Faculty Bibliography

BACKGROUND AND PURPOSE/OBJECTIVE:Patients with intracerebral hemorrhage (ICH) frequently present with hypertension, but it is unclear if this is due to pre-existing hypertension (prHTN) or to the bleed itself or associated pain. We sought to assess the relationship between prHTN and admission systolic blood pressure (aBP) and bleed severity. METHODS:We retrospectively assessed the relationship between prHTN and aBP and NIHSS in patients with ICH at 3 institutions. RESULTS:Of 251 patients, 170 (68%) had prHTN based on history of hypertension/antihypertensive use. Median aBP was significantly higher in those with prHTN (155 mm Hg (IQR 135-181) versus 139 mm Hg (IQR 124-158), P < .001). Patients with left ventricular hypertrophy (LVH) on electrocardiogram (ECG) or transthoracic echocardiogram (TTE) had significantly higher aBP than those without LVH (median aBP 195 mm Hg (IQR 155-216) for patients with LVH on ECG versus 147 mm Hg (IQR 129-163) for patients with no LVH on ECG, P < .001; median aBP 181 mm Hg (IQR 153-214) for patients with LVH on TTE versus 152 mm Hg (IQR 137-169) for patients with no LVH on TTE, P = .01). prHTN was associated with a higher median NIHSS (11 (IQR 3-20) for patients with history of hypertension/antihypertensive use versus 6 (IQR 1-14) for patients without this history (P = .02); 9 (IQR 3-19) versus 5 (IQR 2-13) for patients with/without LVH on ECG (P = .085); and 10 (IQR 5-18) versus 5 (IQR 1-13) for patients with/without LVH on TTE (P = .046). CONCLUSIONS:Patients with ICH who have prHTN have higher aBP and NIHSS, suggesting that prHTN may worsen reactive hypertension in the setting of ICH.

Introduction Tranexamic Acid (TXA) is an intravenous antifibrinolytic agent that is used routinely for elective surgery. We report a case of inadvertent intrathecal injection of TXA resulting in refractory status epilepticus. Methods Case report. Results A 71-year-old healthy female admitted for bilateral total knee replacement was inadvertently administered 300mg of TXA intrathecally instead of bupivacaine. Soon after administration, she developed myoclonic jerking. When the error was identified, 15cc of CSF was removed. She was intubated, administered levetiracetam, started on a propofol infusion, and transferred to the neurointensive care unit (NICU). She developed persistent spontaneous and stimulus induced generalized myoclonus refractory to propofol. Midazolam infusion was added. NCHCT and CTA demonstrated pneumocephalus, but no acute arterial or venous thrombosis or stroke. vEEG revealed generalized nonconvulsive seizures occurring once per minute, not correlating with spinal myoclonus . Propofol and midazolam infusions were increased to 150 mcg/kg/min and 2.6 mg/kg/hr, respectively, to achieve burst suppression, and valproic acid was added. Over the following week, the drips were adjusted to suppress seizure activity. By hospital day 8, she was weaned off all infusions without recurrence of seizures. By hospital day 19, she was on levetiracetam monotherapy. She was discharged to rehab after a 22-day hospital course, and was discharged home 45 days after initial presentation. Residual deficits at the time of discharge included mild cognitive impairment and gait instability. She remains seizure-free since hospital day 45 on levetiracetam 500mg BID. Conclusions We report a case of refractory status epilepticus and spinal myoclonus after accidental intrathecal TXA administration. With aggressive management, the patient survived with mild residual deficits. The mechanism by which TXA causes status epilepticus and spinal myoclonus is hypothesized to be related to its inhibitory effects on GABA and glycine receptors, respectively

BACKGROUND AND PURPOSE/OBJECTIVE:The relationship between in-hospital hyperglycemia and neurological outcome after intracerebral hemorrhage (ICH) is not well studied. METHODS:We analyzed the relationships between pre-hospital and hospital variables including highest in-hospital glucose (HIHGLC) and discharge Glasgow Coma Scale (GCS), discharge Modified Rankin Scale (MRS) and 3-month MRS using a single-institution cohort of ICH patients between 2013 and 2015. RESULTS:There were 106 patients in our sample. Mean HIHGLC was 154 ± 58mg/dL for patients with discharge GCS of 15 and 180 ± 57mg/dL for patients with GCS < 15; 146 ± 55mg/dL for patients with discharge MRS 0-3 and 175 ± 58mg/dL for patients with discharge MRS 4-6; and 149 ± 52mg/dL for patients with 3-month MRS of 0-3 and 166 ± 61mg/dL for patients with 3-month MRS of 4-6. On univariate analysis, discharge GCS was associated with HIHGLC (P = .01), age (P = .006), ICH volume (P = .008), and length of stay (LOS) (P = .01); discharge MRS was associated with HIHGLC (P < .001), age (P < .001), premorbid MRS (P = .046), ICH volume (P < .001), and LOS (P < .001); and 3-month MRS was associated with HIHGLC (P = .006), discharge MRS (P < .001), age (P = .001), sex (P = .002), ICH volume (P = .03), and length of stay (P = .004). On multivariate analysis, discharge GCS only had a significant relationship with ICH volume (odds ratio [OR] .949, .927-.971); discharge MRS had a significant relationship with age (OR 1.043, 1.009-1.079), premorbid MRS (OR 2.622, 1.144-6.011), and ICH volume (OR 1.047, 1.003-1.093); and 3-month MRS only had a significant relationship with age (OR 1.039, 1.010-1.069). CONCLUSIONS:The relationship between in-hospital hyperglycemia and neurological outcomes in ICH patients was meaningful on univariate, but not multivariate, analysis. Glucose control after ICH is important.

