Neurocritical Care (2014) 13:S1–S231
DOI 10.1007/s12028-014-0034-4
NEUROCRITICALCARESOCIETY
12THANNUALMEETING
ABSTRACTSUPPLEMENT
September11Ͳ14,2014
SeattleWestinxxSeattle,Washington
Table of Contents
Oral Presentations
…………………………………………………………...
3 – 16
Oral Abstract Presentations are located in Grand 3
Poster Sessions
…………………………………………………………...
Session I
Session II
Session III
Thursday, September 11 5:15 – 6:45 pm
Friday, September 12
5:15 – 6:45 pm
Saturday, September 13 5:15 – 6:45 pm
Kiosks 1 – 5
Kiosks 6 – 7
located in 5th Ave
located in Grand Crescent
19 – 285
Poster Sessions
Disorders of Consciousness………………………………………………………..….. 258 – 273
Head and Spine Trauma…………………………….........…………………… 48 – 59; 136 – 152
ICU Organization and Technology…………………........…………….……. 60 – 70; 167 – 183
Intracerebral hemorrhage…………………………….......…………….….. 184 – 194; 233 – 249
Ischemic Stroke…………………….…………….........……………….……..
85 – 96; 153 – 166
Medical Issues in NeuroICU………......……………….………. 36 – 47; 124 – 135; 217 – 232
Muscle and Nerve Disorders……………………………………………………..…….. 250 – 251
Pediatric NeuroICU……………………………………………………………….....…… 252 – 253
Peri-Operative Management…………………………………………………........….
Seizures………………………………………………………….……...……..
Subarachnoid hemorrhage…………………….……………….
254– 257
97 – 107; 274 – 285
24 – 35; 112 – 123; 200 – 216
Temperature Modulation…………………………………………………...........…………. 71 – 84
Neurocrit Care
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ORAL ABSTRACTS
ORALABSTRACTSESSIONI
Thursday,September 11භ1:00pm–2:00pm
Grand3
1:00–1:12pm
DavidYamane
ClinicalUtilityandCostofBloodCulturesinIntensiveCareUnitPatientswithSpontaneous
IntracerebralHemorrhage
1:12–1:24pm
DavidHwang
AnalysisofFactorsThatPhysiciansandNursesIncorporateIntoSubjectivePredictionof
IntracerebralHemorrhageOutcome.
1:24–1:36pm
Wijman Young
Investigator
Rahul Damani: Cristanne
Award
VolumetricIntegralPhaseͲshiftSpectroscopy(VIPS),indetectingearlycerebraledema:
hemodialysisasaproofofprinciplemodel.
1:36–1:48pm
JonathanRatcliff
NeurologicDeclineintheEDFollowingTraumaticBrainInjuryisNotIndependentlyAssociated
with6ͲMonthOutcome:AnAnalysisoftheMulticenterTRACKͲTBIStudy
1:48–2:00pm
JenniferMoran
24/7NeurocriticalCareNursePractitionerCoverageDramaticallyReducedDoorͲtoͲNeedle
TimeandImprovedOutcomeinStrokePatientsTreatedwithAlteplase
4
Neurocrit Care
ORAL ABSTRACTS
ORALABSTRACTSESSIONII
Friday,September 12භ1:00 pm – 2:00
pm
Grand3
1:00–1:12pm
NilsHenninger
SevereLeukoaraiosisPortendsaPoorOutcomeAfterTraumaticBrainInjury
1:12–1:24pm
KateKlein
SustainabilityofOutcomesofEarlyMobilityforPatientswithNeurologicalInjury
1:24–1:36pm
MalavikaChandra
ContinuousNonͲinvasiveMeasurementofCerebralBloodFlow,CerebralMetabolicRatefor
OxygenandOxygenExtractionFractioninCriticallyIllBrainInjuredPatients
1:36–1:48pm
FawazAlͲMufti
UltraEarlyVasospasminAneurysmalSAHAssociatedwithIncreasedMortality
1:48–2:00pm
AvaPuccio
BrainTissueOxygenationand3and6ͲmonthNeurologicalOutcomeafterSevereTraumaticBrain
Injury
ORALABSTRACTSESSIONIII
Saturday,September 13භ1:00pm–2:00pm
Grand3
1:00–1:30pm
JoseJavierProvencio: Best Abstract Award
TheTimeͲWindowforNeutrophilDepletionafterSAHtoPreventDelayedDeterioration
1:12–1:30pm
SuhasBajgur
BriefNeurocognitiveScreeningisFeasibleinAssessingCognitiveDeficitsinSubarachnoid
HemorrhagePatients
Neurocrit Care
CLINICAL UTILITY AND COST OF BLOOD CULTURES IN INTENSIVE CARE UNIT PATIENTS WITH
SPONTANEOUS INTRACEREBRAL HEMORRHAGE
David P Yamane1,2, Sukhjit Takhar1, Peter C. Hou1, Susan R. Wilcox2, Hanna Schreiber1, Ikenna Okechukwu2,
Ednan Bajwa2, Dean R. Hess2, Carlos A. Camargo1, Steven M. Greenberg1, Jonathan Rosand1,2, Daniel J. Pallin1,
Joshua N. Goldstein2, Jonathan Elmer3
1
Brigham and Women's Hospital, Boston, MA, USA, 2Massachusetts's General Hospital, Boston, MA, USA,
3
University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Introduction
Fever is common after spontaneous intracerebral hemorrhage (ICH), and may indicate a sterile systemic
inflammatory response syndrome (SIRS) rather than infection. Blood cultures (BCx) are often obtained when
evaluating intensive care unit (ICU) patients for possible infection, but have limited utility in populations where
bacteremia is rare. We hypothesized BCx would be commonly obtained in the first 48 hours after ICH but have low
diagnostic yield.
Methods
We performed a secondary analysis of a large, multicenter cohort of adult patients requiring ICU admission after
spontaneous ICH. We excluded patients with hemorrhage from ischemic transformation, structural lesion or
trauma, comfort measures only, brain death or immunodeficiency. We recorded demographic and clinical
characteristics, daily vital signs, laboratory and BCx results (obtained at the discretion of the treating clinician). We
defined fever as temperature >38.3C. A board-certified infectious disease physician reviewed all BCx results, and
considered all fungi and bacteria, pathogens if they were non skin flora or contaminate species. We estimated a
cost of US$50 per BCx and US$50 for speciation and sensitivities.
Results
Of 697 included patients, 259 patients (37%) had 434 BCx obtained in the first 48h. Fever developed in 25% of
patients and was associated with a significant increase in the odds of BCx (OR 7.05, 95%CI 5.24-9.49). Other risk
factors for BCx were leukocytosis (OR 1.60, 95%CI 1.21-2.12) and >2 SIRS criteria (OR 2.42, 95%CI 1.63-3.60).
