NEUROCRITICAL CARE JOURNAL
VOLUME 30 / FEBRUARY 2019, issue 1
Below are the articles and abstracts from this issue of Neurocritical Care Journal. To access the full issue, click here.
By Eelco F. M. Wijdicks
Neurologic examination of the comatose patient has gradually matured. Less than 50 years ago, neurological examination in coma became a regular part of textbooks with separate chapters devoted to the topic but many were deficient in detail. In 1969, C.M. Fisher published an extraordinary 56-page paper on the examination of the comatose patient. The paper—one of Fisher’s gems—is not well known and infrequently cited. The many new observations collected in this comprehensive paper are reviewed in this vignette, which highlights not only how these contributions shaped our thinking on coma but also questioned shaky concepts.
By Luis C. Ascanio, Georgios A. Maragkos, Brett C. Young, Myles D. Boone, Ekkehard M. Kasper
Stroke in pregnant women has a mortality rate of 1.4 deaths per 100,000 deliveries. Vascular malformations are the most common cause of hemorrhagic stroke in this population; preeclampsia and other risk factors have been identified. However, nearly a quarter of strokes have an undeterminable cause. Spontaneous intracranial hemorrhage (ICH) is less frequent but results in significant morbidity. The main objective of this study is to review the literature on pregnant patients who had a spontaneous ICH. A systematic review of the literature was conducted on PubMed and the Cochrane library from January 1992 to September 2016 following the PRISMA guidelines. Studies reporting pregnant patients with spontaneous intraparenchymal hemorrhage (IPH), subarachnoid hemorrhage (SAH), and subdural hemorrhage (SDH) were selected and included if patients had non-structural ICH during pregnancy or up to 6 weeks postpartum confirmed by imaging. Twenty studies were included, and 43 patients identified. Twenty-two patients (51.3%) presented with IPH, 15 patients (34.8%) with SAH, and five patients (11.6%) with SDH. The most common neurosurgical management was clinical in 76.7% of patients, and cesarean section was the most common obstetrical management in 28% of patients. The most common maternal outcome was death (48.8%), and fetal outcomes were evenly distributed among term delivery, preterm delivery, and fetal or neonatal death. Spontaneous ICH carries a high maternal mortality with IPH being the most common type, most frequently presenting in the third trimester. Diagnosis and management do not differ for the parturient compared to the non-pregnant woman.
By Joseph Driver, Aislyn C. DiRisio, Heidi Mitchell, Zachary D. Threlkeld, William B. Gormley
Seizures due to subdural hematoma (SDH) are a common finding, typically diagnosed using electroencephalography (EEG). At times, aggressive management of seizures is necessary to improve neurologic recovery and outcomes. Here, we present three patients who had undergone emergent SDH evacuation and showed postoperative focal deficits without accompanying electrographic epileptiform activity. After infarction and recurrent hemorrhage were ruled out, seizures were suspected despite a negative EEG. Patients were treated aggressively with AEDs and eventually showed clinical improvement. Long-term monitoring with EEG revealed electrographic seizures in a delayed fashion. EEG recordings are an important tool for seizure detection, but should be used as an adjunct to, rather than a replacement for, the clinical examination in the acute setting. At times, aggressive treatment of suspected postoperative seizures is warranted despite lack of corresponding electrographic activity and can improve clinical outcomes.
By Colin Casault, Abdulaziz S. Al Sultan, Mohammad Banoei, Philippe Couillard, Andreas Kramer, Brent W. Winston
This scoping review will discuss the basic functions and prognostic significance of the commonly researched cytokines implicated in severe traumatic brain injury (sTBI), including tumour necrosis factor-α (TNF-α), interleukin-1β (IL-1β), IL-6, tissue inhibitor of matrix metalloproteinases-1 (TIMP-1), transforming growth factor-β (TGF-β), substance P, and soluble CD40 ligand (sCD40L). A scoping review was undertaken with an electronic search for articles from the Ovid MEDLINE, PUBMED and EMBASE databases from 1995 to 2017. Inclusion criteria were original research articles, and reviews including both animal models and human clinical studies of acute (< 3 months) sTBI. Selected articles included both isolated sTBI and sTBI with systemic injury.
