent an angiogram on admission, and 25 (81%) an additional delayed angiogram. SAH volume was lowest with normal venous drainage bilaterally (4.4 [3.7–16.4] mL) and higher with 1 (12.9 [3.7–20.4]) or 2 (20.9 [12.5–34.6] mL, p = 0.03) discontinuous venous drainages. Patients with reduced platelet activity had more SAH on the diagnostic CT (17.5 [10.6–20.9] vs 6.1 [2.3–15.3] mL) (p = 0.046). SAH volume was greater for patients requiring drainage for hydrocephalus (16.4 [11.5–20.5] vs 5.4 [2.7–16.4] mL) (p = 0.009). Outcomes at 3 months were generally excellent (median mRS = 0, no symptoms). Conclusions: Discontinuous venous drainage and reduced platelet activity were associated with increased SAH volume and hydrocephalus. These factors may explain thick SAH and reduce the need for repeated invasive imaging in such patients.

Subarachnoid Extension of Primary Intracerebral Hemorrhage is Associated With Poor Outcomes

Background and Purpose— Extension of hemorrhage into the subarachnoid space is observed in primary intracerebral hemorrhage (ICH), yet the phenomenon has undergone limited study and is of unknown significance. The objective of this study is to evaluate the incidence, characteristics, and clinical consequences of subarachnoid hemorrhage extension (SAHE) in ICH on functional outcomes. Methods— Patients with primary ICH were enrolled into a prospective registry between December 2006 and June 2012. Patients were managed and serial neuroimaging was obtained per a structured protocol. Presence of any subarachnoid blood on imaging was identified as SAHE by expert reviewers blinded to outcomes. Regression models were developed to test whether the occurrence of SAHE was an independent predictor of functional outcomes as measured with the modified Rankin Scale. Results— Of 234 patients with ICH, 93 (39.7%) had SAHE. Interrater agreement for SAHE was excellent (kappa=0.991). SAHE was associated with lobar hemorrhage location (65% of SAHE vs 19% of non-SAHE cases; P<0.001) and larger hematoma volumes (median 23.8 vs 6.7; P<0.001). Fever (69.9% vs 51.1%; P=0.005) and seizures (8.6% vs 2.8%; P=0.07) were more common in patients with SAHE. SAHE was a predictor of death by day 14 (odds ratio, 4.45; 95% confidence interval, 1.88–10.53; P=0.001) and of higher (worse) modified Rankin Scale scores at 28 days (odds ratio, 1.76 per mRS point; 95% confidence interval, 1.01–3.05; P=0.012) after adjustment for ICH score. Conclusions— SAHE is associated with worse modified Rankin Scale independent of traditional ICH severity measures. Underlying mechanisms and potential treatments of SAHE require further study.

Pearls & Oy-sters: Bilateral thalamic involvement in West Nile virus encephalitis

Bilateral thalamic inflammation in the presence of a clinical picture suggestive of viral encephalitis should raise concern for West Nile virus infection.

Preadmission statin use does not improve functional outcomes or prevent delayed ischemic events in patients with spontaneous subarachnoid hemorrhage.

To determine whether preadmission statin use in patients with spontaneous subarachnoid hemorrhage (SAH) is associated with improved functional outcomes and a lower incidence of delayed cerebral ischemic events compared with statin‐naive patients with SAH.

Acute changes in ventricular volume during treatment for hepatic and renal failure.

Hepatic encephalopathy (HE) exists on a spectrum from minimal dysfunction to coma and may arise from ammonia-associated neurotoxicity whereby metabolic dysfunction leads to glutamine accumulation, astrocyte swelling, and nitric oxide–induced vasodilation.1 Elevated intracranial pressure (ICP), secondary to cerebral edema, is common in liver failure and occurs in 80% of comatose patients.1–3 Nonetheless, invasive ICP monitoring remains contentious in HE due to hemorrhagic complications and lack of evidence supporting benefit.3 A radiographic technique to assess edema could be helpful but head CT is only 33% sensitive for cerebral edema.2,3 We present a case illustrating this limitation of CT, the potential for rapid changes in cerebral edema, and a potential noninvasive means of assessing cerebral edema evolution.