Neurocritical Care Journal

VOLUME 29 / DECEMBER 2018, issue 3

Below are the articles and abstracts from this issue of Neurocritical Care Journal. To access the full issue, click here.

Administrative Medical Databases for Clinical Research: The Good, The Bad, and The Ugly

By Alejandro A. Rabinstein

Mea culpa I have conducted clinical research using administrative databases. These types of studies have strong advocates, convinced of the value of getting access to very large cohorts, and fierce detractors, who contend that administrative databases contain information that is too limited and unreliable to answer any research question with confidence. I went from skeptic to user when I started to understand what administrative databases could offer and, very importantly, what they cannot.

The Timing of Tracheostomy and Outcomes After Aneurysmal Subarachnoid Hemorrhage: A Nationwide Inpatient Sample Analysis

By Hormuzdiyar H. Dasenbrock, Robert F. Rudy, William B. Gormley, Kai U. Frerichs, M. Ali Aziz-Sultan, Rose Du

The goal of this study was to investigate the association of tracheostomy timing with outcomes after aneurysmal subarachnoid hemorrhage (SAH) in a national population. Poor-grade aneurysmal SAH patients were extracted from the Nationwide Inpatient Sample (2002–2011). Multivariable linear regression was used to analyze predictors of tracheostomy timing and multivariable logistic regression was used to evaluate the association of timing of intervention with mortality, complications, and discharge to institutional care. Covariates included patient demographics, comorbidities, severity of subarachnoid hemorrhage (measured using the NIS-SAH severity scale), hospital characteristics, and other complications and length of stay.

Preventable Readmissions and Predictors of Readmission After Subarachnoid Hemorrhage

By John W. Liang, Laura Cifrese, Lili Velickovic Ostojic, Syed O. Shah, Mandip S. Dhamoon

To estimate rates of all-cause and potentially preventable readmissions up to 90 days after discharge for aneurysmal subarachnoid hemorrhage (SAH) and medical comorbidities associated with readmissions. Readmission rate is a common metric linked to compensation and used as a proxy to quality of care. Prior studies in SAH have reported 30-day readmission rates of 7–17% with a higher readmission risk among those with the higher SAH severity, ≥ 3 comorbidities, and non-home discharge. Intermediate-term rates, up to 90-days, and the proportion of these readmissions that are potentially preventable are unknown. Furthermore, the specific medical comorbidities associated with readmissions are unknown.

Stress Ulcer Prophylaxis in Neurocritical Care

By Jeffrey F. Barletta, Alicia J. Mangram, Joseph F. Sucher, Victor Zach

Stress ulcer prophylaxis (SUP) with acid-suppressive drug therapy is widely utilized in critically ill patients following neurologic injury for the prevention of clinically important stress-related gastrointestinal bleeding (CIB). Data supporting SUP, however, largely originates from studies conducted during an era where practices were vastly different than what is considered routine by today’s standard. This is particularly true in neurocritical care patients. In fact, the routine provision of SUP has been challenged due to an increasing prevalence of adverse drug events with acid-suppressive therapy and the perception that CIB rates are sparse. This narrative review will discuss current controversies with SUP as they apply to neurocritical care patients. Specifically, the pathophysiology, prevalence, and risk factors for CIB along with the comparative efficacy, safety, and cost-effectiveness of acid-suppressive therapy will be described.

Cerebral Fat Embolism: Recognition, Complications, and Prognosis

By Daniel Agustín Godoy, Mario Di Napoli, Alejandro A. Rabinstein

Fat embolism syndrome (FES) is a rare syndrome caused by embolization of fat particles into multiple organs including the brain. It typically manifests with petechial rash, deteriorating mental status, and progressive respiratory insufficiency, usually occurring within 24–48 h of trauma with long-bone fractures or an orthopedic surgery. The diagnosis of FES is based on clinical and imaging findings, but requires exclusion of alternative diagnoses. Although there is no specific treatment for FES, prompt recognition is important because it can avoid unnecessary interventions and clarify prognosis. Patients with severe FES can become critically ill, but even comatose patients with respiratory failure may recover favorably. Prophylactic measures, such as early stabilization of fractures and certain intraoperative techniques, may help decrease the incidence and severity of FES.