BACKGROUND AND PURPOSE: The ideal strategy to prevent infections in patients with external ventricular drains (EVDs) is unclear. METHODS: We conducted a cross-sectional survey of members of the Neurocritical Care Society on infection prevention practices for patients with EVDs between April and July 2015. RESULTS: The survey was completed by 52 individuals (5% response rate). Catheter selection, use of prolonged prophylactic systemic antibiotics (PPSAs), cerebrospinal fluid (CSF) collection policies, location of EVD placement, and performance of routine EVD exchanges varied. Antibiotic-impregnated catheters (AICs) and conventional catheters (CCs) were used with similar frequency, but no respondents reported routine use of silver-impregnated catheters (SICs). The majority of respondents were either neutral or disagreed with the need for PPSA with all catheter types (CC: 75%, AIC: 85%, and SIC: 87%). Despite this, 55% of the respondents reported PPSAs were routinely administered to patients with EVDs at their institutions. The majority (80%) of the respondents reported CSF collection only on an as-needed basis. The EVD placement was restricted to the operating room at 27% of the respondents' institutions. Only 2 respondents (4%) reported that routine EVD exchanges were performed at their institution. CONCLUSION: Practice patterns demonstrate that institutions use varying strategies to prevent ventriculostomy-related infections. Identification and further study of optimum care for these patients are essential to decrease the risk of complications and to aid development of practice standards.

Introduction Patients with intracerebral hemorrhage (ICH) frequently present with hypertension. It is unclear whether this is due to preexisting hypertension (prHTN) causing the bleed, an effect of the bleed, or both. Methods We retrospectively analyzed a single-institution cohort of ICH patients presenting between 2013 and 2016. Data included home antihypertensive use; aSBP; TTE, and EKG and imaging results; and nicardipine administration. The primary objective was to assess the relationship between prHTN and aSBP, while the secondary objectives were to assess the relationship between prHTN, imaging and acute antihypertensive requirements. Results 112 ICH patients met inclusion criteria. In our assessment for prHTN, we found that 46% of patients were on antihypertensives, 16% had LVH on EKG, and 15% had LVH on TTE. There was a significant relationship between LVH on TTE and LVH on EKG (p<0.001), but not between home antihypertensive use and presence of LVH using either modality. aSBP was higher for all patients with markers of pHTN, but this was only significant for patients with LVH on TTE (181mmHg, IQR 153-214 vs. 152mmHg, IQR 137-169, p < 0.001) and patients with LVH on EKG (195 mm Hg, IQR 155-216 vs. 147 mm Hg, IQR 129- 163, p<0.001). All patients with markers of prHTN were more likely to require nicardipine, but this was only significant for patients with LVH on TTE (94% vs. 64%, p=0.016) and patients with LVH on EKG (83% vs. 52%, p=0.018). All patients with markers of prHTN were more likely to have deep bleeds (p=0.017 for patients with LVH on EKG vs. those without LVH on EKG). There was no relationship between any markers of prHTN and the presence of a spot sign. Conclusions In patients with ICH, prHTN is related to higher aSBP, deep bleed location, and increased acute antihypertensive requirements

Introduction The development of flow-diverting stents has allowed for new treatment options for giant vertebrobasilar aneurysms. However, the expertise required to perform these procedures safely and concerns about complications continue to limit their use. We sought to identify common complications of this treatment that can be anticipated by neurointensivists, to optimize management in the postoperative period. Methods We retrospectively reviewed our hospital database of treated aneurysms to identify those with giant vertebrobasilar aneurysms. Medical and neurological complications were recorded. Results Six patients (5 male, 1 female) underwent treatment of giant vertebrobasilar aneurysms with pipeline embolization devices. Five received adjunctive coiling. Frequently reported pre-procedure symptoms were dysphagia (n=4), diplopia (n=3), dysarthria (n=3), facial weakness (n=3), hemiparesis (n=2), gaze palsy (n=2), and nystagmus (n=2). Five patients ambulated normally. Due to concerns about necessary procedures after stenting when on antiplatelet therapy, three patients received prophylactic ventriculoperitoneal shunts, two underwent gastrostomy, and two underwent tracheostomy. Angiography confirmed successful aneurysm embolization in all patients. Postoperatively, all patients developed new or worsened symptoms attributed to brainstem edema, including hemiparesis (n=4), facial weakness (n=4), dysphagia (n=4), diplopia (n=4), nystagmus (n=3), gaze palsy (n=3), and dysarthria (n=3). Neurological symptoms were treated with steroids, with most symptoms subsiding by discharge. Five patients had medical complications, including pneumonia (n=2), respiratory failure (n=2), gastrointestinal bleeding (n=2), arrhythmia (n=2), urinary tract infection (n=1), and myocardial infarction (n=1). Two patients were re-intubated, three underwent gastrostomy, and one underwent tracheostomy. Functional status at 3-months was available for five patients. Three achieved modified Rankin Scale scores between 0-2, one regressed to a 5, and one died. Conclusions The treatment of giant vertebrobasilar aneurysms presents significant challenges. Practitioners should anticipate temporary postoperative neurological worsening and various medical complications. Prophylactic shunt placement, gastrostomy, and/or tracheostomy should be considered in patients anticipated to likely need these procedures after treatment