Owen Samuels

Impact of a Dedicated Neurocritical Care Team in Treating Patients with Aneurysmal Subarachnoid Hemorrhage

BackgroundIntensivist staffing of intensive care units (ICUs) has been associated with a reduction in in-hospital mortality. These improvements in patient outcomes have been extended to neurointensivist staffing of neuroscience ICUs for patients with intracranial hemorrhage and traumatic brain injury.ObjectiveThe primary objective of this study is to determine if hospital outcomes (measured by discharge status) for patients admitted with aneurysmal subarachnoid hemorrhage changed after the introduction of a neurointensivist-led multidisciplinary neurocritical care team.MethodsThe authors retrospectively identified 703 patients admitted to the neuroscience ICU with a diagnosis of aneurysmal subarachnoid hemorrhage at a single academic tertiary care hospital between January 1, 1995 and December 31, 2002. It was compared with discharge outcomes for those patients treated prior to and following the development of a multidisciplinary neurocritical care team.ResultsPatients treated after the introduction of a neurocritical care team were significantly more likely to be discharged to home (25.2% vs. 36.5%) and less likely to be discharged to a rehab facility (25.2% vs. 36.5%). Patients treated after introduction of a neurocritical care team were also more likely to receive definitive aneurysm treatment (10.9% vs. 18%).ConclusionThe implementation of a neurointensivist-led neurocritical care team is associated with improved hospital discharge disposition for patients with aneurysmal subarachnoid hemorrhage.

Reversible brain death after cardiopulmonary arrest and induced hypothermia.

Objective: To describe a patient with transient reversal of findings of brain death after cardiopulmonary arrest and attempted therapeutic hypothermia. Design: Case report. Setting: Intensive care unit of an academic tertiary care hospital. Patient: A 55-yr-old man presented with cardiac arrest preceded by respiratory arrest. Cardiopulmonary resuscitation was performed, spontaneous perfusion restored, and therapeutic hypothermia was attempted for neural protection. After rewarming to 36.5°C, neurologic examination showed no eye opening or response to pain, spontaneous myoclonic movements, sluggishly reactive pupils, absent corneal reflexes, and intact gag and spontaneous respirations. Over 24 hrs, remaining cranial nerve function was lost. The neurologic examination was consistent with brain death. Apnea test and repeat clinical examination after a duration of 6 hrs confirmed brain death. Death was pronounced and the family consented to organ donation. Twenty-four hrs after brain death pronouncement, on arrival to the operating room for organ procurement, the patient was found to have regained corneal reflexes, cough reflex, and spontaneous respirations. The care team faced the challenge of offering an adequate explanation to the patients family and other healthcare professionals involved. Interventions: Induced hypothermia and brain death determination. Measurements and Main Results: This represents the first published report in an adult patient of reversal of a diagnosis of brain death made in full adherence to American Academy of Neurology guidelines. Although the reversal was transient and did not impact the patients prognosis, it impacted his eligibility for organ donation and cast doubt about the ability to determine irreversibility of brain death findings in patients treated with hypothermia after cardiac arrest. Conclusions: We strongly recommend caution in the determination of brain death after cardiac arrest when induced hypothermia is used. Confirmatory testing should be considered and a minimum observation period after rewarming before brain death testing ensues should be established.

Incidence and clinical characteristics of takotsubo cardiomyopathy post-aneurysmal subarachnoid hemorrhage

a Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States b Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States c Division of Internal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States d Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States e Department Neurology, Emory University School of Medicine, Atlanta, GA, United States

Stroke and pediatric human immunodeficiency virus infection. Case report and review of the literature.

Stroke is an uncommon complication in pediatric patients with acquired immunodeficiency syndrome (AIDS). However, with the increasing life span of this patient population, more cases of stroke are being reported. We report the case of a 13-year-old girl with a known history of AIDS who presented with new-onset seizures and right hemiparesis. Serial imaging studies revealed progressive occlusion of the left middle cerebral artery and both anterior cerebral arteries with development of collateral circulation. The workup for other etiologies of stroke was negative. This nonatherosclerotic occlusive disease is most likely secondary to vasculopathy caused by the human immunodeficiency virus (HIV). HIV infection should be included in the differential diagnosis of children who present with seizures, mental status change or focal neurological deficits. Treatment options are limited. The different prognoses associated with the etiologies of stroke in this patient population mandate a careful and thorough evaluation.

Interhospital Transfer of Neurosurgical Patients to a High-Volume Tertiary Care Center: Opportunities for Improvement.

