[Show abstract][Hide abstract] ABSTRACT: Objective: To determine the prevalence, type, and significance of brain damage in critically ill patients with a primary non-neurological diagnosis developing acute brain dysfunction.
Methods: This retrospective cohort study was performed at the Johns Hopkins University School of Medicine, an academic tertiary care hospital. Medical records were reviewed of 479 consecutive ICU patients who underwent brain MRI over a 2-year period. Patients were selected for analysis if MRI was obtained to evaluate an acute onset of brain dysfunction (altered mental status, seizures, and/or focal neurological deficit). Subjects with a history of a central nervous system disorder were excluded.
The principal clinical endpoint was Glasgow Outcome Scale (GOS) assessed at discharge. MRI-defined brain abnormalities were classified according to type and location. Factors associated with MRI-defined abnormalities were assessed in uni- and multivariable models.
Results: 146 patients met inclusion criteria (mean age 54±7years). Brain damage was detected in 130 patients (89%). The most prevalent lesions were white matter hyperintensities (104/146, 71%) and acute cerebral infarcts (59/146, 40%). In a multivariable model, lesions on brain MRI were independently associated with unfavorable outcome (GOS1-3 in 71% of patients with lesions vs. 44% in those without, p=0.007). No adverse events occurred in relation to transport and MRI scanning.
Conclusions: In critically ill patients without known neurological disease who have brain dysfunction, MRI reveals an unexpectedly high burden of underlying brain damage, which is associated with unfavorable outcome. The results indicate that brain damage could be an important and under-recognized factor contributing to critical illness brain dysfunction.
Neurocritical Care 10/2015; 23(2):243-252. DOI:10.1007/s12028-015-0110-4 · 2.44 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Patients with acute brain injuries require strict physiologic control to minimize morbidity and mortality. This study aimed to assess in-hospital compliance to strict physiologic parameters (BP, HR, ICP, SpO2) in these populations.
Patients with severe cerebrovascular events were admitted to the neurointensive care unit (NSICU) and were continuously monitored using the BedMasterEX (Excel Medical Electronics Inc, FL) system, which recorded hemodynamic data via an arterial catheter continuously in 5-s intervals. Furthermore, we investigated the impact of healthcare provider shift changes (6-8 a.m./p.m) and of day (6 a.m.-6 p.m.) versus night (6 p.m-6 a.m) shifts in hemodynamic control.
Fifty patients admitted to the NSICU, 50 % male, mean age 59.7 ± 13.9 years with subarachnoid hemorrhage (23), ischemic stroke (8), subdural hematoma (4), intracerebral hemorrhage (3), intraventricular hemorrhage (2), and miscellaneous injuries (10) were enrolled. Data represented 2,337 total hours of continuous monitoring. Systolic BPs (SBP) were on average outside of recommended ranges 32.26 ± 30.46 % of the monitoring period. We subdivided adherence to ideal SBP range: optimal (≥99 % of time spent in NSICU within range) was achieved in 12 %, adequate (90 %) in 16 %, suboptimal (80 %) in 20 %, inadequate I (70 %) in 12 %, and inadequate II (<70 %) in 40 % of patients. Comparison of shift change %time and day versus night %time out of parameter yielded no statistically significant differences across SAH patients.
Hemodynamic management of patients with cerebrovascular injuries, based on targeted thresholds in the NSICU, yielded optimal control of SBP in only 28 % of our patients (within parameters ≥90 % of time).
Neurocritical Care 04/2015; DOI:10.1007/s12028-015-0116-y · 2.44 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Introduction:
The use of mechanical thrombectomy for the treatment of acute ischemic stroke has significantly advanced over the last 5 years. Few data are available comparing the cost and clinical and angiographic outcomes associated with available techniques. The aim of this study is to compare the cost and efficacy of current endovascular stroke therapies.
A single-center retrospective review was performed of the medical record and hospital financial database of all ischemic stroke cases admitted from 2009 to 2013. Three discrete treatment methodologies used during this time were compared: traditional Penumbra System (PS), stent retriever with local aspiration (SRLA) and A Direct Aspiration first Pass Technique (ADAPT). Statistical analyses of clinical and angiographic outcomes and costs for each group were performed.