There were 13 positive BCx of which 12 were false positives with 1 true positive (92% false positive). This patient
grew Enterococcus faecalis in 1 of 4 bottles and afebrile the day of positive BCx. The total cost of the BCx was
US$22,350.
Conclusions
Although BCx are frequently obtained after spontaneous ICH, their clinical utility is limited.
Financial Support: None
ORAL ABSTRACTS
Oral Abstract Presentations
Thursday, September 11, 2014
___________________________________________________________________________________
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ORAL ABSTRACTS
Oral Abstract Presentations
Thursday, September 11, 2014
___________________________________________________________________________________
ANALYSIS OF FACTORS THAT PHYSICIANS AND NURSES INCORPORATE INTO SUBJECTIVE
PREDICTION OF INTRACEREBRAL HEMORRHAGE OUTCOME
David Y. Hwang1, Cameron A. Dell2, Mary J. Sparks2, Tiffany D. Watson2, Carl D. Langefeld3, Mary E. Comeau3,
Jonathan Rosand4, Thomas W.K. Battey4, Sebastian Koch5, Mario L. Perez5, Michael L. James6, Jessica M.
McFarlin6, Jennifer L. Osborne7, Daniel Woo7, Steven J. Kittner2, Kevin N. Sheth1
1
Yale School of Medicine, New Haven, CT, USA, 2University of Maryland School of Medicine, Baltimore, MD, USA,
Wake Forest School of Medicine, Winston-Salem, NC, USA, 4Massachusetts General Hospital, Boston, MA, USA,
5
University of Miami Miller School of Medicine, Miami, FL, USA, 6Duke University Medical Center, Durham, NC,
USA, 7University of Cincinnati College of Medicine, Cincinnati, OH, USA
3
Introduction
Clinical scales for intracerebral hemorrhage (ICH), such as the ICH and FUNC Scores, utilize a number of clinical
and radiographic components for outcome prediction. The factors that physicians and nurses incorporate into
subjective predictions of ICH outcome and how those factors relate with ICH and FUNC Score components are
unknown.
Methods
For each consecutive adult patient admitted with primary ICH at 5 centers, one physician and one nurse on the
treatment team were asked for a prediction of modified Rankin Scale at 3 months. All predictions were
prospectively collected within 24 hours of admission. Providers were also asked to indicate up to 10 factors
influencing their prediction, as well as whether they would recommend comfort measures. Percentages of
responses were calculated.
Results
We collected 100 physician and 100 nurse predictions for 100 ICH patients. With regards to ICH or FUNC Score
components, 84.5% of all respondents listed the Glasgow Coma Scale (GCS) or a component of the GCS as a
factor in outcome prediction. Only 41.0% listed age, 44.5% listed ICH volume, and 24.0% listed ICH location. Of all
the factors listed on surveys, 36.4% were not ICH or FUNC Score components. With regards to clinical factors that
are not ICH or FUNC Score components, 66.0% listed pre-existing co-morbidities, with 10.0% specifically
mentioning prior functional disability. The most common non-clinical factors were family support (8.5%) and the
patient's baseline personality and compliance with clinical treatment (6.0%). Only 3.5% of providers listed a
surrogate request for comfort measures as a factor for outcome prediction.
Conclusions
Physicians and nurses rely heavily on GCS Score in comparison to age, volume, and location when
prognosticating ICH outcome. Consideration of patient co-morbidities, prior functional disability, family support, and
treatment compliance may account for any difference between providers and clinical scales for predicting ICH
outcome.
Financial Support: Funding for this project: American Heart Association Clinical Research Training Award
11CRP5480009, Kevin N. Sheth, MD. NINDS U-01-NS069763, Daniel Woo, MD. Relevant financial disclosures:
International Stroke Conference award and travel stipend, David Y. Hwang, MD.
Neurocrit Care
7
VOLUMETRIC INTEGRAL PHASE-SHIFT SPECTROSCOPY (VIPS), IN DETECTING EARLY CEREBRAL
EDEMA: HEMODIALYSIS AS A PROOF OF PRINCIPLE MODEL.
Rahul Damani, Chethan P Venkatasubba Rao, Nelson Maldonado, Eric Bershad, Eusebia Calvillo, Stelios
Smirnakis, Alexandros Georgiadis, Christos Lazaridis, Jose I Suarez
Baylor College of Medicine, Houston, TX, USA
Introduction
Cerebral edema has been conventionally measured indirectly either through invasive monitors or through imaging
studies. We used Volumetric Integral phase shift spectroscopy (VIPS), a non -invasive device that detects phase
shifts in the radiofrequency waves transmitted through the brain. End Stage Renal Disease (ESRD) patients
undergoing hemodialysis who did not have baseline acute brain injury were chosen because they experience a
drop in serum osmolarity as a result of removal of uremic metabolites during dialysis. Consecutive readings from
the same patient were obtained on two successive dialysis days for internal control.
Methods
The protocol was approved by the institutional review board of Baylor college of Medicine. Patients without a prior
history of stroke or other intracranial serious illnesses were enrolled. VIPS monitoring was performed pre, intra and
post dialysis. Measured and calculated serum osmolarity was obtained and mini mental state examination was
performed before and after dialysis. Of the total 20 patients with 40 readings planned for enrolment we report initial
data from the first 9 readings.
Results
Twelve patients (7 males) were enrolled. Mean age of our cohort was 47.8 years. As of now, eleven patients
underwent the VIPS monitoring before, during and after dialysis. One patient withdrew from the study and two
patients had too many artifacts. OF the remaining 8, the average osmolar difference pre and post dialysis was 8.3
mOsm. There was a mean increase in the intracranial fluid compartment of 7.44% from baseline as measured by
VIPS.
Conclusions
VIPS provides real time non-invasive monitoring of intracranial fluid shifts. Patients with ESRD develop serum
osmolar reductions during dialysis which can potentially be a model for non-invasive evaluation of early cerebral
edema.
Financial Support: The study was funded by Cerebrotech Medical Systems Inc.
