Citations

Background: Elevated intracranial pressure (ICP) is one proposed mechanism leading to poor outcomes in patients with spontaneous intraventricular hemorrhage (IVH). We characterized occurrence and significance of intracranial hypertension in severe IVH requiring extraventricular drainage (EVD). Methods: Prospective analysis of ICP in the first 400 patients enrolled in the CLEAR III trial, a multicenter, double-blind, randomized study comparing EVD plus intraventricular recombinant tissue plasminogen activator (rtPA) vs. EVD plus placebo for treatment of IVH in patients with obstructive IVH and intracerebral hemorrhage (ICH) volume <30cc. Maximum and minimum ICP was recorded every 4 hours in all patients until 7 days post randomization. ICP readings were analyzed at pre-defined thresholds and proportion of high ICP events compared by clinical/radiological variables. Impact on 30 day mortality was assessed. Results: of 17,593 ICP readings, maximum ICP ranged from -4 to 115 mm Hg (median, interquartile range; 11,8); 90.2% (15,861) were ≤ 20 mm Hg, 2.0% were >30, 0.5% were >40, and 0.2% were > 50 mm Hg. Proportion of threshold events > 20 and > 30 mm Hg were more frequent in patients with persistent closure of the lower ventricular system after day 3 (p=0.047 and p=0.04, respectively), but were not correlated with initial or end of treatment (72 hours after last dose of study agent) ICH or IVH volumes. ICP elevation > 20 mm Hg occurred during a required 1 hr EVD closure time after study agent injection in 507/3364 (15.1%) injections although early re-opening of EVDs occurred in only 3.9%. Shunting for hydrocephalus was required in 18% of patients over 1 yr follow-up and was not associated with high ICP events. Percentage of ICP readings per patient > 30 mmHg and ICH/IVH volumes were independent predictors of 30 day mortality after adjustment for other outcome predictors (p=0.01; p=0.04; p<0.001, respectively). Conclusions: ICP is not frequently elevated during monitoring and drainage with an EVD in patients with severe IVH. ICP > 30 mm Hg predicts higher short-term mortality. Early opening of the lower ventricular system may reduce frequency of high ICP events. Injection of thrombolytics can be performed without additional ICP management in the majority of patients.

Objective: This study seeks to investigate the impact of antithrombotics, including Aspirin, Clopidogrel, and Warfarin, on the severity of bleeding and outcomes in patients with subarachnoid hemorrhage (SAH). We hypothesize that patients with a history of antithrombotic use have a more severe injury from SAH. Methods: Two hundred twenty-eight patients admitted to the Mayo Clinic Florida consecutively between July 2008 and July 2011 were studied retrospectively. Of this group, 77 patients had a known history of antithrombotic use while 151 did not. Both aneurysmal and non-aneurysmal cases were included in the study. Each patient’s Hunt and Hess Score, Fisher Grade, modified Rankin Scale (mRS) and Glasgow Coma Scale (GCS) were evaluated. Associations between history of antithrombotic use and severity of SAH were assessed using Spearman’s test of correlation and Mann-Whitney tests. Results: There was strong evidence of higher mRS grades in patients with a history of antithrombotic use compared to other patients (Median: 3 vs. 2, P=0.001). There was no significant difference between patients with and without a history of antithrombotic use regarding SAH Fisher grade (Median: 3 vs. 3, P=0.31) and Hunt and Hess score (Median: 2 vs. 2, P=0.93). The difference in GCS score was not statistically significant (Median: 14 vs. 15, P=0.20). Conclusion: This analysis found a significant effect of previous use of antithrombotics on overall outcome following SAH. Further analysis is needed to correlate the outcomes with specific medications and investigate the role of aggressive reversal of coagulopathy on overall outcomes.

AbstractTelemedicine is a rapidly growing field of medicine due to a combination of high-speed global telecommunication systems and accessibility of small, fast mobile computing platforms with bidirectional audiovisual camera capabilities. Teleneurology is a subset of telemedicine. TeleNeuroICU, one form of teleneurology, is the practice of virtually consulting on patients in the ICU setting with neurological and neurosurgical conditions. Given the current and future shortage of neurologists and neurointensivists, there is a high demand for TeleNeuroICU services around the globe and this is expected to increase in the future. This review summarizes the state of the art around the TeleNeuroICU practice for practitioners in the field, emerging research in this area, and new technologies and integrations that enhance the value of TeleNeuroICU to health care systems.

The recognition and management of stroke in the prehospital setting has become increasingly important to improve patient outcomes. Several strategies to advance prehospital stroke care have been developed, including the mobile stroke unit and the telemedicine-enabled ambulance—or “mini-MSU.” These strategies both incorporate ambulance-based audio-visual telemedicine evaluation with a vascular neurologist to facilitate faster treatment but differ in several areas including upfront and recurring costs, scalability or growth potential, ability to integrate into existing emergency medical services systems, and interoperability across multiple specialties or conditions. While both the mobile stroke unit and mini-mobile stroke unit model are valid approaches to improve stroke care, the authors aim to compare these models based on costs, scalability, integration, and interoperability in order to guide our prehospital leaders to find the best solutions for their communities.

ABSTRACT Guillain-Barré syndrome (GBS) is an immune-mediated polyneuropathy, which is characterized by areflexia and ascending paresthesia which can progress to a respiratory failure. Certain conditions, such as vasculitis and heavy metal and drug toxicity, may have misleadingly similar clinical presentation to GBS. We describe a case of a patient with cystic fibrosis and intravenous colistin-induced neurotoxicity mimicking GBS. The patient had used inhaled colistin on five occasions with no adverse effects, however, developed symptoms on the second day of intravenous treatment. Overlapping findings between immune-mediated polyneuropathy and drug-induced neurotoxicity include limb paresthesia and decreased reflexes. Perioral tingling, however, is a common presentation of colistin-induced neurotoxicity, and therefore, is an important differentiating factor. Early diagnosis prevents further neurologic decline, extensive unnecessary workup and potentially harmful incorrect management.