222 patients (45% men) underwent mechanical thrombectomy. Successful revascularization was defined as Thrombolysis In Cerebral Infarction (TICI) 2b/3 flow, which was achieved in 79% of cases with PS, 83% of cases with SRLA, and 95% of cases with ADAPT. The average total cost of hospitalization for patients was $51 599 with PS, $54 700 with SRLA, and $33 611 with ADAPT (p<0.0001). Average times to recanalization were 88 min with PS, 47 min with SRLA, and 37 min with ADAPT (p<0.0001). Similar rates of good functional outcomes were seen in the three groups (PS 36% vs SRLA 43% vs ADAPT 47%; p=0.4).
The ADAPT technique represents the most technically successful yet cost-effective approach to revascularization of large vessel intracranial occlusions.
Journal of Neurointerventional Surgery 07/2014; 7(9). DOI:10.1136/neurintsurg-2014-011282 · 2.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Patients in the critical care unit often receive nutrition through enteral access. A common complication of enteral nutrition is the occlusion of the enteral tube. This complication occurs at a rate as high as 35 %. A clog that cannot be dissolved may require replacement of the enteral tube, which increases the risk of adverse outcomes and cost. To prevent this complication critical care practitioners should be diligent in recognizing risk factors and using best practice to help prevent an occlusion from forming. Some of the risk factors of enteral occlusion include contact of enteral nutrition with acidic fluid, intact protein and high-fiber formulations, improper administration of medications, and slowing or stopping the flow of enteral nutrition. Prevention is of utmost importance in maintaining enteral tube patency and includes proper tube feed flushing with sterile water. When treatment is required for an occluded tube, warmwater flushes are the first-line agent to restore patency. Second-line therapy includes activated pancreatic enzyme solution. When all treatment options have failed, replacement of the enteral tube is necessary.
Diet and Nutrition in Critical Care, 01/2014: pages 1-10; , ISBN: 978-1-4614-8503-2
[Show abstract][Hide abstract] ABSTRACT: Novel oral anticoagulants present challenges and uncertainties in the management of hemorrhagic emergencies. An 84-year-old man taking dabigatran presented with a subdural hematoma requiring neurosurgical intervention. Routine coagulation assays were prolonged at admission and following administration of Factor VIII Inhibitor Bypassing Activity (FEIBA). Thromboelastography (TEG(®)) was utilized to assess clot dynamics prior to placement of a subdural drain, which was safely inserted despite a prolonged thrombin time (TT). Exclusive reliance on the TT may delay necessary interventions. TEG(®) may be a valuable tool to investigate hemostasis in patients on dabigatran requiring emergent procedures.
Journal of Thrombosis and Thrombolysis 05/2013; 37(2). DOI:10.1007/s11239-013-0933-9 · 2.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
The "white cerebellum" sign is a rare imaging finding described mainly in children with hypoxic brain injury.
Materials and methods:
Single case report and review of the literature.
We describe a child with acute bacterial meningitis in whom plain CT and MRI showed the white cerebellum sign. The subtle imagings findings were not recognized and a lumbar puncture was performed. Markedly increased intracranial pressure was documented by lumbar puncture and by placement of an intraparenchymal monitor. Contrary to most prior descriptions the patient made a very good recovery.
The white cerebellum sign is a subtle imaging finding seen in patients with diffuse cerebral edema, such finding may not be as ominous as previously thought.
Neurocritical Care 04/2013; 18(3). DOI:10.1007/s12028-013-9836-z · 2.44 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Introduction:
Perimesencephalic subarachnoid hemorrhage is a rare neurologic condition of unclear etiology. Multiple mechanisms have been postulated as potential triggers, but none are universally accepted.
Single observational case report and review of the literature.
We describe a patient who developed perimesencephalic subarachnoid hemorrhage in the setting of "hypoxic training" (breath-holding while swimming). We describe the plausible pathophysiologic events that caused the hemorrhage.
The occurrence of perimesencephalic subarachnoid hemorrhage during hypoxic training suggests that acute venous congestion may be a triggering factor. The increasing popularity of hypoxic training demands vigilance from health care providers.
Neurocritical Care 03/2013; 18(3). DOI:10.1007/s12028-013-9827-0 · 2.44 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Although headaches are common in the general population and have many causes, headaches secondary to inflammatory processes in the blood vessels in the Central Nervous System (CNS) are not so common. The most common types of vasculitis that are associated with headaches include primary CNS vasculitis, systemic necrotizing arteritis, granulomatous vasculitis, and systemic collagen diseases. It is important to differentiate between "true" vasculitides and a condition known and reversible cerebral vasoconstriction syndrome (RCVS). While treatment for many of the vasculitides consists of anti-inflammatory medications, this approach may produce significant complications in RCVS. It is up to the clinician to judiciously use imaging and laboratory data to reach the proper diagnosis and therefore offer the correct treatment to these patients.