ORAL ABSTRACTS
Oral Abstract Presentations : "Cristanne Wijman Young Investigator Award"
Thursday, September 11, 2014
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ORAL ABSTRACTS
Oral Abstract Presentations
Thursday, September 11, 2014
___________________________________________________________________________________
NEUROLOGIC DECLINE IN THE ED FOLLOWING TRAUMATIC BRAIN INJURY IS NOT INDEPENDENTLY
ASSOCIATED WITH 6-MONTH OUTCOME: AN ANALYSIS OF THE MULTICENTER TRACK-TBI STUDY
Jonathan J. Ratcliff1, Opeolu Adeoye1, John K. Yue2, Natalie Kreitzer1, Esther L. Yuh3, Hester F. Lingsma4, Wayne
A. Gordon5, Alex B. Valadka6, David O. Okonkwo7, Andrew I. R. Maas8, Geoffrey T. Manley2
1
University of Cincinnati, Emergency Medicine and Neurocritical Care, Cincinnati, OH, USA, 2University of
California at San Francisco, Neurological Surgery, San Francisco, CA, USA, 3University of California, San
Francisco, Radiology and Biomedical Imaging, San Francisco, CA, USA, 4Erasmus MC, Public Health, Rotterdam,
Netherlands, 5Mount Sinai School of Medicine, Rehabilitation Medicine, New York, NY, USA, 6Seton Brain and
Spine Institute, Austin, TX, USA, 7University of Pittsburgh, Neurological Surgery, Pittsburgh, PA, USA, 8University
Hospital Antwerp, Neurosurgery, Edegem, Belgium
Introduction
Traumatic brain injury (TBI) is a major cause of morbidity and mortality and a common presentation to US
Emergency Departments (ED). Neurologic decline in the ED is a significant event in the course of care of TBI
patients. We sought to elucidate the relationship between acute neurologic decline in the ED and six month
outcomes in a cohort of TBI patients.
Methods
Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) pilot study was a
multicenter, prospective, cohort study of patients with TBI presenting within 24 hours of injury, had a head CT in the
ED, and were English speaking. This analysis was performed across the injury spectrum (GCS 3-15). Neurologic
decline was defined as a drop in GCS by 2 or more points and/or the loss of pupil function during the ED course.
The outcome of interest was Glasgow Outcome Scale-Extended (GOSE) at six months. Ordinal logistic regression
was used to evaluate the relationship between ED neurologic decline and GOSE.
Results
Of 348 included patients, 69% (242/348) were male, average age was 45.2 years (SD = 18.8) and median baseline
GCS was 15 (Range: 3-15). Twenty-one (6%) patients had neurologic decline in the ED. In univariate analysis the
odds ratio (95% CI) for neurologic decline predicting worse GOSE was 4.45 (2.02 - 9.81). In the multivariable
model which contained: neurologic decline, hypoxia, age (years), Marshall Classification, and presenting GCS,
neurologic decline was no longer a significant predictor of 6-month GOSE with an OR= 1.47 (95% CI=0.58 - 3.69).
The remaining variables were all statistically significant predictors of GOSE at 6 months.
Conclusions
There was no independent association between acute neurologic decline in the ED and 6 month outcome. Early
neurologic decline in TBI may be an indicator of underlying disease severity and CT findings.
Financial Support: None
Neurocrit Care
24/7 NEUROCRITICAL CARE NURSE PRACTITIONER COVERAGE DRAMATICALLY REDUCED DOOR-TONEEDLE TIME AND IMPROVED OUTCOME IN STROKE PATIENTS TREATED WITH ALTEPLASE
Jennifer L Moran1, Susan M Asai1, Kazuma Nakagawa1,2, Tina M Robertson1, James A Shirley1, Kristen M Shaw1,
Cherylee WJ Chang1, Matthew A Koenig1,2
1
The Queen's Medical Center, Honolulu, HI, USA, 2The University of Hawaii John A. Burns School of Medicine,
Honolulu, HI, USA
Introduction
The impact of acute care nurse practitioner (ACNP) first responders was studied on alteplase treatment rate, doorto-needle time, and outcome at a Primary Stroke Center that previously lacked 24/7 on-site stroke code coverage.
Methods
Using the Get With the Guidelines-Stroke database from the only Joint Commission-accredited Primary Stroke
Center in Hawaii, we compared consecutive periods of 30 months before and 34 months after addition of
neurocritical care ACNPs as stroke code first responders. During the pre-intervention period, hospital-employed
neurologists were first responders but were not on-site 24/7. Data included patient characteristics, target times,
alteplase utilization, and discharge modified Rankin Scale (mRS).
Results
In the pre-intervention period (July 1, 2009 to June 30, 2011), there were 394 acute stroke codes, of which 151
patients were diagnosed with ischemic stroke. During the post-intervention period (July 1, 2011 to March 31, 2014),
there were 789 acute stroke codes, of which 388 patients were diagnosed with ischemic stroke. The alteplase
treatment rate was 29.1% (44/151) in the pre-intervention period and 31.4% (122/388) in the post-intervention
period (p=0.60). Age, gender distribution, and initial NIH stroke scale were similar in the pre- and post-intervention
periods. The door-to-needle time improved from 68.5±38.9 minutes pre-intervention to 49.5±21.8 minutes (p<
0.001) post-intervention. Onset-to-door, door-to-activation, and door-to-CT times were similar in the pre- and postintervention periods. After adjusting for age and initial NIH stroke scale in a multivariable logistic regression model,
the post-intervention period was independently associated with higher likelihood of achieving a discharge mRS 2
(OR 2.95, 95% CI 1.21-7.19, p=0.02) and a discharge mRS 3 (OR 4.16, 95% CI 1.83-9.46, p=0.001).
Conclusions
Addition of 24/7 on-site neurocritical care ACNP first responder coverage for acute stroke codes reduced the doorto-needle time by nearly 20 minutes and improved functional outcomes among acute stroke patients treated with
alteplase.
Financial Support: None
ORAL ABSTRACTS
Oral Abstract Presentations
Thursday, September 11, 2014
___________________________________________________________________________________
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ORAL ABSTRACTS
Oral Abstract Presentations
Friday, September 12, 2014
___________________________________________________________________________________
SEVERE LEUKOARAIOSIS PORTENDS A POOR OUTCOME AFTER TRAUMATIC BRAIN INJURY.
NILS HENNINGER, MD1, 2, SAEF IZZY, MD1, RAPHAEL CARANDANG, MD1, 3, WILEY HALL, MD1, 3, SUSANNE
MUEHLSCHLEGEL, MD1, 3, 4
1
Departments of Neurology, Worcester, MA, USA, 2Psychiatry, Worcester, MA, USA, 3Surgery, Worcester, MA,
USA, 4Anesthesia/Critical Care, University of Massachusetts Medical School, Worcester, MA, USA
Introduction
It is now well accepted that traumatic white matter injury constitutes a critical determinant of post-traumatic
functional impairment. However, the contribution of preexisting white matter rarefaction on outcome following
traumatic brain injury (TBI) is unknown. Hence, we sought to determine whether the burden of preexisting
leukoaraiosis of presumed ischemic origin is independently associated with outcome after TBI.