Oxygen Therapy with High-Flow Nasal Cannula as an Effective Treatment for Perioperative Pneumocephalus: Case Illustrations and Pathophysiological Review

By Jason L. Siegel, Karen Hampton, Alejandro A. Rabinstein, Diane McLaughlin, Jose L. Diaz-Gomez

Pneumocephalus (PNC) is a condition in which when air is trapped inside the intracranial vault. The causes are varied, but include trauma and intracranial surgery. Treatment of PNC typically consists of augmenting patient oxygenation with the attempt of washing out pulmonary nitrogen, creating a gradient in which nitrogen in the intracranial air bubble diffuses out of the lungs via the blood. Though several high flow methods have been tested, the ideal mode of oxygenation has not fully been investigated. Here we present 3 cases of post-operative PNC who we felt were symptomatic from PNC. With administration of high-flow nasal cannula (HFNC), all patients improved both clinically and radiographically within a few hours, faster than in both anecdotal experience and published trials. Due to its steady FiO2 administration, positive pressure, comfort, and low side-effect profile, HFNC may be the ideal mode of oxygen delivery in PNC. We present a review of the physiology of PNC and the characteristics of several oxygen delivery systems to build a case for HFNC in this disease process.

Malnutrition in Stroke Patients: Risk Factors, Assessment, and Management

By Toni Sabbouh, Michel T. Torbey

Stroke is the fourth leading cause of death in the USA and one of the major causes of disability generating a massive economic burden. Ischemic strokes account for 65–85% of stroke patients in the Western world, and the rest are hemorrhagic strokes which are more disabling. Only 10–20% of hemorrhagic stroke patients will recover functional independence. In order to improve neurological and cognitive functions of stroke patients, numerous rehabilitation interventions are implemented, including nutritional interventions, in attempt to overcome the metabolic consequences of stroke. Even though malnutrition in stroke patients is under-recognized and undertreated, its prevalence on admission is estimated to be around 20%. However, the prevalence of malnutrition after acute stroke varies widely ranging between 6.1 and 62%.

Metabolic Encephalopathy: Behind the Name

By Eelco F. M. Wijdicks

Metabolic encephalopathy may be the most common diagnosis in consultative acute neurology. The origin of this term is not generally known but can be traced back. The term replaced more commonly used designations such as organic or functional. The term metabolic encephalopathy was originally linked to organ dysfunction but subsequently became more imprecise. When it expanded to include a large number of diseases, it evolved to “metabolic neuronal dysfunction” and soon could not be distinguished from “quiet delirium” and other designations. This vignette summarizes why the terminology has confused more than clarified but also why it will likely stay in the neurologist’s vernacular.

Early Epileptiform Discharges and Clinical Signs Predict Nonconvulsive Status Epilepticus on Continuous EEG

By Johannes Koren, Johannes Herta, Simone Draschtak, Georg Pötzl, Franz Fürbass, Manfred Hartmann, Tilmann Kluge, Andreas Gruber, Christoph Baumgartner

Critical care continuous electroencephalography (CCEEG) represents the gold standard for detection of nonconvulsive status epilepticus (NCSE) in neurological critical care patients. It is unclear which findings on short-term routine EEG and which clinical parameters predict NCSE during subsequent CCEEG reliably. The aim of the present study was to assess the prognostic significance of changes within the first 30 min of EEG as well as of clinical parameters for the occurrence of NCSE during subsequent CCEEG. Systematic analysis of the first 30 min and the remaining segments of prospective CCEEG recordings according to the ACNS Standardized Critical Care EEG Terminology and according to recently proposed NCSE criteria as well as review of clinical parameters of 85 consecutive neurological critical care patients. Logistic regression and binary classification tests were used to determine the most useful parameters within the first 30 min of EEG predicting subsequent NCSE.