By Christos Lazaridis
Withdrawal of life-sustaining treatment (WOLST) is the leading proximate cause of death in patients with perceived devastating brain injury (PDBI). There are reasons to believe that a potentially significant proportion of WOLST decisions, in this setting, are premature and guided by a number of assumptions that falsely confer a sense of certainty.
By Vytautas Petkus, Aidanas Preiksaitis, Solventa Krakauskaite, Laimonas Bartusis, Romanas Chomskis, Yasin Hamarat, Erika Zubaviciute, Saulius Vosylius, Saulius Rocka, Arminas Ragauskas
This prospective study of an innovative non-invasive ultrasonic cerebrovascular autoregulation (CA) monitoring method is based on real-time measurements of intracranial blood volume (IBV) reactions following changes in arterial blood pressure. In this study, we aimed to determine the clinical applicability of a non-invasive CA monitoring method by performing a prospective comparative clinical study of simultaneous invasive and non-invasive CA monitoring on intensive care patients.
By Andreas H. Kramer, Philippe L. Couillard, David A. Zygun, Marcel J. Aries, Clare N. Gallagher
Guidelines recommend maintaining cerebral perfusion pressure (CPP) between 60 and 70 mmHg in patients with severe traumatic brain injury (TBI), but acknowledge that optimal CPP may vary depending on cerebral blood flow autoregulation. Previous retrospective studies suggest that targeting CPP where the pressure reactivity index (PRx) is optimized (CPPopt) may be associated with improved recovery.
By Gyanendra Kumar, Oana M. Dumitrascu, Chia-Chun Chiang, Cumara B. O’Carroll, Andrei V. Alexandrov
Cerebral catheter angiography is the gold standard for diagnosing cerebral artery vasospasm (vasospasm) in aneurysmal subarachnoid hemorrhage (SAH). We have previously published a meta-analysis of prediction of delayed cerebral ischemia (DCI) from transcranial Doppler (TCD) evidence of vasospasm. Analogous data relating to prediction of DCI have not been previously collated for cerebral angiography nor reconciled against TCD.
By David R. Busch, Ramani Balu, Wesley B. Baker, Wensheng Guo, Lian He, Mamadou Diop, Daniel Milej, Venkaiah Kavuri, Olivia Amendolia, Keith St. Lawrence, Arjun G. Yodh, W. Andrew Kofke
Diffuse correlation spectroscopy (DCS) noninvasively permits continuous, quantitative, bedside measurements of cerebral blood flow (CBF). To test whether optical monitoring (OM) can detect decrements in CBF producing cerebral hypoxia, we applied the OM technique continuously to probe brain-injured patients who also had invasive brain tissue oxygen (PbO2) monitors.
By Li TuXiujuan Liu, Tian Li, Xiulin Yang, Yipin Ren, Qian Zhang, Huan Yao, Xiang Qu, Qian Wang, Tian Tian, Jinyong Tian
Prognostic significance of serum calcium level in patients with intracerebral hemorrhage is not well studied. The aim of the study was to identify if a relationship between admission serum calcium level and prognosis exists in patients with intracerebral hemorrhage. A total of 1262 confirmed intracerebral hemorrhage patients were included. Demographic data, medical history, medicine history, laboratory data, imaging data, clinical score, and progress note were collected from their medical records. All images of head computed tomography were reanalyzed. Ninety-day prognosis was recorded, and poor outcome was defined as death or major disability caused by intracerebral hemorrhage.
By Daniel Hänggi, Nima Etminan, Stephan A. Mayer, E. Francois Aldrich, Michael N. Diringer, Erich Schmutzhard, Herbert J. Faleck, David Ng, Benjamin R. Saville, R. Loch Macdonald, for the NEWTON Investigators
Nimodipine is the only drug approved in the treatment of aneurysmal subarachnoid hemorrhage (aSAH) in many countries. EG-1962, a product developed using the Precisa™ platform, is an extended-release microparticle formulation of nimodipine that can be administered intraventricularly or intracisternally. It was developed to test the hypothesis that delivering higher concentrations of extended-release nimodipine directly to the cerebrospinal fluid would provide superior efficacy compared to systemic administration.