Methods
We retrospectively analyzed consecutive, prospectively enrolled patients of 50 years (n = 136) who were admitted
to a single neurological/trauma intensive care unit. Supratentorial white matter hypoattenuation on head CT was
graded on a 5-point scale (range 0-4) reflecting increasing severity of leukoaraiosis. Outcome was ascertained
according to the modified Rankin Scale (mRS) and Glasgow outcome scale (GOS) at 3 and 12 months,
respectively.
Results
After adjustment for other factors, leukoaraiosis severity was significantly associated with a poor outcome at 3 and
12 months defined as mRS 3-6 and GOS 1-3, respectively. The independent association between leukoaraiosis
and poor outcome remained when the analysis was restricted to patients who survived up to 3 months, had
moderate-to-severe TBI [enrollment Glasgow Coma Scale (GCS) 12; p = 0.001], or had mild TBI (GCS 13-15;
p = 0.002), respectively.
Conclusions
We provide first evidence that preexisting cerebral small vessel disease independently predicts a poor functional
outcome after closed head TBI. This association is independent of other established outcome predictors such as
age, comorbid state as well as intensive care unit complications and interventions. This knowledge may help
improve prognostic accuracy, clinical management, and resource utilization.
Financial Support: None
Neurocrit Care
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SUSTAINABILITY OF OUTCOMES OF EARLY MOBILITY FOR PATIENTS WITH NEUROLOGICAL INJURY
Kate E. Klein MS, ACNP-BC, James F. Bena, MS, Nancy M. Albert, PhD, CCN, FC
Cleveland Clinic Foundation, Cleveland, OH, USA
Introduction
A nurse driven early progressive mobility protocol (EPMP) pre- to post-implementation trial increased patient
mobility, some quality metrics, and neurological intensive care unit (NICU) and hospital length of stay (LOS). An
EPMP in an ICU requires nurses and other healthcare providers to plan-act-evaluate and sustain actions that
facilitate mobility activities. This investigation sought to determine sustainability of clinical outcomes of an EPMP in
patients treated in a NICU after formal intervention activation was completed.
Methods
Prospective, longitudinal, pre-post(x2) comparative study. Patients treated in a 22-bed NICU of a quaternary-care
medical center were included. Quality metrics and LOS collected on all patients and psychological profile
(depression, anxiety and hostility) was collected on patients who met inclusion criteria and were willing to
participate. Pre-, immediate post- and 8-months post-intervention data were collected on highest mobility level,
patient demographics, medical history, acuity level, quality metrics, psychological profile and clinical outcomes.
Analyses included comparative statistics and multivariable modeling.
Results
Of 1117 patients enrolled (pre-intervention n=260, post-implementation n=377, and 8-month post-implementation
n=480), there were no differences in patient demographics, acuity or comorbidities; however, use of walking aids
and walking barriers were more frequent at 8-months post implementation and ventilator use was more frequent
pre-intervention (all p< 0.0167). Patient level of mobility increased over time (walking increased from 9.6% to
17.5%, p< 0.001), NICU and hospital LOS decreased, and psychological profile scores were closer to norms in the
8-month cohort compared to pre-EPMP implementation (all p< 0.001). There were no differences in discharge
disposition, mortality or quality metrics between groups.
Conclusions
Implementation of a NICU EPMP led to sustained improvement in patients' level of mobility, reduced NICU and
hospital LOS, and normalization of depression, anxiety and hostility.
Financial Support: None
ORAL ABSTRACTS
Oral Abstract Presentations
Friday, September 12, 2014
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12
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ORAL ABSTRACTS
Oral Abstract Presentations
Friday, September 12, 2014
___________________________________________________________________________________
CONTINUOUS NON-INVASIVE MEASUREMENT OF CEREBRAL BLOOD FLOW, CEREBRAL METABOLIC
RATE FOR OXYGEN AND OXYGEN EXTRACTION FRACTION IN CRITICALLY ILL BRAIN INJURED
PATIENTS
Malavika Chandra1, Ramani Balu2, Arjun Yodh1, Suzanne Frangos3, Soojin Park2,3, William A. Kofke4
1
Department of Physics, University of Pennsylvania, Philadelphia, PA, USA, 2Neurocritical Care Division,
Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA,
3
Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA,
4
Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine,
Philadelphia, PA, USA
Introduction
Prevention of secondary ischemic brain injury by maintaining perfusion and oxygenation is a core principle of
neurocritical care. Identifying episodes of reduced cerebral perfusion in brain-injured patients remains a challenge.
We used DCS, a novel non-invasive optical method that measures light scattering by moving particles in optically
thick tissues, combined with static near infrared spectroscopy (NIRS) to provide real time measurements of relative
changes in cerebral blood flow(rCBF), cerebral metabolic rate for oxygen(rCMRO2), and oxygen extraction
fraction(rOEF) in patients with severe brain injury.
Methods
We recruited 16 patients with acute subarachnoid hemorrhage (SAH), severe traumatic brain injury (TBI) or primary
intracerebral hemorrhage (ICH) from a single NeuroICU. rCBF and tissue oxygen saturation(StO2) in both
hemispheres were measured for ~2 hours daily for up to 7 consecutive days using a custom built, NIRS-DCS
apparatus. For each recording epoch, rOEF was calculated based on StO2 and peripheral arterial O2 saturation,
and time-varying changes in rCMRO2 were calculated by multiplying rOEF by rCBF.
Results
Overall, rCMRO2 was highly correlated with rCBF, suggesting that for the majority of time points changes in rCBF
matched the metabolic demands of brain tissue. However, we identified multiple instances with abrupt decreases in
the correlation between rCMRO2 and rCBF; these instances occurred during abrupt changes in OEF. The strength
of the correlation between rCMRO2 and rCBF varied with initial assumed values for mean total hemoglobin (THB)
and mean tissue oxygenation (StO2). Time points with abrupt increases in rOEF and time matched reductions in
rCMRO2/CBF correlation may correspond to acute ischemic events, even though these events were not always
accompanied by reductions in rCBF.
Conclusions
We demonstrate combined non-invasive real time measurements of rCBF, rOEF and rCMRO2 in brain-injured
patients. Such measurements may be particularly useful in identifying episodes of compromised tissue perfusion or
of dysautoregulation. Supported by NIH: 5R21NS61074-2
Financial Support: None
Neurocrit Care
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ULTRA EARLY VASOSPASM IN ANEURYSMAL SAH ASSOCIATED WITH INCREASED MORTALITY
Fawaz Al-Mufti1, Michael Schmidt1, Shouri Lahiri1, Neha Dangayach1, Kaitlin Reilly1, Emma Meyer1, Sachin
Agarwal1, Stephan Mayer2, Jan Claassen1
1
Columbia University Medical Center, New York, NY, USA, 2Icahn School of Medicine at Mount Sinai, New York,
NY, USA
Introduction
Ultra early vasospasm (UEV), defined as arterial narrowing seen on diagnostic angiography within the first 48
hours of aneurysmal rupture, is a rare and poorly characterized phenomenon in patients with subarachnoid
hemorrhage (SAH). The purpose of this study was to understand the clinical and prognostic implications of this
finding.
