Syed Omar Shah

CSF Flow through the Upper Cervical Spinal Canal in Chiari I Malformation

BACKGROUND AND PURPOSE: Previous studies have quantified CSF flow in patients with Chiari I at the foramen magnum with single-axial or single-sagittal PCMR. The goal of this study was to measure CSF velocities at multiple cervical spinal levels in patients with Chiari I malformation. MATERIALS AND METHODS: In a patient registry, consecutive patients without surgery who had PCMR flow images in 5–8 axial planes between the foramen magnum and C4 were identified. Four contiguous regions were defined from the foramen magnum to C4. In each region, the fastest positive flow (PSV) and fastest negative flow (PDV) were tabulated. Changes in peak velocity by cervical spinal level and age and sex were tested for significance with linear mixed-effects models. RESULTS: In 17 patients studied, PSV increased progressively and significantly from the foramen magnum to C4. PDVs increased slightly from the foramen magnum to C3. The changes in velocity over the 4 regions tended to be smaller in the 13 patients with tonsilar ectopia than in the 4 patients without it. Age and sex had an effect on peak velocities. CONCLUSIONS: Peak diastolic and systolic CSF velocities are significantly greater below than at the foramen magnum.

Late-onset neurodegeneration with brain iron accumulation with diffusion tensor magnetic resonance imaging.

Introduction: Neuroferritinopathy is an autosomal dominant neurodegenerative disorder that includes a movement disorder, cognitive decline, and characteristic findings on brain magnetic resonance imaging (MRI) due to abnormal iron deposition. Here, we present a late-onset case, along with diffusion tensor imaging (DTI). Case Presentation: We report the case of a 74-year-old Caucasian female with no significant past medical history who presented for evaluation of orofacial dyskinesia, suspected to be edentulous dyskinesia given her history of ill-fitting dentures. She had also developed slowly progressive dysarthria, dysphagia, visual hallucinations as well as stereotypic movements of her hands and feet. Results: The eye-of-the-tiger sign was demonstrated on T2 MRI. Increased fractional anisotropy and T2 hypointensity were observed in the periphery of the globus pallidus, putamen, substantia nigra, and dentate nucleus. T2 hyperintensity was present in the medial dentate nucleus and central globus pallidus. Discussion: The pallidal MRI findings were more typical of pantothenate kinase-associated neurodegeneration (PKAN), but given additional dentate and putamenal involvement, lack of retinopathy, and advanced age of onset, PKAN was less likely. Although the patient’s ferritin levels were within low normal range, her clinical and imaging features led to a diagnosis of neuroferritinopathy. Conclusion: Neurodegeneration with brain iron accumulation (NBIA) is a rare cause of orofacial dyskinesia. DTI MRI can confirm abnormal iron deposition. The location of abnormal iron deposits helps in differentiating NBIA subtypes. Degeneration of the dentate and globus pallidus may occur via an analogous process given their similar T2 and DTI MRI appearance.

Early Mobilization in the Neuro-ICU: How Far Can We Go?

Immobility that is frequently encountered in the intensive care unit (ICU) can lead to patient complications. Early mobilization of patients in the ICU has been shown to reduce the complications associated with critical illness; however, early mobilization in the neurological intensive care unit (NICU) presents a unique challenge for the multidisciplinary team. The early mobilization of patients with acute neurologic injuries such as acute ischemic stroke, aneurysmal subarachnoid hemorrhage, intracerebral hemorrhage, and neurotrauma varies because of differing disease processes and management. When developing an early mobility program in the NICU, the following should be considered: the effect of positional changes and exercise, the time from symptom onset to the initiation of early mobilization, and the type and intensity of the exercise prescribed.

Decompressive Hemicraniectomy in Acute Neurological Diseases

Increased intracranial pressure (ICP) secondary to severe brain injury is common. Increased ICP is commonly encountered in malignant middle cerebral artery ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage. Multiple interventions—both medical and surgical—exist to manage increased ICP. Medical management is used as first-line therapy; however, it is not always effective and is associated with significant risks. Decompressive hemicraniectomy is a surgical option to reduce ICP, increase cerebral compliance, and increase cerebral blood perfusion when medical management becomes insufficient. The purpose of this review is to provide an up-to-date summary of the use of decompressive hemicraniectomy for the management of refractory elevated ICP in malignant middle cerebral artery ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage.