By KongMiao Lu, HaiRong Wang, XiaoLi Ge, QingHua Liu, Miao Chen, Yong Shen, Xuan Liu, ShuMing Pan
To investigate the effects of hyperbaric oxygen (HBO) on brain damage and autophagy levels in a rat model of middle cerebral artery occlusion. Neurologic injury and infarcted areas were evaluated according to the modified neurological severity score and 2,3,5-triphenyltetrazolium chloride staining. Western blots were used to determine beclin1, caspase-3 and fodrin1 protein expression. Beclin1 protein expression (an autophagy marker), positive terminal dUTP nick-end labeling (TUNEL) staining (an apoptosis marker) and positive propidium iodide (PI) staining (a necrosis marker) were detected by immunofluorescence.
By Günseli Orhun, Figen Esen, Perihan Ergin Özcan, Serra Sencer, Başar Bilgiç, Canan Ulusoy, Handan Noyan, Melike Küçükerden, Achmet Ali, Mehmet Barburoğlu, Erdem Tüzün
Incidence and patterns of brain lesions of sepsis-induced brain dysfunction (SIBD) have been well defined. Our objective was to investigate the associations between neuroimaging features of SIBD patients and well-known neuroinflammation and neurodegeneration factors. In this prospective observational study, 93 SIBD patients (45 men, 48 women; 50.6 ± 12.7 years old) were enrolled. Patients underwent a neurological examination and brain magnetic resonance imaging (MRI). Severity-of-disease scoring systems (APACHE II, SOFA, and SAPS II) and neurological outcome scoring system (GOSE) were used. Also, serum levels of a panel of mediators [IL-1β, IL-6, IL-8, IL-10, IL-12, IL-17, IFN-γ, TNF-α, complement factor Bb, C4d, C5a, iC3b, amyloid-β peptides, total tau, phosphorylated tau (p-tau), S100b, neuron-specific enolase] were measured by ELISA. Voxel-based morphometry (VBM) was employed to available patients for assessment of neuronal loss pattern in SIBD.
By Janelle O. Poyant, Philip J. Kuper, Kristin C. Mara, Ross A. Dierkhising, Alejandro A. Rabinstein, Eelco F. M. Wijdicks, Brianne M. Ritchie
Blood pressure variability (BPV) is an independent predictor for early hematoma expansion, neurologic deterioration, and mortality. There are no studies on the effect of intravenous (IV) antihypertensive drugs on BPV. We sought to determine whether patients have more BPV with certain antihypertensive agents, in particular the effect of IV nicardipine. We conducted a single-center, retrospective chart review of individuals diagnosed with spontaneous intracerebral hemorrhage (ICH) receiving labetalol, hydralazine, and/or nicardipine within 24 h of hospital admission to assess the primary endpoint of BPV, defined as the standard deviation of systolic BP, with labetalol and/or hydralazine compared to nicardipine ± labetalol and/or hydralazine. Repeated measures linear regression was performed to compare BPV over 24 h between regimens, and Cox proportional hazards regression was used to compare the time to goal SBP between regimens.
By Nicholas R. Nelson, Kathryn A. Morbitzer, J. Dedrick Jordan, Denise H. Rhoney
Traumatic brain injury (TBI) is associated with secondary complications, including infection, and patients with TBI often exhibit augmented renal clearance (ARC). This phenomenon has been associated with subtherapeutic levels of renally cleared drugs such as vancomycin, which is dosed based on body weight and creatinine clearance (CrCl). Many clinicians, however, cap CrCl at 120 mL/min/1.73 m2 when calculating vancomycin dosing regimens. We hypothesize that capping patient CrCl, as opposed to utilizing the non-capped CrCl, when determining vancomycin dosing schemes results in subtherapeutic serum trough concentrations in patients with TBI.