Methods
We analyzed data from a single center, prospective, observational cohort database. Patient inclusion criteria were
age 18 years and the presence of aneurysmal SAH. Admission and follow up computerized tomographic
angiographic scans or digital subtraction angiography were assessed for the presence of radiographic vasospasm.
Univariate and multivariate logistic regression analysis were performed to identify independent associations.
Results
Over the period of 11 years, between April 2003 and Feb 2014, 922 patients were admitted to our neurological
intensive care unit with subarachnoid hemorrhage and prospectively enrolled in our subarachnoid hemorrhage
outcomes project (SHOP) database. 634 patients (68.7%) developed radiographic vasospasm during their
hospitalization. 66 patients (10.4%) were found to have UEVS and 568 patients (89.5%) developed radiographic
vasospasm on day 3 and beyond. Amongst admission clinical and radiographic variables only poor clinical grade
(Hunt & Hess Score >= 4) was associated with developing UEV (OR: 7, 95% CI: 2 to 22.5). Additionally patients
with UEV were almost 4 times more likely to develop infarctions from vasospasm (OR: 3.781, 95% CI: 1.45 to
9.89). After controlling for admission clinical grade, age, and infarction from vasospasm, UEV was independently
associated with a 30 times higher risk of death (OR: 29.5, 95% CI: 11 to 78) within the first 14 days of SAH than
patients having vasospasm later in their ICU course.
Conclusions
Ultra early vasospasm is strongly associated with increased risk of delayed infarction and death in the first 14 days.
Further study is needed to determine whether this finding represents a modifiable factor that can be treated or can
help treatment planning.
Financial Support: None
ORAL ABSTRACTS
Oral Abstract Presentations
Friday, September 12, 2014
___________________________________________________________________________________
14
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ORAL ABSTRACTS
Oral Abstract Presentations
Friday, September 12, 2014
___________________________________________________________________________________
BRAIN TISSUE OXYGENATION AND 3 AND 6-MONTH NEUROLOGICAL OUTCOME AFTER SEVERE
TRAUMATIC BRAIN INJURY
Ava M. Puccio1, Yue-Fang Chang1, Lori A. Shutter2, David O. Okonkwo1
1
Neurological Surgery, Pittsburgh, PA, USA, 2Critical Care Medicine, Pittsburgh, PA, USA
Introduction
Brain tissue oxygenation (PbtO2) monitoring has been utilized in the severe traumatic brain injury (sTBI) population
as an in vivo tool to detect oxygenation changes. It has been previously reported that the longer the time a patient
experiences a PbtO2 of 15 torr, the greater the mortality. The purpose of this study is to assess PbtO2 values and
its relationship to 3 and 6-month outcome in adult sTBI.
Methods
PbtO2 data were prospectively collected on sTBI patients (Glasgow Coma Scale (GCS) score < 9) during the acute
5 days following injury. Glasgow Outcome Scale (GOS) score was assessed at 3 and 6-months from injury and
dicotomized into poor (GOS 1-3) and favorable outcome (GOS 4-5). Statistical analyses were performed using a
logistic regression model controlling for age and initial severity of injury.
Results
258 adult, sTBI patients with 3 and 6-month outcome were included. The mean age (± SD) was 38 (± 17) years,
with 69% male and a median GCS of 6. ICU management included ICP management per Guidelines of sTBI
Management; however, PbtO2 was not treated, just monitored. Post-trauma day (PTD) 2 PbtO2 data was chosen
for analysis to avoid insertional microtrauma. Logistic regression resulted in cut-off values of minimum PbtO2 <
16.03 and maximum PbtO2 < 37.15 being significant for poor 3-month neurological outcome [OR 2.46 (1.29, 4.68),
p=.004, OR 2.71 (1.37, 5.33), p=.006 respectively). There was no residual significance for 6-month neurological
outcome at these same cutoffs; however, PTD2 PbtO2 values in combination for minimum < 18.3, maximum < 37.2
and average < 24.3 had a OR 2.02 (1.11, 3.67), p=.021.
Conclusions
Monitoring of PbtO2 in the adult sTBI population may be predictive of 3 month neurological outcome and providing
a target cohort for early rehabilitation efforts. Additional studies are needed to assess the effectiveness of treating
PbtO2 values.
Financial Support: None
Neurocrit Care
15
THE TIME-WINDOW FOR NEUTROPHIL DEPLETION AFTER SAH TO PREVENT DELAYED
DETERIORATION.
Jose Javier Provencio1,2, Valerie Swank1, Himabindu Seerapu1
1
Cleveland Clinic Lerner Research Institute Neuroinflammation Research Center, Cleveland Clinic, OH, USA,
2
Cleveland Clinic Cerebrovascular Center, Cleveland Clinic, OH, USA
Introduction
Delayed deterioration after subarachnoid hemorrhage (SAH) is an important untreatable complication in the
management of cerebral aneurysm ruptures. Until recently, research focus has been on the vasculopathy
(vasospasm) that is associated with the deterioration. Our lab has shown that selective depletion of Ly6G/C+ cells
(dLy6G/C) PRIOR TO SAH ameliorates both vasospasm and behavioral deficits seen in delayed deterioration. In
this study we test the hypothesis that depletion of Ly6G/C and Ly6G+ cells (dLy6G) AFTER SAH have similar
effects.
Methods
In our murine model of mild SAH, we subjected animals to sham surgery, experimental SAH, or SAH followed by
depletion of Ly6G+ cells and Ly6G/C+ cells after SAH. We evaluated the development of vasospasm by India ink
angiography, short-term behavioral deficits with the Barnes Maze test, and longer-term behavioral deficits with the
Morris Water Maze test.
Results
dLy6G 0.5 and 1 days after SAH did not significantly improve vasospasm (remained significantly different from
Sham) on India ink at 6 days (p=0.0006 and p=0.0003, respectively). Three days after SAH, both dLy6G and
dLy6G/C ameliorated vasospasm at day 6 (p=NS for both). Likewise, dLy6G 0.5 and 1 days after SAH did not
improve performance on Barnes Maze (ANOVA, p=0.3771). Alternatively, dLy6G and dLy6G/C 3 days after SAH
improved performance on Barnes Maze (ANOVA, p=0.0002 and p=0.0003 respectively). dLy6G 0.5 and 3 days
after SAH showed rescue from cognitive deficits in Morris water maze trials (ANOVA, p=0.0068 and p=0.0464,
respectively).