Current Pain and Headache Reports 03/2013; 17(3):320. DOI:10.1007/s11916-012-0320-9 · 2.26 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Hunger strikes are not infrequent occurrences in military and civilian prisons. Although practicing clinicians are familiar with the management of patients who have limited oral intake, managing hunger strikers is unfamiliar to most. The psychological, physiological, and social events that surround hunger strikes are very complex and need to be understood by those caring for hunger strike patients. To provide adequate medical care to hunger strike patients, clinicians most understand the physiological events that ensue after prolonged starvation. Careful vigilance for development of refeeding syndrome is of key importance. A multidisciplinary approach to hunger strikes is of utmost importance, and involvement of a multidisciplinary clinical team as well as prison officials is essential.
Nutrition in Clinical Practice 10/2012; 28(1). DOI:10.1177/0884533612462896 · 2.40 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Patient selection for acute ischemic stroke has been largely driven by time-based criteria, although emerging data suggest that image-based criteria may be useful. The purpose of this study was to directly compare outcomes of patients treated within a traditional time window with those treated beyond this benchmark when CT perfusion (CTP) imaging was used as the primary selection tool.
A prospectively collected database of all patients with acute ischemic stroke who received intra-arterial therapy at the Medical University of South Carolina was retrospectively analyzed, regardless of time from symptom onset. At presentation, CTP maps were qualitatively assessed. Selected patients underwent intra-arterial therapy. Functional outcome according to the modified Rankin scale (mRS) score at about 90 days was documented.
140 patients were included in the study. The median time from symptom onset to groin access was 7.0 h. Overall, 28 patients (20%) had bleeding complications, but only 10 (7.1%) were symptomatic. The average National Institute of Health Stroke Scale (NIHSS) score for patients treated ≤ 7 h from symptom onset was 17.3 and 30.2% had a mRS score of 0-2 at 90 days. Patients treated >7 h from symptom onset had an average NIHSS score of 15.1 and 45.5% achieved a mRS score of 0-2 at 90 days (p=0.104). Patients in the two groups had similar rates of symptomatic intracerebral hemorrhage (8.5% and 5.8%, respectively; p=0.745).
No difference was found in the rates of good functional outcome between patients treated ≤ 7 h and those treated >7 h from symptom onset. These data suggest that imaging-based patient selection is a safe and viable methodology.
Journal of Neurointerventional Surgery 08/2012; 5(6). DOI:10.1136/neurintsurg-2012-010452 · 2.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Recent evidence indicates that multidisciplinary care improves patient outcomes in cerebrovascular (CV) disease. A multidisciplinary integrated CV program was recently instituted at a high-volume tertiary referral center, providing the opportunity to evaluate patient outcomes before and after its introduction. OBJECTIVE: To evaluate outcomes after treatment of patients with intracranial aneurysm in relation to the introduction of a CV program at our institution. METHODOLOGY: A retrospective chart review was performed on all new patient encounters for a 6-month period each before and immediately after the introduction of the CV program, as well as at a more recent 6-month period to evaluate long-term results. Data were collected on demographic variables, rupture status, medical comorbidities, hospital complications, in-hospital procedures, hospital course and modified Rankin score at discharge and follow up. RESULTS: The total number of patients treated increased from 55 in the 6-month period before the introduction of the CV program to 112 in the most recent time period (p<0.05). Both the surgical clipping and endovascular coiling procedures increased (p<0.05). A significant increase occurred in patients with multiple comorbidities (30.5% vs 34.7%, p=0.035). The mean length of stay decreased from 12.22±13.26 days before the program to 9.23±12.04 days in the most current data (p<0.05). CONCLUSIONS: Creation of an integrated CV program at a large-volume tertiary referral center resulted in better outcomes for an increased number of more medically complicated patients with intracranial aneurysms. This study provides preliminary data for developing an integrated model of multidisciplinary care for the management of CV disease.