Asymptomatic Central Pontine Myelinolysis: A Case Report

Introduction: Central pontine myelinolysis (CPM) is an acquired demyelinating lesion of the basis pontis that typically occurs after rapid correction of hyponatremia. There are only a few reported cases of patients without symptoms that have demonstrated CPM on imaging. Case Presentation: We report the case of a 26-year-old Hispanic male with history of alcohol abuse who was transferred to our medical center for acute onset diffuse abdominal pain. During his work up, a computed tomography scan demonstrated a large pancreatic mass. He underwent an endoscopic guided biopsy which demonstrated a rare and aggressive natural killer T cell lymphoma. His laboratory values were consistent with hyponatremia, which the medical team gently corrected. An MRI was performed for staging purposes which revealed findings consistent with CPM. A full neurological exam demonstrated no deficits. Materials and Methods: We conducted a PubMed search using the following keywords: asymptomatic, central, pontine, and myelinolysis in order to find other case reports of asymptomatic CPM. Results: Of the 29 results, only 6 previous case reports with English language abstracts of asymptomatic CPM were present since 1995. Conclusion: Despite slow correction of hyponatremia, CPM can be an important consequence, especially in patients with chronic alcoholism. Although this patient did not demonstrate any neurological deficits, the fact that there were changes seen on MRI should caution physicians in aggressively treating hyponatremia. Furthermore, if there is a decision to treat, then fluid restriction and reversal of precipitating factors (i.e. diuretics) should be used initially, unless there is concern for hypovolemia.

Early Ambulation in Patients With External Ventricular Drains: Results of a Quality Improvement Project

Introduction: Prolonged immobility in patients in the intensive care unit (ICU) can lead to muscle wasting and weakness, longer hospital stays, increased number of days in restraints, and hospital-acquired infections. Increasing evidence demonstrates the safety and feasibility of early mobilization in the ICU. However, there is a lack of evidence in the safety and feasibility of mobilizing patients with external ventricular drains (EVDs). The purpose of this study was to determine the safety and feasibility of early mobility in this patient population. Methods: We conducted a prospective, observational study. All patients in the study were managed with standard protocols and procedures practiced in our ICU including early mobility. Patients with an EVD who received early mobilization were awake and following commands, had a Lindegaard ratio <3.0 or middle cerebral artery (MCA) mean flow velocity <120 cm/s, a Mean Arterial Pressure (MAP) > 80 mm Hg, and an intracranial pressure consistently <20 mm Hg. Data were collected by physical therapists at the time of encounter. Results: Ninety patients with a total of 185 patient encounters were recorded over a 12-month period. The average time between EVD placement and physical therapy (PT) session was 8.3 ± 5.5 days. In 149 (81%) encounters, patients were at least standing or better. Patients were walking with assistance or better in 99 (54%) encounters. There were 4 (2.2%) adverse events recorded during the entire study. Conclusion: This observational study suggests that PT is feasible in patients with EVDs and can be safely tolerated. Further research is warranted in a larger patient population conducted prospectively to assess the potential benefit of early mobility in this patient population.

DHE-Induced Peripheral Arterial Vasospasm in Primary Raynaud Phenomenon: Case Report

Dihydroergotamine (DHE) is primarily a serotonin 5HT1B and 5HT1D receptor agonist used for acute migraine treatment. It is associated with acute vasoconstriction mediated through the 5HT1B receptor and is contraindicated in patients with history of cardiac disease and peripheral vascular disease. We present a case of acute peripheral arterial vasospasm in a patient with primary Raynaud phenomenon while receiving inpatient treatment for status migrainosus with intravenous (IV) DHE. The patient is a 35-year-old female with a history of chronic migraine and primary Raynaud phenomenon. After 15 doses of IV DHE, the patient reported paresthesias of the right hand and was noted to have absent right radial and ulnar pulses to palpation. Portable arterial Doppler study demonstrated abnormal flat line pulse volume recordings (PVRs) in the right second, third, and fourth digits, with markedly dampened PVR in the right thumb and fifth finger along with no ulnar PVR detectable at the wrist. Duplex revealed bilateral severely diminished flow in the right ulnar and radial arteries without acute occlusions. Computed tomography angiogram of right upper extremity visualized arteries through the mid-forearm but not distally. Dihydroergotamine was discontinued, and the patient was started on oral amlodipine and aspirin. Repeat Doppler ultrasound 3 days later revealed normal arm and digital waveforms bilaterally consistent with resolution of vasospasm. This case highlights a potential complication of IV DHE therapy. Risk may be increased in patients with primary Raynaud phenomenon. We suggest cautious use of IV DHE in this population.

