Shaheryar Hafeez

The Safety and Feasibility of Admitting Patients With Intracerebral Hemorrhage to the Step-Down Unit.

Background: Intracerebral hemorrhage (ICH) is a devastating and costly condition. Although the American Heart Association/American Stroke Association recommends admitting patients with ICH to a neurocritical care unit (NCCU), this strategy may accrue unnecessary cost for patients with relatively milder presentation. We conducted a prospective observational study to determine the safety and feasibility of admitting patients with mild ICH directly to a step-down unit (SDU) instead of an NCCU. Methods: Consecutive patients with “mild presentation,” defined as a combination of ICH score ≤2, National Institutes of Health Stroke Scale (NIHSS) ≤ 15, and Graeb score ≤2 (if intraventricular hemorrhage was present), were admitted to the SDU. Data were collected on age, gender as well as the initial NIHSS, Glasgow Coma Scale (GCS), ICH, and Graeb scores. Primary end point was any complication or death during hospital stay. Results: Twenty patients were admitted to the SDU. No patient was transferred to the NCCU from the SDU. One patient, who eventually died, had respiratory insufficiency due to hospital-acquired pneumonia. Conclusion: Admission of ICH patients with mild symptoms to the SDU is safe and feasible. Larger prospective studies are needed to define the specific criteria for admission.

Hypomagnesemia in Intracerebral Hemorrhage

BACKGROUND Magnesium (Mg) is an essential element for the bodys normal physiological functioning. It has a major role in modulating vascular smooth muscle tone and peripheral arterial resistance. A low serum Mg level on admission (HMg0) has been associated with more severe presentation in patients with subarachnoid hemorrhage. However, data on HMg0 specifically in relation to intracerebral hemorrhage (ICH) are scarce. We sought to determine the incidence and clinical significance of HMg0 in patients with ICH. METHODS We reviewed the records of consecutive patients with ICH over a 2-year period. Data collected included initial Mg levels (Mg0), clinical and radiologic characteristics on presentation, and discharge outcomes. Regression analysis was performed to look for any association of low Mg0 with admission blood pressure (BP) and Glasgow Coma Scale (GCS) scores. We also examined the correlation of HMg0 with clinical/radiologic features, admission severity (based on the ICH score), and poor outcome on discharge. RESULTS In all, 33.6% presented with HMg0. Mg0 levels were negatively associated with systolic BP presentation (P < 0.0001) and positively associated with the initial GCS scores (P = 0.01). Multivariate logistic regression showed an association between HMg0 and severity at presentation (P = 0.03), but not with poor outcome on discharge (P = 0.26). CONCLUSIONS HMg0 occurs in one third of patients with ICH and is associated with more severe presentation and intraventricular hemorrhage. Mg levels on admission correlate inversely with systolic BP and directly with GCS scores at presentation. HMg0 does not influence outcomes at discharge.

Clinical Course and Outcomes of Small Supratentorial Intracerebral Hematomas

BACKGROUND AND PURPOSE Intracerebral hemorrhage (ICH) volume, particularly if ≥30 mL, is a major determinant of poor outcome. We used a multinational ICH data registry to study the characteristics, course, and outcomes of supratentorial hematomas with volumes <30 mL. METHODS Basic characteristics, clinical and radiological course, and 30-day outcomes of these patients were recorded. Outcomes were categorized as early neurological deterioration (END), hematoma expansion, Glasgow Outcome Scale (GOS), and in-hospital death. Poor outcome was defined as composite of in-hospital death and severe disability (GOS ≤ 3). Comparison was conducted based on hemorrhage location. Logistic regression using dichotomized outcome scales was applied to determine predictors of poor outcome. RESULTS Among 375 cases of supratentorial ICH with volumes <30 mL, expansion and END rates were 19.2% and 7.5%, respectively. Hemorrhage growth was independently associated with END (odds ratio: 28.7, 95% confidence interval [CI]: 8.51-96.5; P < .0001). Expansion rates did not differ according to ICH location. Overall, 13.9% (exact binomial 95% CI: 10.5-17.8) died in the hospital and 29.1% (CI: 24.5-34.0) had severe disability at 30 days; there was a cumulative poor outcome rate of 42.9% (CI: 37.9-48.1). Age, admission Glasgow Coma Scale, intraventricular extension, and END were independently associated with poor outcome. There was no difference in poor outcome rates between lobar and deep locations (40.2% versus 43.8%, P = .56). CONCLUSION Patients with supratentorial ICH <30 mL have high rates of poor outcome at 30 days, regardless of location. Nearly 1 in 5 hematomas <30 mL expands, leading to END or death.