Journal of Neurointerventional Surgery 04/2012; 5(3). DOI:10.1136/neurintsurg-2012-010309 · 2.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: REACH Medical University of South Carolina (MUSC) provides stroke consults via the internet in South Carolina. From May 2008 to April 2011 231 patients were treated with intravenous (IV) thrombolysis and 369 were transferred to MUSC including 42 for intra-arterial revascularization [with or without IV tissue plasminogen activator (tPA)]. Medical outcomes and hemorrhage rates, reported elsewhere, were good (Lazaridis et al., 2011). Here we report operational features of REACH MUSC which covers 15 sites with 2,482 beds and 471,875 Emergency Department (ED) visits per year. Eight Academic Faculty from MUSC worked with 165 different physicians and 325 different nurses in the conduct of 1085 consults. For the 231 who received tPA, time milestones (in minutes) were: Onset to Door: 62 (mean), 50 (median); Door to REACH Consult: 43 and 33, Consult Request to Consult Start: was 9 and 7, Consult Start to tPA Decision: 31 and 25; Decision to Infusion: 20 and 14, and total Door to Needle: 98 and 87. The comparable times for the 854 not receiving tPA were: Onset to Door: 140 and 75; Door to REACH Consult: 61 and 41; Consult Request to Consult Start: 9 and 7, Consult Start to tPA Decision: 27 and 23. While the consultants respond to consult requests in <10, there is a long delay between arrival and Consult request. Tracking of operations indicates if we target shortening Door to Call time and time from tPA decision to start of drug infusion we may be able to improve Door to Needle times to target of <60. The large number of individuals involved in the care of these patients, most of whom had no training in REACH usage, will require novel approaches to staff education in ED based operations where turnover is high. Despite these challenges, this robust system delivered tPA safely and in a high fraction of patients evaluated using the REACH MUSC system.
Frontiers in Neurology 03/2012; 3:33. DOI:10.3389/fneur.2012.00033
[Show abstract][Hide abstract] ABSTRACT: Traditional treatment in acute ischemic stroke is based on time criteria when administering intravenous and intra-arterial therapies. However, recent evidence suggests that image-based criteria may be useful for selecting patients for intra-arterial interventions. The use of CT perfusion (CTP)-based criteria, regardless of time from symptom onset, in patient selection for intra-arterial treatment of ischemic stroke was assessed.
Patients with ischemic stroke who presented to the emergency department at the Medical University of South Carolina with a National Institute of Health Stroke Scale score of ≥ 8, regardless of time from symptom onset, were assessed retrospectively. CTP maps were qualitatively assessed for the presence of penumbra and infarction. Selected patients underwent mechanical aspiration of their occlusion using the Penumbra system. Functional outcome was then recorded using the modified Rankin scale (mRS) at 90 days or the closest follow-up to 90 days.
53 patients were included in the study. The median time from symptom onset to groin vascular access was 6.3 h. Eight patients (15%) had bleeding complications including subarachnoid hemorrhage, parenchymal hemorrhage and intraventricular hemorrhage. After CTP-based selection, the patients were divided into two groups for analysis: ≤6 h and >6 h from symptom onset to endovascular procedure. No difference was found in functional outcome between the two groups (38.5% and 40.7% achieved 90-day mRS ≤2, respectively (p=1.0) and 57.7% and 51.9% achieved 90-day mRS ≤3, respectively (p=0.785)). There was no difference in the rate of intracranial hemorrhage between the two groups (11.5 vs 18.5, p=0.704).
This study demonstrated similar rates of good functional outcome and intracranial hemorrhage in patients with ischemic stroke when endovascular treatment was performed based on CTP selection rather than time-guided selection. These findings suggest that endovascular reperfusion in ischemic stroke may be effective and safe, and may allow patient selection not solely based on time from symptom onset.
Journal of Neurointerventional Surgery 09/2011; 4(4):261-5. DOI:10.1136/neurintsurg-2011-010067 · 2.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Family history is a recognized risk factor in aneurysmal subarachnoid hemorrhage (SAH). The genetic and environmental contributions are actively researched. The authors of this report present a case series of 3 first-degree siblings affected by nontraumatic, angiographically negative SAH. Data in this study suggest that familial predisposition may also apply to spontaneous, nonaneurysmal SAH and that family history should be actively investigated in all such patients. The identification of families with multiple affected members could lead to an improved understanding of the genetic and environmental factors associated with this condition.
Journal of Neurosurgery 06/2011; 115(3):621-3. DOI:10.3171/2011.5.JNS1119 · 3.74 Impact Factor