Combination of Clinical Exam, MRI and EEG to Predict Outcome Following Cardiac Arrest and Targeted Temperature Management

By Matthew B. Bevers, Benjamin M. Scirica, Kathleen Ryan Avery, Galen V. Henderson, Alexander P. Lin, Jong W. Lee

Despite the widespread adoption of targeted temperature management (TTM), coma after cardiac arrest remains a common problem with a high proportion of patients suffering substantial disability. Prognostication after cardiac arrest, particularly the identification of patients with likely good outcome, remains difficult. We performed a retrospective study of 78 patients who underwent TTM after cardiac arrest and were evaluated with both electroencephalography (EEG) and magnetic resonance imaging (MRI). We hypothesized that combining malignant versus non-malignant EEG classification with clinical exam and quantitative analysis of apparent diffusion coefficient (ADC) and fluid-attenuated inversion recovery imaging would improve prognostic ability.

Impact of Acute Cardiac Complications After Subarachnoid Hemorrhage on Long-Term Mortality and Cardiovascular Events

By Erik Norberg, Helena Odenstedt-Herges, Bertil Rydenhag, Jonatan Oras

Cardiac complications frequently occur after subarachnoid hemorrhage (SAH) and are associated with an increased risk of neurological complications and poor outcomes. The aim of this study was to evaluate the impact of acute cardiac complications after SAH on long-term mortality and cardiovascular events. All patients admitted to our Neuro intensive care unit with verified SAH from January 2010 to April 2015, and electrocardiogram, echocardiogram, and troponin T or NTproBNP data obtained within 72 h of admission were included in the study. Mortality data were obtained from the Swedish population register. Data regarding cause of death and hospitalization for cardiovascular events were obtained from the Swedish Board of Health and Welfare.

Evaluation of STESS, mRSTESS, and EMSE to Predict High Disability and Mortality at Hospital Discharge in Ecuadorian Patients with Status Epilepticus

By Dannys Rivero Rodríguez, Claudio Scherle Matamoros, Kimberly Sam, Daniela DiCapua Sacoto, Nelson Maldonado Samaniego, Yanelis Pernas

Adequate identification of the severity of status epilepticus (SE) contributes to individualized treatment. The scales most widely used for this purpose are: Status Epilepticus Severity Score (STESS), Epidemiology-Based Mortality Score in Status Epilepticus (EMSE) and modified Rankin Scale STESS (mRSTESS). The aim of this study was to evaluate the performance of the STESS, EMSE and mRSTESS scales to predict high disability and hospital mortality at discharge (HD/HM). A prospective study was conducted in which total of 41 patients were registered from November 2015 to January 2018 at Eugenio Espejo Hospital. Clinical variables such as age, sex, clinical status at the beginning of the SE, initial symptom of SE, as well as the STESS, mRSTESS and EMSE variant scales were studied at the time of the diagnosis of SE.

Minority Patients are Less Likely to Undergo Withdrawal of Care After Spontaneous Intracerebral Hemorrhage

By Cora H. Ormseth, Guido J. Falcone, Sara D. Jasak, David M. Mampre, Audrey C. Leasure, Laura C. Miyares, David Y. Hwang, Michael L. James, Fernando D. Testai, Kyra J. Becker, David L. Tirschwell, Carl D. Langefeld, Daniel Woo, Kevin N. Sheth

Prior studies of patients in the intensive care unit have suggested racial/ethnic variation in end-of-life decision making. We sought to evaluate whether race/ethnicity modifies the implementation of comfort measures only status (CMOs) in patients with spontaneous, non-traumatic intracerebral hemorrhage (ICH). We analyzed data from the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study, a prospective cohort study specifically designed to enroll equal numbers of white, black, and Hispanic subjects. ICH patients aged ≥ 18 years were enrolled in ERICH at 42 hospitals in the USA from 2010 to 2015. Univariate and multivariate logistic regression analyses were implemented to evaluate the association between race/ethnicity and CMOs after adjustment for potential confounders.