Neurological Critical Care Services’ Influence Following Large Hemispheric Infarction and Their Impact on Resource Utilization

Introduction: Acute ischemic stroke (AIS) is the fourth leading cause of death in the US. Numerous studies have demonstrated the use of comprehensive stroke units and neurological intensive care units (NICU) in improving outcomes after stroke. We hypothesized that an expanded neurocritical care (NCC) service would decrease resource utilization in patients with LHI. Methods: Retrospective data from consecutive admissions of large hemispheric infarction (LHI) patients requiring mechanical ventilation were acquired from the hospital medical records. Between 2011-2013, there were 187 consecutive patients admitted to the Jefferson Hospital for Neuroscience (Philadelphia, USA) with AIS and acute respiratory failure. Our intention was to determine the number of tracheostomies done over time. The primary outcome measure was the number of tracheostomies over time. Secondary outcomes were, ventilator-free days (Vfd), total hospital charges, intensive care unit length of stay (ICU-LOS), and total hospital length of stay (hospital-LOS), including ICU LOS. Hospital charges were log-transformed to meet assumptions of normality and homoscedasticity of residual variance terms. Generalized Linear Models were used and ORs and 95% CIs calculated. The significance level was set at α = 0.05. Results: Of the 73 patients included in this analysis, 33% required a tracheostomy. There was a decrease in the number of tracheostomies undertaken since 2011. (OR 0.8; 95% CI 0.6-0.9: p=0.02). Lower Vfd were seen in tracheostomized patients (OR 0.11; 95%CI 0.1-0.26: p<0.0001). The log-hospital charges decreased over time but not significantly (OR 0.9; 95%CI 0.78-1.07: p=0.2) and (OR 0.99; 95%CI 0.85-1.16: p=0.8) from 2012 to 2013 respectively. The ICU-LOS at 23 days vs 10 days (p=0.01) and hospital-LOS at 33 days vs 11 days (p=0.008) were higher in tracheostomized patients. Conclusion: The data suggest that in LHI-patients requiring mechanical ventilation, a dedicated NCC service reduces the overall need for tracheostomy, increases Vfd, and decreases ICU and hospital-LOS. Keywors: neurocritical care, neurological critical care, large hemispheric infarct, malignant stroke, extubation, tracheostomy, resource utilization Received: 18 June 2017 / Accepted: 12 December 2017 * Correspondence to: Syed Omar Shah, Department of Neurological Surgery, Thomas Jefferson University and Jefferson College of Medicine. 909 Walnut Street, 3rd Floor, Philadelphia, PA 19107. E-Mail:syed.o.shah@jefferson.edu DOI: 10.2478/jccm-2018-0001 6 • The Journal of Critical Care Medicine 2018;4(1) Available online at: www.jccm.ro

758: CAN PROCALCITONIN DIFFERENTIATE BETWEEN CENTRAL AND INFECTIOUS FEVER IN PATIENTS WITH ICH

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) median dose of 4FPCC in the SD and HD groups was 25 units/kg and 50 units/ kg, respectively. The repeat INR post 4FPCC in the SD was 1.2 [1.2–1.3] and 1.1 [1.1–1.2] in the HD 4FPCC group (p=0.19). No difference was observed in achieving an INR of 1.3 or less when comparing the HD and SD 4FPCC groups (77 vs 82%, p=0.72). Hematoma expansion occurred equally in both groups at 13% (p=0.96). Lastly, in the HD group, there was one thrombotic event reported vs none in the SD group. Conclusions: Administering SD or HD 4FPCC to patients with WICH effectively lowered the INR to 1.3 or less in most patients. HD 4FPCC was not associated with a significant increase in thrombotic events. Further studies are warranted to evaluate the impact of HD 4FPCC on functional outcomes and mortality.