Conclusions
dLy6G/C and dLy6G 3 days after SAH prevents the development of vasospasm and the development of behavioral
deficits up to 11 days after SAH. This suggests that myeloid cell physiology around day 3 is critical for the
development of the delayed deterioration syndrome. This opens the door for a potential treatment of this syndrome
by targeting innate immune cells at the proper time.
Financial Support: None
ORAL ABSTRACTS
Oral Abstract Presentations : "Best Abstract Award"
Saturday, September 13, 2014
___________________________________________________________________________________
16
Neurocrit Care
ORAL ABSTRACTS
Oral Abstract Presentations
Saturday, September 13, 2014
___________________________________________________________________________________
BRIEF NEUROCOGNITIVE SCREENING IS FEASIBLE IN ASSESSING COGNITIVE DEFICITS IN
SUBARACHNOID HEMORRHAGE PATIENTS
Suhas S Bajgur1,2, Kim Yen Thi Vu3, Nasim Rezanejad1, Ranier G Reyes1, Rahul R Karamchandani2, Janete
Sheiner3, Christine Glendening3, Nancy J Edwards1,2, Tiffany R Chang1,2, Kiwon Lee1,2, Nicole Harrison3, Sean I
Savitz2, H. Alex Choi1,2
1
University of Texas Health Science Center at Houston/Department of Neurosurgery, Houston, TX, USA,
University of Texas Health Science Center at Houston/Department of Neurology, Houston, TX, USA, 3Mischer
Neuroscience Institute, Houston, TX, USA
2
Introduction
Cognitive dysfunction (CD) is a significant cause of disability after subarachnoid hemorrhage (SAH). New
mandates from the joint commission have emphasized the importance of measuring early CD after SAH. In this
study, we sought to assess the feasibility of using mini-Montreal Cognitive Assessment (mini-MoCA) to measure
CD after SAH in the acute setting.
Methods
This is a retrospective study of patients admitted with SAH between February 2013 and December 2013 at a
tertiary academic institution. Patients were assessed by a speech pathologist for presence of cognitive dysfunction
using the mini-MoCA. Attempts were made to perform the mini-MoCA 1-2 days before discharge. A cut-off of less
than 9 was used as a positive screening for CD.
Results
134 patients were admitted with SAH: mean age 55 years (±13), 62% woman, median Hunt-Hess score 3. 85%
(105/124) of all eligible patients were screened for CD, the median (IQR) MoCA score was 8 (4-9). 59% (62/105) of
patients screened positive for CD (score< 9). Screening positive for CD was associated with female sex (OR 2.6,
p< 0.05), poor grade HH (3-5) (OR 3.8,p< 0.01) and delayed cerebral ischemia (OR 3.5, p< 0.05). Lower MiniMoCA scores were associated with outcome at discharge (mRS) independent of age, sex and initial HH score
(p=0.03). Mini-MoCA scores have a strong negative correlation with hospital length of stay and ICU length of stay
(r=-0.536, p< 0.01; r=-0.471, p< 0.01).
Conclusions
In-hospital systematic screening and early identification of CD is feasible. CD in the acute setting after SAH is very
common. Patients with poor HH grade and those who develop delayed cerebral ischemia are more likely to
develop CD. Further studies are needed to elucidate the relationship between early CD and long term clinical
outcomes.
Financial Support: None
The Westin Seattle
1900 5th Avenue Seattle, Washington 98101 United States
Q
Q
Phone (206) 728-1000
Q
Fax (206) 728-2259
Symposium
Exhibits
GRAND BALLROOM
GRAND I
GRAND II
GRAND III
GRAND FOYER
FIFTH AVENUE ROOM
GRAND CRESCENT
Eposter kiosks 6-7
and Late Breaking
GRAND LEVEL
Eposter kiosks 1 - 5
3
18
Neurocrit Care
SCHEDULE
ePoster Presentation Schedule
Kiosk
Thursday, Sept. 11
(5:15 – 6:45 PM)
Subarachnoid hemorrhage
Medical Issues in the Neuro
ICU
Friday, Sept. 12
(5:15 – 6:45 PM)
Subarachnoid hemorrhage
Medical Issues in the Neuro ICU
3
4
Head and Spine Trauma
ICU Organization and
Technology
5
Temperature Management
Head and Spine Trauma
Head and Spine Trauma/ Ischemic
Stroke/ ICU Organization and
Technology
Ischemic Stroke
6
7
Ischemic Stroke
Seizures/ Temperature
Management
N/A
1
2
8
Saturday, Sept. 13
(5:15 – 6:45 PM)
Subarachnoid hemorrhage
Subarachnoid
hemorrhage/Medical Issues in the
Neuro ICU/ Intracerebral
hemorrhage
Medical Issues in the Neuro ICU
Intracerebral hemorrhage
ICU Organization and Technology
Intracerebral hemorrhage
Disorders of Consciousness/ PeriOperative Management/ Pediatric
NeuroICU/ Muscle and Nerve
Disorders
Disorders of Consciousness
Seizures
N/A
Late-breaking
Neurocrit Care
19
Thursday, September 11
Session I
5:15 – 6:45 pm
Kiosks 1 - 5 located in 5th Ave
Kiosks 6 - 7 located in Grand Crescent
Subarachnoid hemorrhage – Kiosk 1
#
Time
Title
13
5:15
14
15
5:23
5:31
16
5:39
17
5:47
18
19
5:55
6:03
20
21
6:11
6:19
22
6:27
23
6:35
24
6:43
CocaineUseisanIndependentPredictorofSeizuresfollowingAneurysmal
SubarachnoidHemorrhage
EarlyNeuronalInjuryinPatientsWithGoodGradeSubarachnoidHemorrhage
CSFMicroRNAͲ181bisAssociatedwithPoor6ͲmonthOutcomeFollowing
SubarachnoidHemorrhage
Domarkersofpremorbidnutritionalstatuspredictcognitiveoutcomesin
aneurysmalsubarachnoidhemorrhage?