Effects of Diabetes Mellitus and Admission Glucose in Patients Receiving Mechanical Thrombectomy: A Systematic Review and Meta-analysis

By Guang-Dong Lu, Zi-Qi Ren, Jin-Xing Zhang, Qing-Quan Zu, Hai-Bin Shi

We performed a meta-analysis to evaluate the outcomes of acute ischemic stroke (AIS) in patients treated with mechanical thrombectomy (MT), according to diabetes mellitus and admission glucose level (AGL). We systematically reviewed previous studies in PubMed that reported outcomes of MT in AIS patients and their relationships with diabetes mellitus or AGL. We used functional independence (modified Rankin score ≤ 2 at 3 months) as the primary end point.

Accuracy and Safety of External Ventricular Drain Placement by Physician Assistants and Nurse Practitioners in Aneurysmal Acute Subarachnoid Hemorrhage

By Alejandro Enriquez-Marulanda, Luis C. Ascanio, Mohamed M. Salem, Georgios A. Maragkos, Ray Jhun, Abdulrahman Y. Alturki, Justin M. Moore, Christopher S. Ogilvy, Ajith J. Thomas

In the current dynamic health environment, increasing number of procedures are being completed by advanced practitioners (nurse practitioners and physician assistants). This is the first study to assess the clinical outcomes and safety of external ventricular drain (EVD) placements by specially trained advanced practitioners. Compare the safety and outcomes of EVD placement by advanced practitioners in patients with subarachnoid hemorrhage (SAH).

Early Hyperoxia in Patients with Traumatic Brain Injury Admitted to Intensive Care in Australia and New Zealand: A Retrospective Multicenter Cohort Study

By Diarmuid Ó Briain, Christopher Nickson, David V. Pilcher, Andrew A. Udy

Early hyperoxia may be an independent risk factor for mortality in critically ill traumatic brain injury (TBI) patients, although current data are inconclusive. Accordingly, we conducted a retrospective cohort study to determine the association between systemic oxygenation and in-hospital mortality, in critically ill mechanically ventilated TBI patients. Data were extracted from the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation Adult Patient Database. All adult TBI patients receiving mechanical ventilation in 129 intensive care units between 2000 and 2016 were included in analysis. The following data were extracted: demographics, illness severity scores, physiological and laboratory measurements, institutional characteristics, and vital status at discharge. In-hospital mortality was used as the primary study outcome. The primary exposure variable was the ‘worst’ partial arterial pressure of oxygen (PaO2) recorded during the first 24 h in ICU; hyperoxia was defined as > 299 mmHg. Adjustment for illness severity utilized multivariable logistic regression, the results of which are reported as the odds ratio (OR) 95% CI.

Successful Wean Despite Emergence of Ictal–Interictal EEG Patterns During the Weaning of Prolonged Burst-Suppression Therapy for Super-Refractory Status Epilepticus

By Alvin S. Das, Jong Woo Lee, Eric S. Rosenthal, Henrikas Vaitkevicius

Management of refractory status epilepticus (SE) commonly involves the induction of burst suppression using intravenous anesthetic agents. However, the endpoints of these therapies are not well defined. Weaning anesthetic agents are complicated by the emergence of electroencephalogram (EEG) patterns along the ictal–interictal continuum (IIC), which have uncertain significance given that IIC patterns may worsen cerebral metabolism and oxygenation, have a dissociation between scalp and depth EEG recordings, or may indicate a late stage of SE itself. Determining the significance of IIC patterns in the unique context of anesthetic weaning is important to prevent the potential for unnecessarily prolonging anesthetic coma.