By Hermann Neugebauer, Flora MalakouIngo Uttner, Melitta Köpke, Eric Jüttler, for the IGNITE Study Group (Initiative of German NeuroIntensive Trial Engagement)
Attitudes toward the degree of acceptable disability and the importance of aphasia are critical in deciding on decompressive hemicraniectomy (DHC) in space-occupying middle cerebral artery stroke (SOS). The attitudes of nurses deserve strong attention, because of their close interaction with patients during acute stroke treatment. This is a multicenter survey among 627 nurses from 132 hospitals in Germany. Questions address the acceptance of disability, importance of aphasia, and the preferred treatment in the hypothetical case of SOS.
By Ward Eertmans, Cornelia Genbrugge, Jolien Haesen, Carolien Drieskens, Jelle Demeestere, Margot Vander Laenen, Willem Boer, Dieter Mesotten, Jo Dens, Ludovic Ernon, Frank Jans, Cathy De Deyne
We previously validated simplified electroencephalogram (EEG) tracings obtained by a bispectral index (BIS) device against standard EEG. This retrospective study now investigated whether BIS EEG tracings can predict neurological outcome after cardiac arrest (CA). Bilateral BIS monitoring (BIS VISTA™, Aspect Medical Systems, Inc. Norwood, USA) was started following intensive care unit admission. Six, 12, 18, 24, 36 and 48 h after targeted temperature management (TTM) at 33 °C was started, BIS EEG tracings were extracted and reviewed by two neurophysiologists for the presence of slow diffuse rhythm, burst suppression, cerebral inactivity and epileptic activity (defined as continuous, monomorphic, > 2 Hz generalized sharp activity or continuous, monomorphic, < 2 Hz generalized blunt activity). At 180 days post-CA, neurological outcome was determined using cerebral performance category (CPC) classification (CPC1-2: good and CPC3-5: poor neurological outcome).
By J. F. Willms, O. Boss, E. Keller
Fever control plays a key role in therapy of patients with acute brain injury. The infusion of cold saline could serve as an alternative or additional method for targeted temperature management. However, it is difficult to estimate the amount of fluid required to achieve normothermia merely on the basis of body weight. There is no standardized load management regarding the administration of cold saline, and no closed-loop systems based on continuous temperature-controlled feedback are available. The primary purpose of the present study was to evaluate the feasibility, efficacy, and safety of a new automated fluid infusion system.
By Robert H. Bonow, Alex Quistberg, Frederick P. Rivara, Monica S. Vavilala
Patients with mild traumatic brain injury (TBI) are frequently admitted to an intensive care unit (ICU), but routine ICU use may be unnecessary. It is not clear to what extent this practice varies between hospitals. We conducted a retrospective cohort study using the National Trauma Data Bank. Patients with at least one TBI ICD-9-CM diagnosis code, a head abbreviated injury score (AIS) ≤ 4, and Glasgow coma scale (GCS) ≥ 13 were included; individuals with only a concussion and those with a non-head AIS > 2 were excluded. Primary outcomes were ICU admission and “overtriage” to the ICU, defined by: ICU stay ≤ 1 day; hospital stay ≤ 2 days; no intubation; no neurosurgery; and discharged to home. Mixed effects multivariable models were used to identify patient and facility characteristics associated with these outcomes.
By Nicholas A. Morris, Abhinaba Chatterjee, Oluwayemisi L. Adejumo, Monica Chen, Alexander E. Merkler, Santosh B. Murthy, Hooman Kamel
Case series have reported reversible left ventricular dysfunction, also known as stress cardiomyopathy or Takotsubo cardiomyopathy (TCM), in the setting of acute neurological diseases such as subarachnoid hemorrhage. The relative associations between various neurological diseases and Takotsubo remain incompletely understood. We performed a cross-sectional study of all adults in the National Inpatient Sample, a nationally representative sample of US hospitalizations, from 2006 to 2014. Our exposures of interest were primary diagnoses of acute neurological disease, defined by ICD-9-CM diagnosis codes. Our outcome was a diagnosis of TCM. Binary logistic regression models were used to examine the associations between our pre-specified neurological diagnoses and TCM after adjustment for demographics.
