Sarice L. Bassin

Reduced Platelet Activity Is Associated With Early Clot Growth and Worse 3-Month Outcome After Intracerebral Hemorrhage

Background and Purpose— Antiplatelet medication use and reduced platelet activity may be associated with mortality after intracerebral hemorrhage (ICH). We tested the hypothesis that reduced platelet activity is associated with early ICH clot growth and worse outcomes. Methods— We prospectively identified patients with spontaneous ICH, measured platelet activity (VerifyNow-ASA, Accumetrics) on admission, and recorded antiplatelet medication use. ICH volume was calculated using computerized volumetric analysis. Data were analyzed with nonparametric statistics and repeated measures ANOVA as appropriate. Patients were prospectively followed for functional outcomes. Data are presented as mean±SD or median [Q1 to Q3]. Results— Reduced platelet activity (≤550 aspirin reaction units [ARU]) was associated with increased ICH volume growth (P<0.05) for patients with the diagnostic CT within 12 hours. In the subset of patients not known to take aspirin, 24% had reduced platelet activity. Sixteen (24%) patients received a platelet transfusion 21.2±11.4 hours after symptom onset with an increase in platelet activity (448 [414-479] to 586 [530-639] ARU, P=0.001), but without impact on outcomes. Reduced platelet activity was associated with worse modified Rankin Scores at 3 months (P=0.02). Conclusions— Reduced platelet activity was associated with early ICH volume growth and worse functional outcome. Because platelet activity can be increased with platelet transfusion, increasing platelet activity is a potential method to reduce ICH volume growth and improve functional outcomes.

Clinical review: Status epilepticus

Status epilepticus (SE) has an annual incidence exceeding 100,000 cases in the United States alone, of which more than 20% result in death. Thus, increased awareness of presentation, etiologies, and treatment of SE is essential in the practice of critical care medicine. This review discusses current definitions of SE, as well as its clinical presentation and classification. The recent literature on epidemiology is reviewed, including morbidity and mortality data. An overview of the systemic pathophysiologic effects of SE is presented. Finally, significant studies on the treatment of acute SE and refractory SE are reviewed, including the use of anticonvulsants, such as benzodiazepines, and other drugs.

Platelet activity and outcome after intracerebral hemorrhage

There are few data on platelet function in intracerebral hemorrhage (ICH). We prospectively enrolled 69 patients with ICH and measured platelet function on admission. Aspirin use before ICH was associated with reduced platelet activity. Less platelet activity was associated with intraventricular hemorrhage (516.5 [interquartile range (IQR), 454–629.25] vs 637 [IQR, 493–654] aspirin reaction units; p = 0.04) and death at 14 days (480.5 [IQR, 444.5–632.5] vs 626 [IQR, 494–652] aspirin reaction units; p = 0.04). Objective measures of platelet function on admission are associated with intraventricular hemorrhage and death after ICH. Ann Neurol 2009;65:352–356

Medical Complications Drive Length of Stay After Brain Hemorrhage: A Cohort Study

IntroductionLonger length of stay (LOS) is associated with higher complications and costs in ICU patients, while hospital protocols may decrease complications and LOS. We hypothesized that medical complications would increase LOS after spontaneous subarachnoid (SAH) and intracerebral (ICH) hemorrhage after accounting for severity of neurologic injury in a cohort of consecutively admitted patients.MethodsWe prospectively recorded admission characteristics, hospital complications, and LOS for 122 patients with SAH and 56 patients with ICH from February 2006 through March 2008. A multidisciplinary Neuro-ICU team included a dedicated pharmacist and intensivist on daily rounds. Hospital protocols set glucose control with intravenous insulin, ventilator bundles, pharmacist involvement, and hand hygiene. Associations were explored with univariate statistics (t-tests, ANOVA, or non-parametric statistics as appropriate) and linear regression (repeated after log transformation of ICU and hospital LOS).ResultsFactors associated with longer LOS after SAH and ICH were similar. In both SAH and ICH the strongest drivers of LOS were infection, fever, and acute lung injury. For SAH, vasospasm and Glasgow Coma Scale were also significant in some models, while in patients with ICH the volume of the initial bleed was significant in some models.ConclusionLOS after spontaneous brain hemorrhage is driven by medical complications even after the adoption of dedicated intensive care medical staff, pharmacist involvement, and evidence-based protocols for ICU care. Further alterations in care will be necessary to eliminate “preventable” complications and minimize LOS after brain hemorrhage.

Classification of cerebral infarction after subarachnoid hemorrhage impacts outcome

OBJECTIVECerebral infarction (CI) after subarachnoid hemorrhage (SAH) is well described, but there is no validated classification. METHODSWe prospectively enrolled 119 consecutive patients with SAH. We recorded admission World Federation of Neurological Societies grade and Columbia computed tomographic scores. Vasospasm was defined as transcranial Doppler of greater than 120 cm/second or typical clinical symptoms. CI was defined by computed tomographic or magnetic resonance imaging scan, and the date of discovery was recorded. CI was classified by a previously published method (single versus multiple, cortical versus deep versus combined). Outcomes were assessed at 14 days or discharge with the National Institutes of Health Stroke Scale and modified Rankin Scale (mRS), and at 28 days and 3 months with the mRS. RESULTSVasospasm was associated with a higher risk of CI (odds ratio, 2.6; 95% confidence interval, 1.3–5.6; P = 0.01). The median time to detection was 4.2 days (interquartile range, 1.6–7.6 days) after SAH onset. CI classification was associated with the National Institutes of Health Stroke Scale score at 14 days (P = 0.002) and intensive care unit length of stay (P = 0.001). CI location (cortical, deep, or combined) was associated with National Institutes of Health Stroke Scale and mRS score at 14 days, and mRS score at 28 days and 3 months (P ≤ 0.02 for all). In a multiple logistic regression model, CI classification, World Federation of Neurological Societies grade, aneurysm diameter, and age were all associated with mRS score at 28 days and 3 months (P ≤ 0.05). Combined cortical and deep CI was associated with less improvement and poor outcome. CONCLUSIONCI classification predicts outcomes after SAH. Future reports of CI after SAH should include this or similar descriptive information.

Barbiturates for the treatment of intracranial hypertension after traumatic brain injury.

In their article on the use of barbiturates for the treatment of intracranial hypertension after traumatic brain injury, Perez-Barcena and colleagues conclude that thiopental was more effective than pentobarbital in decreasing intracranial pressure. Here we discuss the limitations of this study and review areas of controversy surrounding barbiturate use in neurocritical care.

Coagulation Management in Neurosurgical Critical Care

Neurocritical care patients are at extremely high risk for complications related to hereditary or acquired coagulopathies, as well as venous thromboembolic complications. The benefits of pharmacologic prevention and treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) must be weighed against the risk of catastrophic intracranial or perispinal hemorrhage. This section focuses on the two most common coagulation management issues: (1) thromboembolic disease and (2) coagulopathy.