Long-Term Outcomes in Patients with Anemia And Cerebral Venous Thrombosis

By Kai Liu, Bo Song, Yuan Gao, Lu Zhao, Hui Fang, Yunchao Wang, Lulu Pei, Kaihao Han, Shen Li, Yusheng Li, Yuming Xu

Anemia is associated with unfavorable functional outcome in ischemic and hemorrhagic stroke. However, the relationship between anemia and prognosis in patients with cerebral venous thrombosis (CVT) has not been studied. Consecutive CVT patients were retrospectively identified from November 2011, through January 2017. Anemia was defined according to the World Health Organization criteria (non-pregnant female hemoglobin level < 120 g/L, pregnant female < 110 g/L and male < 130 g/L), which was further classified as mild, moderate, and severe anemia according to hemoglobin concentration, and as microcytic, normocytic, and macrocytic anemia according to mean corpuscular volume. Unfavorable outcome was defined as modified Rankin Scale (mRS) of 3–6. Factors such as age, sex, coma, malignancy, intracerebral hemorrhage, and straight sinus and/or deep CVT involved, premorbid mRS were adjusted to evaluate the relationship between anemia and prognosis in CVT patients.

Safety and Reliability of Bedside, Single Burr Hole Technique for Intracranial Multimodality Monitoring in Severe Traumatic Brain Injury

By Brandon Foreman, Laura B. Ngwenya, Erica Stoddard, Jason M. Hinzman, Norberto Andaluz, Jed A. Hartings

We aimed to provide a systematic description of our 2-year experience using a standardized bedside, single burr hole approach to intracranial multimodality monitoring (MMM) in patients with severe traumatic brain injury (sTBI), focusing on safety and probe reliability. We performed this observational cohort study at a university-affiliated, Level I trauma center with dedicated 20-bed neuroscience intensive care unit. We included 43 consecutive sTBI patients who required MMM to guide clinical care based on institutional protocol and had a four-lumen bolt placed to measure intracranial pressure, brain tissue oxygen, regional cerebral blood flow, brain temperature, and intracranial electroencephalography.

Clinical Correlates of Periodic Discharges and Nonconvulsive Seizures in Posterior Reversible Encephalopathy Syndrome (PRES)

By Laure Bastide, Benjamin Legros, Nishi Rampal, Emily J. Gilmore, Lawrence J. Hirsch, Nicolas Gaspard

The pathophysiological mechanisms of Posterior Reversible Encephalopathy Syndrome (PRES) and related seizures remain poorly understood. The prevalence and clinical significance of nonconvulsive seizures (NCSz) and related epileptiform patterns during continuous electroencephalography monitoring (CEEG) in PRES have not been well described. To report the prevalence, characteristics and risk factors for NCSz and related highly epileptiform patterns in patients with PRES, and to determine their relation to imaging abnormalities and outcome.

Safety and Efficiency of Intravenous Push Lacosamide Administration

By K. Erin Davidson, Joshua Newell, Khalid Alsherbini, Joseph Krushinski, G. Morgan Jones

Intravenous (IV) lacosamide use for status epilepticus has increased in recent years and is recommended for refractory status epilepticus by current guidelines. Per the lacosamide package labeling, the preferred route of administration is diluted and infused over 30–60 min; however, administration undiluted is also acceptable and recent literature demonstrated safety at a maximum rate of 80 mg per minute (Kellinghaus et al. in Acta Neurol Scand 123:137–141, 2011). Undiluted administration as an IV push has potential to increase efficiency of administration to patients needing urgent seizure control since it may be dispensed from automatic dispensing cabinets in patient care areas. This study aims to compare safety outcomes and efficiency of administration in patients receiving lacosamide IV push compared to IV piggyback.