By Andrew Martin, Monica L. Chen, Abhinaba Chatterjee, Alexander E. Merkler, Caroline D. Chung, Xian Wu, Nicholas A. Morris, Hooman Kamel
We sought to characterize the specialty classification of US physicians who provide critical care for neurological/neurosurgical disease. Using inpatient claims between 2009 and 2015 from a nationally representative 5% sample of Medicare beneficiaries, we selected hospitalizations for neurological/neurosurgical diseases with potential to result in life-threatening manifestations requiring critical care. Using Current Procedural Terminology® codes, we determined the medical specialty of providers submitting critical care claims, and, using National Provider Identifier numbers, we merged in data from the United Council for Neurologic Subspecialties (UCNS) to determine whether the provider was a UCNS diplomate in neurocritical care. We defined providers with a clinical neuroscience background as neurologists, neurosurgeons, and/or UCNS diplomates in neurocritical care. We defined neurocritical care service as a critical care claim with a qualifying neurological/neurosurgical diagnosis in patients with a relevant primary hospital discharge diagnosis and ≥ 3 total critical care claims, excluding claims from the first day of hospitalization since these were mostly emergency-department claims. Our findings were reported using descriptive statistics with exact confidence intervals (CI).
By Khalid Alsherbini, Nitin Goyal, E. Jeffrey Metter, Abhi Pandhi, Georgios Tsivgoulis, Tracy Huffstatler, Hallie Kelly, Lucas Elijovich, Marc Malkoff, Andrei Alexandrov
Ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) patients often require endotracheal intubation (EI) and mechanical ventilation (MV). Predicting the need for prolonged EI and timing of tracheostomy (TR) is challenging. While TR is performed for about 10–15% of patients in the general intensive care unit (ICU), the rate in the neurological ICU and for stroke patients ranges between 15 and 35%. Thus, we performed an external validation of the recently published SETscore.
By Binod Balakrishnan, Katherine T. Flynn-O’Brien, Pippa M. Simpson, Mahua Dasgupta, Sheila J. Hanson
Traumatic brain injury (TBI) is the leading cause of death and long-term disability among injured children. Early feeding has been shown to improve outcomes in adults, with some similar evidence in children with severe TBI. We aimed to examine the current practice of initiation of enteral nutrition in children with TBI and to evaluate the risk factors associated with delayed initiation of enteral nutrition.
By Paul Pham, Jessica Bindra, Anders Aneman, Alwin Chuan, John M. Worthington, Matthias Jaeger
Cerebrovascular autoregulation can be continuously monitored from slow fluctuations of arterial blood pressure (ABP) and regional cerebral oxygen saturation (rSO2). The purpose of this study was to evaluate the index of dynamic cerebrovascular autoregulation (TOx) and the associated ‘optimal’ ABP in normal adult healthy subjects. Twenty-eight healthy volunteers were studied. TOx was calculated as the moving correlation coefficient between spontaneous fluctuations of ABP and rSO2. ABP was measured with the Finometer photoplethysmograph. The ABP with optimal autoregulation (ABPOPT) was also determined as the ABP level with the lowest associated TOx (opt-TOx).
By Tanuwong Viarasilpa, Nicha Panyavachiraporn, Gamaleldin Osman, Christopher Parres, Panayiotis Varelas, Meredith Van Harn, Stephan A. Mayer
Clinical seizures and status epilepticus are frequent complications of encephalitis, can lead to depressed level of consciousness, and are associated with poor outcome. We sought to determine the frequency, risk factors, and clinical impact of electrographic seizures detected with continuing electroencephalography (cEEG) in patients with encephalitis and altered level of consciousness.
By Jan Küchler, Franziska Tronnier, Emma Smith, Jan Gliemroth, Volker M. Tronnier, Claudia Ditz
Patients with severe acute brain injury (ABI) often require intrahospital transports (IHTs) for repeated computed tomography (CT) scans. IHTs are associated with serious adverse events (AE) that might pose a risk for secondary brain injury. The goal of this study was to assess IHT-related alterations of cerebral metabolism in ABI patients. We included mechanically ventilated patients with ABI who had continuous multimodality neuromonitoring during an 8-h period before and after routine IHT. Intracranial pressure (ICP), cerebral perfusion pressure (CPP), brain tissue oxygenation (PtiO2) as well as cerebral and subcutaneous microdialysis parameters (lactate, pyruvate, glycerol, and glutamate) were recorded. Values were compared between an 8-h period before (pre-IHT) and after (post-IHT) the IHT.