EarlyandprolongedhypothermiainpoorͲgradeͲSAHreducesdegreeof
vasospasmandrateofdelayedcerebralinfarctions
A23Ͳyearoldwomanwithvariantneurogenicstunnedmyocardium
EffectofDexmedetomidineonCerebralAutoregulationinPatientswith
AneurysmalSubarachnoidHemorrhage
AccuracyofNimodipineCapsuleGelExtraction
Accuracyofscreeninglungultrasoundforthedetectionofpulmonaryedema
followingsubarachnoidhemorrhage
EarlyCardiacUncouplingAssociatedwithThreeͲMonthMorbidityandMortlity
afterSubarachnoidHemorrhage
EffectofOralNimodipineonCerebralBloodFlowandBrainTissueOxygenation
FollowingSAH
InterͲraterAgreementForDelayedIschemicEventsAfterAneurysmal
SubarachnoidHemorrhage
Presenting
Author
T.Chang
H.Mangat
S.Chou
N.Dangayach
J.Kuramatsu
E.Mahanna
E.Meyers
D.Oyler
V.Rajajee
J.M.Schmidt
H.Tran
S.Zafar
Medical Issues in NeuroICU - Kiosk 2
#
Time
Title
25
5:15
26
5:23
27
5:31
28
5:39
29
5:47
30
5:55
31
6:03
AcuteBloodPressureReductioninStrokePatientswithClevidipineor
Nicardipine
ComparativeEvaluationofLocalCNSAntibioticTherapyWithorWithout
ConcomitantSystemicAntibiotics
CerebralToxemiafromHyperammonemia:AdultͲOnsetDisordersofUreaCycle
Metabolism
ACaseReportOfListeriamonocytogenesAbscessesPresentingAsCortically
PredominantRingEnhancingLesions
CaseReport:TuberculousMeningitisinanElderlyPatientwithInitialConcerns
forMetastaticCerebralDisease
AMultiͲfacetedProgramtoReducetheRatesofCatheterͲAssociatedUrinary
TractInfections
AntiͲNͲmethylͲDͲaspartatereceptorencephalitis(NMDARE)inducedautonomic
instabilitynecessitatingpacemakerplacement:acasestudy
Presenting
Author
T.Allison
K.Bolla
M.Chandra
I.DeJesus
B.Krueger
M.Lusby
S.Mehr
SEPTEMBER 11
ePoster Presentations
20
Neurocrit Care
SEPTEMBER 11
32
6:11
33
6:19
34
6:27
35
36
6:35
6:43
APredictiveModelforAssessmentofPulmonaryEmbolisminNeuroͲIntensive
CareUnitPatients
AComparisonofGCSandAPACHEIIIScoringSystemsinPredictingMortalityof
PatientsintheNeurologicIntensiveCareUnit
AntifactorXaLevelsversusActivatedPartialThrombplastinTimeforMonitoring
UnfractionatedHeparin.WhichOnetoBelieve?APilotStudy
AnunusualcaseofshockinapatientwithaneurysmalSAH
CharacteristicsOfTerminalExtubationInTheNeurointensiveCareUnit
D.Roberts
F.Sadaka
S.Samuel
I.Sankara
L.Wendell
Head and Spine Trauma – Kiosk 3
#
Time
Title
37
5:15
38
5:23
39
5:31
40
5:39
41
5:47
42
5:55
43
6:03
44
45
6:11
6:19
46
6:27
47
6:35
48
6:43
AbilitytoPreventKchannelMediatedVasodilatorImpairmentAsaDeterminant
inSexDependentPressorChoiceToProtectCerebralAutoregulationAfter
PediatricTBI.
ActivatedPartialThromboplastinTime(aPTT),notProthrombinTime(PT),is
morecloselycorrelatedwithmortalityaftersevereTraumaticBrainInjury(TBI)
AntiplateletAgentUseIsAssociatedWithIncreasedIntracranialHemorrhage
Volumes,ButNotProgressiveHemorrhagicInjury,AfterTramaticBrainInjury
AdherencetoGuidelinesforManagementofCerebralPerfusionPressureand
OutcomeinPatientswhohaveSevereTraumaticBrainInjury
Hemoglobintimeindexabove90g/Lisassociatedwithimproved6month
functionaloutcomesinpatientswithseveretraumaticbraininjury
AcuteMicroglialActivationinTraumaticBrainInjury:a[11C](R)PK11195Positron
EmissionTomographyStudy
AcuteTimeͲcourseofUbiquitinCͲterminalHydrolaseͲL1and145kDaSpectrin
BreakdownProductinSerumafterSevereTraumaticBrainInjuryinChildren
Acuteadrenalinsufficiencyincervicalspinalcordinjury
EffectofTransfusionThresholdonEarlyCerebralHemodynamicsAfterSevere
TraumaticBrainInjury
EvaluationofanovelcerebralbioͲimpedancemonitortononͲinvasivelymeasure
intracranialpressureinsevereTBIpatients
EffectsofDocosahexaenoicAcidonMicroglialandMacrophageM1/M2Marker
ExpressioninRatPupBrainafterTraumaticBrainInjury
Associationbetweenopticnervesheathdiameterandmortalityinpatients
withseveretraumaticbraininjury
Presenting
Author
W.
Armstead
R.Choi
R.Choi
D.Griesdale
D.Griesdale
A.Lombardo
R.Metzger
J.Pellot
C.Robertson
G.Rosenthal
M.Schober
M.Sekhon
ICU Organization and Technology – Kiosk 4
#
Time
Title
Presenting
Author
49
50
5:15
5:23
AdvancedPracticeProvidersinNeurocriticalCare:AnEvidencedͲBasedReview
BrainsonBeethoven,AFeasibilityStudyofMusicTherapyintheNeuroICU
J.Aparicio
A.Aysenne
52
5:39
D.Jaskulski
53
5:47
AnInterdisciplinaryCollaborativeApproachtoImplementingCRRTin
NeurocriticalCare
EstimatedRadiationExposureintheNeuroICU:aretrospectivesnapshotof
patternsofexposureinalargeacademicmedicalcenter.
A.Kumar
Neurocrit Care
5:55
55
6:03
56
57
6:11
6:19
58
6:27
59
60
6:35
6:43
ChallengesintheTreatmentofAcuteNeurologicalIllnessesinaTeaching
HospitalinTanzania
DecliningPostͲCardiacArrestMortality:WheredoPatientsDieandWheredo
theySurvive?
CerebralCriticalClosingPressure:CanWeOvercomeNonPhysiologicalResults?