Objective: Study perioperative strategies for optimizing neuroprotection in complex spine deformity correction surgery. Methods: We report the case of a patient with severe lumbar dextroscoliosis, thoracolumbar junction hyperkyphosis with a 40-degree Cobb angle levoconvex scoliosis who underwent spinal deformity correction with loss of neuromonitoring during surgery. We performed a literature review on perioperative management of complex spine deformity. Results: A 50-year-old man presented with lumbar pain and right L4 radiculopathy. Surgical intervention for deformity correction and decompression was indicated with T4−L4 posterior instrumentation L2/L3 and L3/L4 transforaminal lumbar interbody fusion. Surgery was aborted due to the loss of neuromonitoring. Postsurgery, the patient had left sensory deficit and the neurocritical care team clinically suspected and deduced the anatomic location of the spinal cord compression. Magnetic resonance imaging confirmed a T10−T11 hyperintensity suggestive of cord ischemia due to osteophyte compressing the spinal cord. The patient underwent a second corrective surgery with no intraoperative events and has no long-term neurological sequela. Conclusions: This case illustrates that a comprehensive perioperative approach and individualized risk factor assessment is useful in complex spine deformity surgery. Further research is needed to determine how this individualized comprehensive approach can lead to intraoperative and postoperative countermeasures that improved spine surgery outcomes. Level of Evidence: Level V.

IntroductionGuillain-Barré syndrome precipitated by hepatitis E virus infection is rare, yet its incidence is increasing.Clinical FindingsA 57-year-old man was transferred from another facility with fatigue, orange urine, and progressive weakness over 4 to 6 weeks. Initial laboratory results included total bilirubin, 9.0 mg/dL; direct bilirubin, 6.4 mg/dL; aspartate aminotransferase, 1551 U/L; alanine aminotransferase, 3872 U/L; and alkaline phosphatase, 430 U/L. Immunoglobulin M and quantitative polymerase chain reaction test results were positive for hepatitis E virus. Contrast-enhanced magnetic resonance imaging of the brain and spine showed no gross abnormalities. Analysis of cerebrospinal fluid obtained by lumbar puncture revealed the following (reference values in parentheses): total white blood cell count, 15/μL (0–5/μL), with 33% neutrophils and 54% lymphocytes; protein, 0.045 g/dL (0.015–0.045 g/dL); and glucose, 95 mg/dL (within reference range). Neurological examination revealed weakness in both upper extremities, with proximal strength greater than distal strength. The patient could not elevate either lower extremity off the bed and had areflexia and reduced sensation throughout all extremities.DiagnosisGuillain-Barré syndrome secondary to acute hepatitis E virus infection was diagnosed on the basis of clinical characteristics, serum and cerebrospinal fluid analyses, and nerve conduction studies.ConclusionsNurses and clinicians should obtain a thorough history and consider hepatitis E virus infection as a precipitating factor in patients with sensory and motor disturbances consistent with Guillain-Barré syndrome. The case gives insight into the diagnostic process for Guillain-Barré syndrome and highlights the vital role of bedside nurses in evaluating and treating these patients.

Background: Elevated intracranial pressure (ICP) and inadequate cerebral perfusion pressure (CPP) are mechanisms causing poor outcomes in spontaneous intraventricular hemorrhage (IVH). We characterized intracranial hypertension in severe IVH requiring extraventricular drainage (EVD). Methods: Prospective analysis of ICP in all 500 patients enrolled in the CLEAR III trial, a multicenter, double-blind, randomized study comparing EVD + intraventricular recombinant tissue plasminogen activator (rtPA) vs. EVD + placebo for treatment of obstructive IVH and intracerebral hemorrhage (ICH) volume <30cc. Maximum and minimum ICP/CPP were recorded every 4 hours until 7 days post randomization (rand), analyzed at pre-defined thresholds and compared by clinical and radiological variables. Results: of 23,406 ICP readings, maximum ICP ranged from 0-97 mmHg (median, IQR; 11,8); 90.7% (21,223) were ≤20mmHg, 1.8% >30, 0.5% >40, and 0.2% > 50mm Hg. Proportion of threshold events >20mmHg were more frequent with persistent closure of the lower ventricular system after day 3 (p=0.02), and was correlated with initial and end of treatment (72 hours post rand) ICH volumes (p=0.01, p=0.04, respectively). ICP elevation >20mmHg occurred during a required 1 hr EVD closure interval after 566/3712 (15.3%) study agent injections. Early re-opening of the EVD occurred in 3.9%. Shunting for hydrocephalus occurred in 18.6% over 1 year follow-up and was associated with % of high ICP events >20 and 30 mmHg (p=0.01 for both). After adjustment for ICH severity factors and IVH volume, % of ICP readings>20 mmHg was significantly associated with 30 and 180 day mortality (p=0.01; p=0.03 respectively), and borderline with modified Rankin Scale (mRS4-6) (p=0.09; p=0.11 respectively). Proportion of CPP readings <70mmHg was associated with day 30 poor mRS (p=0.02), with a weaker association for day 180 mRS (p=0.07). Conclusions: Elevated ICP and inadequate CPP are not infrequent during monitoring and EVD drainage in severe IVH and predict higher short and long-term mortality. Early opening of the lower ventricular system may reduce high ICP events. These results permit future correlation of ICP and CPP with treatment rendered (thrombolysis vs placebo), with upcoming unblinding of the trial.