BACKGROUND Neurosurgical indications for patient transfer include absence of local or available neurosurgical coverage, subspecialty or interdisciplinary requirements, and family preference. Transfer of patients to regional centers will increase with further centralization of medical care. OBJECTIVE To report the transfer records of a large tertiary care center to identify trends, failures, and opportunities to improve interhospital transfer of neurosurgical patients. METHODS All consecutive, prospectively documented requests for interhospital patient transfer to the adult neurosurgical service of Emory University Hospitals were retrospectively identified from a centralized transfer center database for a 1-year study period. RESULTS Requests for neurosurgical care constituted 1323 of the 9087 calls (14.6%); 81.1% of these requests were accepted, and a total of 984 patients (74.4%) arrived at our institutions. Patients arrived from 133 unique facilities throughout a catchment area of 66 287 sq miles. Although the median travel time for transfer patients was 36 minutes, the median interval between the request and patient arrival was 4 hours 2 minutes. The most frequent diagnoses were intracranial hemorrhage (31.8%), subarachnoid hemorrhage (31.2%), and intracranial tumor (15.2%). The overall diagnostic error rate was 10.3%. Only 42.5% of patients underwent neurosurgical intervention, and 57 patients admitted to intensive care were immediately transitioned to a lower level of care. CONCLUSION Interhospital transfer requires a coordinated effort among hospital administrators, physicians, and staff to make complex decisions that govern this important and costly process. These data suggest common failures and numerous opportunities for improvement in transfer efficiency, diagnostic accuracy, triage, and resource allocation.

Is Neurointensive Care Really Optional for Comprehensive Stroke Care

To the Editor: Expertise matters. The recent recommendations for Comprehensive Stroke Centers (CSC) put forth by the Brain Attack Coalition (BAC) make this argument convincingly using consensus and medical evidence when available.1 This document represents a landmark in advancing the care of stroke patients and will likely have important policy implications for hospitals, administrators, and regulatory agencies in planning for identification, certification, and management of CSCs. Certainly, this has been the case for the certification of Primary Stroke Centers recently implemented by the Joint Commission on Accreditation of Healthcare Organizations. Given the important implications of the CSC recommendations, it is unfortunate that the BAC has actually created recommendations that …

Emergency Neurological Life Support: Subarachnoid Hemorrhage.

Subarachnoid hemorrhage (SAH) is a neurological emergency because it may lead to sudden neurological decline and death and, depending on the cause, has treatment options that can return a patient to normal. Because there are interventions that can be life-saving in the first hour of onset, SAH was chosen as an Emergency Neurological Life Support protocol.

Care of the Stroke Patient: Routine Management to Lifesaving Treatment Options

The management of the acute ischemic stroke patient spans the time course from the emergency evaluation and treatment period through to the eventual discharge planning phase of stroke care. In this article we evaluate the literature and describe what have become standard treatments in the care of the stroke patient. We will review the literature that supports the use of a dedicated stroke unit for routine stroke care which has demonstrated reduced rates of morbidity and mortality. Also reviewed is the use of glycemic control in the initial setting along with data supporting the use of prophylactic treatments options in order to aide in the prevention of life threatening medical complications. In addition, lifesaving treatments will be discussed in light of new literature demonstrating reduced mortality in large hemispheric stroke patients undergoing surgical decompressive surgery. Both medical and surgical treatment options are discussed and compared.

Interhospital Transfer of Neurosurgical Patients: Implications of Timing on Hospital Course and Clinical Outcomes

BACKGROUND: Interhospital transfer of neurosurgical patients is common; however, little is known about the impact of transfer parameters on clinical outcomes. Lower survival rates have been reported for patients admitted at night and on weekends in other specialties. Whether time or day of admission affects neurosurgical patient outcomes, specifically those transferred from other facilities, is unknown. OBJECTIVE: To examine the impact of the timing of interhospital transfer on the hospital course and clinical outcomes of neurosurgical patients. METHODS: All consecutive admissions of patients transferred to our adult neurosurgical service were retrospectively analyzed for a 1‐year study period using data from a central transfer database and the electronic health record. RESULTS: Patients arrived more often at night (70.8%) despite an even distribution of transfer requests. The lack of transfer imaging did not affect length of stay, intervention times, or patient outcomes. Daytime arrivals had shorter total transfer time, but longer intenstive care unit and overall length of stay (8.7 and 11.6 days, respectively), worse modified Rankin Scale scores, lower rates of functional independence, and almost twice the mortality rate. Weekend admissions had significantly worse modified Rankin Scale scores and lower rates of functional independence. CONCLUSIONS: The timing of transfer arrivals, both by hour or day of the week, is correlated with the time to intervention, hospital course, and overall patient outcomes. Patients admitted during the weekend suffered worse functional outcomes and a trend towards increased mortality. While transfer logistics clearly impact patient outcomes, further work is needed to understand these complex relationships.