Intracerebral hemorrhage patients presenting with normal blood pressure

There are patients with intracerebral hemorrhage (ICH) who present with blood pressure (BP) values below the standard treatment threshold recommended by the American Heart Association/American Stroke Association (AHA/ASA; systolic o150mmHg). Specific data on this category of ICH patients is, however, scarce. In this study, we looked at the proportion of ICH patients who present with systolic BP o150mmHg, their clinical/radiological features, initial severity and discharge outcomes. We determined that ~ 1 in 10 ICH patients presents with systolic BP o150mmHg, and the majority are lobar. Moreover, presentation with systolic BP lower than the standard treatment threshold has no association with initial severity or discharge outcomes. The cornerstone of acute therapy for patients with intracerebral hemorrhage (ICH) is BP control, notwithstanding the absence of convincing evidence that acute BP lowering has a positive impact on outcomes. Currently, it is the recommendation of the AHA/ASA that BP be lowered in ICH patients presenting with a systolic value ⩾ 150mmHg. This leaves a management gap with regard to patients who present with systolic BP o150mmHg. The aim of this study was to determine the proportion of ICH patients who present with systolic BP o150 mmHg, their clinical features, severity and discharge outcomes. An institutional review board approval was obtained for this study. A retrospective review of the medical records of consecutive patients with nontraumatic ICH treated at the Ohio State University between January 2011 and December 2013 was conducted. The International Classification of Diseases, Ninth Revision, diagnosis code for ICH (431) was used to compile a list of patients for analysis. Patients with ICH related to tumor, aneurysm or arteriovenous malformation were excluded. To prevent the confounding effects of surgery on outcomes, we also excluded patients who underwent emergency craniotomy for hematoma evacuation. All ICH patients were managed in accordance with the ASA/AHA guidelines, including timely initiation of intravenous antihypertensive medications. The following data were recorded: presentation systolic BP and Glasgow Coma Scale (GCS) score, age, gender, admission International Normalization Ratios (INRs), hourly systolic BP values for up to 24 h, hematoma volume and location, intraventricular hemorrhage and length of stay (LOS). The ICH Score, a clinical grading scale that allows risk stratification on presentation with ICH, was a used to estimate clinical severity. An ICH score ⩾ 3 was considered severe. Hematoma volume was measured on the initial head computed tomography scan using the ABC/2 method. Outcomes on hospital discharge were recorded as scores on the modified Rankin Scale (mRS), a stroke outcome scale with scores ranging from 0 (no symptoms at all) to 6 (dead). At the Ohio State University Medical Center, based on institutional policy, mRS scores at discharge are documented for all stroke patients. For the purpose of this study, systolic BP of o150 mmHg was considered ‘normal’. A dichotomy was created between hypertensive (systolic BP ⩾ 150 mmHg) and normotensive (systolic BP o150mmHg). Student’s t-test was used to measure any significant difference between the two groups in relation to continuous variables (age, systolic BP, GCS, ICH volume and LOS). The following features were also dichotomized to create categorical variables: good outcome and poor outcome (mRS ⩾ 4), and high (41.4) and normal INR, and severe (ICH Score ⩾ 3) and non-severe presentation. The equality of proportions was compared with the use of Fisher’s exact test and the χ-test. A P-value of 0.05 or less was considered significant. Of the 433 patients gathered via the initial query, 128 patients met our inclusion criteria; 16 (12.5%) presented with systolic BP o150 mmHg (Po0.0001). The mean age for this group was 67.4 ± 15.4. There were 11 lobar, 3 basal ganglia and 2 cerebellar hematomas. Mean systolic BP for the normotensive and hypertensive groups were 136.3 ± 7.8 and 188.3 ± 18.4 mmHg, respectively (Po0.0001). Between the normotensive and the hypertensive groups, there was no difference in admission severity (P= 0.39) or poor outcomes on discharge (P= 0.89). Hematomas in the normotensive group were mostly lobar (P= 0.01). Table 1 displays the characteristic differences between the two groups in more detail. Overall, there was no significant difference between any clinical or radiological features between the normotensive and hypertensive ICH patients. Although it seemed that INR 41.4 was more prevalent in normotensive (37.5%) than hypertensive patients (16.9%), this difference was not significant (P= 0.085). Following systolic BP values for 24 h for each normotensive patient showed elevation above 150mmHg in only two patients. Each of these patients received an intravenous antihypertensive bolus with good response; neither were started on continuous infusion. This study showed that ~ 1 in every 10 patients with ICH presents with systolic BP o150mmHg; a significant fraction statistically. Clinical characteristics of these patients were no different than those presenting with high BP. Moreover,

Recent Innovations in the Management of Low-Grade Gliomas

Opinion statementAdvancement in the understanding of biologic mechanisms of low-grade glioma pathophysiology has allowed the modern era of patient-specific genetic profiling, molecular biology, and neuroimaging to design new methods of surgery, radiation, and chemotherapy in hopes of preventing malignant transformation and improving outcomes. Recent innovations in the understanding of MGMT promoter methylation, IDH1 and IDH2 mutations, temozolomide chemotherapy, vascular monoclonal antibody treatment, use of radiation therapy, choice of antiepileptic drugs, surgical resection, and neuroimaging of low-grade gliomas are reviewed.