By William D. Freeman, Wendy C. Ziai, Daniel Hanley
We read with great interest the article by Gozal et al. on ventriculostomy-associated infection (VAI) . The authors propose that a standardized definition for VAI should be a CSF microbiological culture that is positive for microorganism and associated with fever or low CSF glucose. While the authors should be commended on their attempt to define VAI with unifying nomenclature and classification in the literature, there is a problem regarding neuroICU patients with ventriculostomy and neurogenic fever: Prone patients such as subarachnoid hemorrhage (SAH) and/or intraventricular hemorrhage (IVH) patients with ventricular catheters who have a CSF microbial contaminant that is not found on repeat CSF testing should be excluded from this definition. The other nosocomial organisms that the authors report, such as MRSA and Pseudomonas, are rarely contaminants, similar to Candida and various fungal species.
By Bruno Mégarbane, Antoine Villa
We read with great interest the practical pearl report by Henry-Lagarrigue and colleagues  and would like to comment on their interpretation of their poisoned patient’s features. The authors reported a massive ingestion of alcohol hand rub (composition: 43% ethanol and 16% 2-propanol) in a 33-year-old depressed woman resulting in a profound coma with a transient mild lactate elevation (initial blood concentration: 3.4 mmol/l and peak blood concentration: 4.8 mmol/l). Outcome was favorable following airway support with mechanical ventilation for 6 h. The authors attributed the deep coma to ethanol and the observed transient hyperlactatemia to the liver alcohol dehydrogenase (ADH)-mediated metabolism of 2-propanol, reported to be a two-step pathway: transformation of 2-propanol to propylene glycol and oxidation of propylene glycol to lactic and pyruvic acids.
By Paul T. Akins
Dr. Shulz-Stubner makes an excellent point that desmopressin can quickly reverse platelet dysfunction, through its action to release von Willebrand factor. Since the desmopressin effect is short-acting and neurosurgical re-bleeding carries such adverse consequences, we view this treatment as emergent and temporizing until fresh platelets can be transfused. The caution to watch for water retention after desmopressin is quite germane in neurocritical care patients. This can lead to hyponatremia with additional adverse effects on brain edema and risk of seizures.
By Brian Y. Hwang, Geoffrey Appelboom, Christopher P. Kellner, E. Sander Connolly Jr.
The original intracerebral hemorrhage (oICH) score is one of the most commonly used intracerebral hemorrhage (ICH) clinical grading scales . The score has been shown to be a good predictor of 30-day mortality and functional outcome in populations with distinct geographical, cultural, and socioeconomic factors . Nevertheless, the oICH score’s limitations have led many studies to develop either modified versions of the score or new clinical grading scales in efforts to improve risk-stratification and outcome prediction after ICH.
By Adrian A. Jarquin-Valdivia, Robbie Franklin
A 25-year-old Mexican immigrant acutely became unconscious. The initial head computed tomography scan demonstrated hydrocephalus, with a mass lesion in posterior third ventricle. The brain magnetic resonance imaging (MRI) (Fig. 1a, T2 axial, and T1 sagittal) showed a single cystic lesion in the posterior third ventricle. A lateral ventriculostomy was placed. Two days later, in preparation for transcallosal endoscopic surgery, a pre-surgical brain MRI (Fig. 1b, axial T1, coronal T1 + C, sagittal T1) demonstrated the cystic lesion had spontaneously migrated into the fourth ventricle, changing the surgical approach. Via a suboccipital approach, the lesion was removed. Pathological specimen corresponded to a complete, immature, larval Taenia solium cysticercus measuring 2.6 cm × 1.5 cm × 1.4 cm (Fig. 1c). Albendazole was initiated after the surgery. He had an excellent clinical outcome, without requiring permanent cerebrospinal fluid derivation. When dealing with intraventricular cysticerci(us), it is prudent to repeat brain imaging just prior to surgical removal.