Faculty Bibliography

BACKGROUND: Aneurysmal subarachnoid hemorrhage (SAH) with associated intracerebral hemorrhage (ICH) is often treated with concomitant surgical clipping and ICH evacuation. The aim of this study was to determine if aneurysm coiling followed by ICH evacuation is a viable alternative treatment. METHODS: A retrospective review was conducted between July 2000 and March 2009 of patients with aneurysmal SAH plus ICH (>30 ml or with midline shift >5 mm) who underwent aneurysm repair (either coiling or clipping) and craniotomy for ICH evacuation. Demographic and radiographic criteria, time to aneurysm protection, length of stay (LOS), treatment complications, discharge disposition and 3 month functional outcome were compared between groups. RESULTS: Of 18 SAH+ICH patients, 10 underwent aneurysm coiling followed by ICH evacuation and eight underwent clipping with ICH evacuation. Compared with clipped patients, coiled patients had a lower Glasgow Coma Scale score (median 5.5 vs 7.5), higher ICH score (median 3 vs 2), worse modified Fisher score (median 4 vs 3) and higher rate of herniation at presentation (50% vs 25%). Median time to aneurysm protection was shorter in coiled patients (299 vs 885 min, p<0.001). Comparing coiled with clipped patients, rates of death (30% vs 25%), poor outcome (70% vs 50%), median ICU LOS (20 vs 22 days), median hospital LOS (27 vs 29 days) and total median direct costs ($64,537 vs $61,243) were similar, as were complication rates (all p>0.05). CONCLUSIONS: Coiling followed by ICH evacuation is associated with faster time to aneurysm protection and similar outcome, LOS and cost as clipping and evacuation. This may be a viable alternative to clipping and ICH evacuation.

Introduction. Elevated intracranial pressure that occurs at the time of cerebral aneurysm rupture can lead to inadequate cerebral blood flow, which may mimic the brain injury cascade that occurs after cardiac arrest. Insights from clinical trials in cardiac arrest may provide direction for future early brain injury research after subarachnoid hemorrhage (SAH). Methods. A search of PubMed from 1980 to 2012 and clinicaltrials.gov was conducted to identify published and ongoing randomized clinical trials in aneurysmal SAH and cardiac arrest patients. Only English, adult, human studies with primary or secondary mortality or neurological outcomes were included. Results. A total of 142 trials (82 SAH, 60 cardiac arrest) met the review criteria (103 published, 39 ongoing). The majority of both published and ongoing SAH trials focus on delayed secondary insults after SAH (70%), while 100% of cardiac arrest trials tested interventions within the first few hours of ictus. No SAH trials addressing treatment of early brain injury were identified. Twenty-nine percent of SAH and 13% of cardiac arrest trials showed outcome benefit, though there is no overlap mechanistically. Conclusions. Clinical trials in SAH assessing acute brain injury are warranted and successful interventions identified by the cardiac arrest literature may be reasonable targets of the study.

BACKGROUND: Interhospital transfer of patients with intracranial hemorrhage can offer improved care, but may be associated with complications. METHODS: A prospective single-center study was conducted between 2/2008 and 6/2010 of patients with subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH) and subdural hemorrhage (SDH), admitted to the neuro-ICU at a tertiary-care academic hospital. Admission demographics, complications and 3-month functional outcomes were compared between directly admitted and transferred patients. The effect of transfer time on complications and outcomes was assessed. RESULTS: Of 257 total patients, 120 (47%) were transferred and 137 (53%) were directly admitted. About 86 (34%) had SAH, 80 (31%) had ICH and 91 (35%) had SDH. The median transfer time was 190 min (46-1,446). Transferred patients were significantly less educated, less likely to be insured and more frequently had SAH as a diagnosis than directly admitted patients (all P < 0.05), though admission neurological and cognitive status was similar. Complications did not differ between transferred and directly admitted patients; however, among transferred patients, longer transfer time was associated with aneurysm rebleed (7.3 vs. 1.8%, P = 0.007) and tracheostomy (20 vs. 17.5%, P = 0.013). In multivariate analysis, after adjusting for other predictors, transferred patients had worse cognitive outcome at 3-months (adjusted OR 12.4, 95% CI 1.2-125.2, P = 0.033) compared to direct admits, though there were no differences in death, disability or length of stay (LOS). CONCLUSIONS: Transferred patients had similar rates of death, disability and LOS as directly admitted patients, though worse 3-month cognitive outcomes. Prolonged time to interhospital transfer was associated with an increased risk of aneurysm rerupture and tracheostomy.

PURPOSE OF REVIEW: This article summarizes the most common etiologies and approaches to management of metabolic encephalopathy. RECENT FINDINGS: Metabolic encephalopathy is a frequent occurrence in the intensive care unit setting. Common etiologies include hepatic failure, renal failure, sepsis, electrolyte disarray, and Wernicke encephalopathy. Current treatment paradigms typically focus on supportive care and management of the underlying etiology. Directed therapies that target neurochemical and neurotransmitter pathways that mediate encephalopathy are not currently available and represent an important area for future research. Although commonly thought of as reversible neurologic insults, delirium and encephalopathy have been associated with increased mortality, prolonged length of stay and hospital complications, and worse long-term cognitive and functional outcomes. SUMMARY: Recognition and treatment of encephalopathy is critical to improving outcomes in critically ill patients.

Dietary restriction (DR) extends lifespan across multiple species including mouse. Antioxidant plant extracts rich in polyphenols have also been shown to increase lifespan. We hypothesized that polyphenols might potentiate DR-induced lifespan extension. Twenty week old C57BL/6 mice were placed on one of three diets: continuous feeding (control), alternate day chow (Intermittent fed, IF), or IF supplemented with polyphenol antioxidants (PAO) from blueberry, pomegranate, and green tea extracts (IF+PAO). Both IF and IF+PAO groups outlived the control group and the IF+PAO group outlived the IF group (all p<0.001). In the brain, IF induced the expression of inflammatory genes and p38 MAPK phosphorylation, while the addition of PAO reduced brain inflammatory gene expression and p38 MAPK phosphorylation. Our data indicate that while IF overall promotes longevity, some aspects of IF-induced stress may paradoxically lessen this effect. Polyphenol compounds, in turn, may potentiate IF-induced longevity by minimizing specific components of IF-induced cell stress.