Complications of invasive intracranial pressure monitoring devices in neurocritical care.

Intracranial pressure monitoring devices have become the standard of care for the management of patients with pathologies associated with intracranial hypertension. Given the importance of invasive intracranial monitoring devices in the modern neurointensive care setting, gaining a thorough understanding of the potential complications related to device placement-and misplacement-is crucial. The increased prevalence of intracranial pressure monitoring as a management tool for neurosurgical patients has led to the publication of a plethora of papers regarding their indications and complications. The authors aim to provide a concise review of key contemporary articles in the literature concerning important complications with the hope of elucidating practices that improve outcomes for neurocritically ill patients.

Laboratory characteristics of ischemic stroke patients with atrial fibrillation on or off therapeutic warfarin

In patients with atrial fibrillation (AF), despite adequate anticoagulation, ischemic stroke (IS) is an uncommon yet concerning occurrence.

Superficial temporal artery haemorrhage caused by neurophysiological monitoring: a unique MRI finding.

A woman aged 66 years with a history of diplopia, headaches and left Cranial Nerve 3 palsy was found to have a 2 cm left paraclinoid internal carotid artery aneurysm. She was started on aspirin and clopidogrel and underwent flow diversion treatment with Pipeline (Covidien Neurovascular, Irvine, California, USA) embolisation of the aneurysm. Intraoperative neurophysiological monitoring via EEG and somatosensory evoked potentials was performed. After the procedure, she was found to have a large right scalp haematoma extending to the right orbit anteriorly and the back of the head posteriorly. Despite manual compression, …

Intraventricular Nicardipine for Reversible Vasospasm Related to CryptococcalMeningovasculitis

Basilar meningovasculitis causing diffuse vasospasm is an under recognized complication of CNS cryptococcal infection. We report the case of cryptococcal meningitis causing severe vasospasm and its successful treatment with intraventricular (IVT) nicardipine.

Enhanced external counter pulsation and neurologic recovery for cardiac arrest: is it ready for prime time?*.

www.ccmjournal.org 1593 In this issue of Critical Care Medicine, Li et al (1) induced cardiac arrest (CA) in a dog CA model and randomized treatment to enhanced external counter pulsation (EECP), hypertensive therapy (mean arterial pressure > 140 mm Hg), or controls. Currently, the clinical use of EECP is limited to patients with disabling chronic angina and heart failure. The device works by mimicking an intra-aortic balloon pump— increasing venous return and cardiac output by increasing diastolic pressure. The authors have proposed the use of EECP as a technique to induce double pulsatile flow with the hypothesize that it increases endothelial shear stress resulting in an enhanced production of vasodilators and anticoagulants, which in turn will reduce microvascular thrombosis. Furthermore, they propose that double pulsatile flow may improve cerebral blood flow (CBF) and cerebral blood volume (CBV) and subsequently improve neurologic outcome after ROSC (1). The importance of developing noninvasive techniques to improve outcomes after CA is paramount to the success of treating postcardiac arrest syndrome. Postcardiac arrest syndrome is characterized by whole-body hypoperfusion resulting in impaired cerebrovascular autoregulation, myocardial hypokinesis, and a systemic inflammatory response syndrome (SIRS) (2). The syndrome carries a very high mortality rate and survival is usually marred by significant neurovascular morbidity. The neurologic morbidity can include cognitive dysfunction, epilepsy, or persistent vegetative state. Currently, therapeutic hypothermia is the standard of care in treating postcardiac arrest syndrome (3, 4). A major weakness of this study is not including hypothermia as a treatment arm. The study could have had more clinical impact if EECP was directly compared with therapeutic hypothermia or used before or after therapeutic hypothermia was initiated. The authors hypothesize that initiating EECP or hypertensive therapy after approximately 6 minutes of CA can be used to combat the no-reflow phenomenon by increasing the endothelial shear stress and the production of vasodilators and anticoagulants. The increase of these vasodilators and anticoagulants is hypothesized to inhibit microvascular thrombosis, which is one of the greatest strengths of this study. If cerebral microvascular thrombosis can be decreased, then reperfusion injury can possibly be reduced or prevented and axonal connections may not be as disrupted. Moreover, in the context of therapeutic hypothermia, EECP produces pulsatile perfusion, and studies have suggested that it may have many advantages over nonpulsatile perfusion under conditions of profound hypothermia with total circulatory arrest. During high-risk cardiac surgery maintenance of adequate CBF is one of the highest goals of the anesthesiologist. Studies have indicated CBF can be improved and a longer period of circulatory arrest may be possible with the use of pulsatile perfusion. During hypothermia without circulatory arrest, pulsatile vs. nonpulsatile flow showed no difference in cardiac surgery models (5). Overall, this study does demonstrate the need for further noninvasive techniques to improve the outcome in postcardiac arrest syndrome. It is paramount to develop strategies that improve postcardiac arrest brain injury, decrease myocardial dysfunction, limit SIRS, and prevent ongoing pathology.