Cerebral Metabolic Changes Related to Oxidative Metabolism in a Model of Bacterial Meningitis Induced by Lipopolysaccharide

By M. Munk, F. R. Poulsen, L. Larsen, C. H. Nordström, T. H. Nielsen

Cerebral mitochondrial dysfunction is prominent in the pathophysiology of severe bacterial meningitis. In the present study, we hypothesize that the metabolic changes seen after intracisternal lipopolysaccharide (LPS) injection in a piglet model of meningitis is compatible with mitochondrial dysfunction and resembles the metabolic patterns seen in patients with bacterial meningitis. Eight pigs received LPS injection in cisterna magna, and four pigs received NaCl in cisterna magna as a control. Biochemical variables related to energy metabolism were monitored by intracerebral microdialysis technique and included interstitial glucose, lactate, pyruvate, glutamate, and glycerol. The intracranial pressure (ICP) and brain tissue oxygen tension (PbtO2) were also monitored along with physiological variables including mean arterial pressure, blood glucose, lactate, and partial pressure of O2 and CO2. Pigs were monitored for 60 min at baseline and 240 min after LPS/NaCl injection.

A Callosal Catastrophe: Toxic Leukoencephalopathy Associated with Thermogenic Weight Loss Supplement Use

By Zakraus K. Mahdavi, Ram Narayan, Shraddha Mainali, Benjamin M. Greenberg, Venkatesh Aiyagari, David L. McDonagh

The use of weight loss drugs and dietary supplements is common, but safety profiles for these drugs are largely unknown. Reports of toxicity have been published, and the use of these agents should be considered in clinical differential diagnoses. We report the case of a patient with toxic leukoencephalopathy and hyponatremia associated with oral consumption of a thermogenic dietary supplement and essential oils. A 30-year-old woman presented after 2 days of headache, blurred vision, photophobia, vomiting, and hand spasms. She was taking a thermogenic dietary supplement daily for 6 months as well as a number of essential oils. Examination revealed mild right sided ataxia and diffuse hyperreflexia. Neuroimaging demonstrated bilaterally symmetric T2 hyperintensities of the corpus callosum and periventricular white matter. Approximately 18 h after admission she became unresponsive with brief extensor posturing and urinary incontinence. She partially recovered, but 1 h later became unresponsive with dilated nonreactive pupils and extensor posturing (central herniation syndrome). She was intubated, hyperventilated, and given hyperosmotic therapy. Emergent imaging showed diffuse cerebral edema. Intracranial pressure was elevated but normalized with treatment; she regained consciousness the following day. She was extubated one day later and discharged on hospital day 5. She was seen 2 months later with no further symptoms and a normal neurologic examination.

Medulla Oblongata Hemorrhage and Reverse Takotsubo Cardiomyopathy

By Kevin T. Gobeske, Maurice E. Sarano, Jennifer E. Fugate, Eelco F. Wijdicks

Acute brain injury with strong surges of adrenergic outflow has resulted in takotsubo cardiomyopathy, but there are surprisingly few reports of takotsubo cardiomyopathy after intracranial hemorrhage, and none have been described from hemorrhage within the brainstem. We describe a patient with reverse and reversible cardiomyopathy following a hemorrhage in the lateral medulla oblongata. While it is limited in size, the location of the hemorrhage caused acute systolic failure with left ventricular ejection fraction of 27% and vasopressor requirement for cardiogenic shock and pulmonary edema. There was full recovery after 7 days.

Prolonged Post-Traumatic Vasospasm Resulting in Delayed Cerebral Ischemia After Mild Traumatic Brain Injury

By Masoom Desai, Nicholas A. Morris

Post-traumatic vasospasm (PTV) is an important cause of secondary brain injury in patients with severe traumatic brain injury (TBI) and independently predicts poor outcomes. The incidence of PTV has been varyingly reported from 35.6 to 61%. Important risk factors for PTV include severity of TBI determined by the Glasgow coma score (GCS) and radiographic criteria, young age, fever on admission and volume of cisternal blood. PTV has been associated with traumatic subarachnoid hemorrhage (tSAH), a marker of severity of TBI. Increased incidence of PTV has also been linked with worse Rotterdam Scores. PTV usually begins around day 2–3 and lasts from 5 to 10 days. Moreover, less than 20% of patients develop clinical sequelae from PTV, mostly seen in severe TBI.