BrainTissueOxygenMonitoring:EvaluationofaNovelMultiparametricBrain
TissueProbeApplyingNearInfraredSpectroscopyandIndocyanineGreenDye
Dilution
CerebralhypoxemiadetectionusingnearinfraͲredspectroscopyandoutcomein
patientswithacuteneurologicalinjury
DevelopmentoftheNeurocriticalCareNursePractitioner
EnhancingStrokeTeamCareandCommunicationthrough
Automation:ImplementationofaMultidisciplinary"StrokeDocFlowsheet"
H.Mangat
Y.Moradiya
C.Puppo
M.Seule
S.Sharma
G.Silva
J.Thomas
Temperature Modulation – Kiosk 5
#
Time
Title
61
5:15
62
63
5:23
5:31
64
5:39
65
5:47
66
5:55
67
68
6:03
6:11
69
70
6:19
6:27
71
6:35
72
6:43
InterleukinsExpressioninaModelofIsolatedControlledHypothermiaFollowed
byRewarmingtoNormothermia
GlycemicControlinControlledNormothermiaforAcuteBrainInjury
DiffusionͲweightedImagingImprovePrognosticationPowerinPatientswith
TherapeuticHypothermiaafterCardiacArrest
EarlyAbsentPupillaryReflexesafterCardiacArrestTreatedwithTherapeutic
Hypothermia.
EffectofAntibioticProphylaxisonPneumoniainCardiacArrestSurvivorsTreated
withTargetedTemperatureManagement
StatusEpilepticusdoesnotAlwaysIndicatePoorOutcomeinTherapeutic
HypothermiaafterCardiacArrest
SystematicQualityAssessmentofPublishedAntishiveringProtocols
RetrospectiveComparisonofIVversusEnteralIbuprofenforFeverControlin
NeurocriticallyillPatients
ImpactofBodyTemperatureonOutcomeafterTBI
SocioͲeconomicDisparitiesandTrendsinTherapeuticHypothermiaUtilization
afterCardiacArrestintheUnitedStates,2006Ͳ2011
EfficacyofNonͲPharmacologicalAntishiveringInterventions:ASystematic
Assessment/Analysis
GlycemicControlinProlongedTherapeuticHypothermiaforAcuteBrainInjury
Presenting
Author
V.Burgos
K.Morbitzer
YͲJCho
L.Dhakal
D.Gagnon
K.M.Kim
J.Lee
C.Lesch
L.Madden
Y.Moradiya
B.Park
C.Witenko
Temperature Modulation (overflow) – Kiosk 7
#
Time
Title
96
6:43
97
6:51
VancomycinPharmacokineticParametersinPatientswithAcuteBrainInjury
UndergoingControlledNormothermia
VancomycinPharmacokineticParametersinPatientswithAcuteBrainInjury
UndergoingPentobarbitalInfusionorTherapeuticHypothermia
Presenting
Author
K.Morbitzer
K.Morbitzer
SEPTEMBER 11
54
21
22
Neurocrit Care
SEPTEMBER 11
Ischemic Stroke – Kiosk 6
#
Time
Title
73
5:15
74
5:23
75
5:31
76
5:39
77
5:47
78
5:55
79
6:03
80
6:11
81
6:19
82
6:27
83
6:35
84
6:43
TheHeartͲBrainconnection.Suddenunexpectedcardiacdeathinlateral
medullarysyndrome:Amissinglink?
PredictorsofhemorrhagictransformationinpatientstreatedwithintraͲarterial
thrombolysisandmechanicalthrombectomy:arealworldexperience
RecurrentischemicstrokeasafirstmanifestationofPoorlyDifferentiated
Carcinoma(PDC)ofunknownetiology.
MortalityandLocationofLongͲTermCareAmongOlderIschemicStrokePatients
UndergoingDecompressiveHemicraniectomyintheUnitedStates.
PrognosticMeaningofLeftVentricularDiastolicDysfunctionInPatientsWith
AcuteIschemicStroke
TwoReportsofSuccessfulEndovascularTreatmentofCarotidDissectionwith
FlowLimitation
Recanalizationandclinicaloutcomeofacuteischemicstrokepatientswithmiddle
cerebralarteryocclusionwhounderwentnewgenerationthrombectomyͲasingle
centerexperience
ModificationofPostStrokeCentralNervousSystemExtracellularMatrixwith
PolylysinePromotesNeuriteFormationandIncreasedNeuriteLength.
SafetyofAcuteReperfusionTherapyinAcuteIschemicStrokePatientsWho
HarborMultipleUnrupturedIntracranialAneurysm;ACaseSeries.
VolumetricThresholdforMedicalInterventionorSurgicalDecompressionafter
CerebellarIschemicStroke
TheRoadtoRehabinAcuteStroke:UsingEarlyNeurostimulantstoHelpPavethe
Way
SafetyofIntravenousThrombolysisforAcuteIschemicStrokeinPatientswith
PreͲexistingIntracranialNeoplasms
Presenting
Author
M.A.Babi
E.Silva
D.Choufani
C.Fehnel
SͲBKo
L.Koffman
Y.Lodi
E.Marrotte
A.Mowla
A.Raya
M.Reznik
K.Singh
Seizures – Kiosk 7
#
Time
Title
85
5:15
86
5:23
ImpactofIctalandEpileptiformEEGActivityonOutcomeinCardiacArrest
PatientsTreatedwithTherapeuticHypothermia
ContinuousEEGartifactscausedbytwonewcardiacoutputmonitors
87
5:31
88
5:39
89
5:47
90
5:55
91
6:03
92
6:11
93
6:19
IsolatedsuppressionͲburstpatternoncontinuousEEGisnotassociatedwithpoor
neurologicoutcomefollowingresuscitationfromcardiacarrest
AutomaticEvaluationofContinuousEEGforNeuromonitoringofCriticalIll
Patients
ContinuousEEGsignificantlyimpactsmedicalmanagementofpatientsadmitted
toICU:aprospectivestudy
Newonsetrefractorystatusepilepticus(NORSE):Areportofoutcomesinten
consecutivepatients
ARareCauseofAsepticMeningitisandNORSEͲNewOnsetRefractoryStatus
Epilepticus
CardiacElectricalInstabilityAssessedbyTͲWaveAlternansinPatientswithStatus
EpilepticusintheIntensiveCareUnit
FrequencyͲdependentdissociationbetweenbraintissueoxygenationand
cerebralbloodflowofperiodicepileptiformdischarges
Presenting
Author
S.Agarwal
K.
Alsherbini
E.Amorim
F.Fürbass
A.Khawaja
A.Khawaja
S.Peacock
A.Schomer
J.Witsch
Neurocrit Care
6:27
95
6:35
ClinicalSpectrumofMalignantNonͲconvulsiveStatusEpilepticus(mNCSE)in
NeurocriticalCare
MyxedemaComaAssociatedWithNonͲConvulsiveStatusEpilepticus
S.Yang
A.Zidan
SEPTEMBER 11
94
23
SUBARACHNOID HEMMORAGE
24
Neurocrit Care
ePoster 13
___________________________________________________________________________________
COCAINE USE IS AN INDEPENDENT PREDICTOR OF SEIZURES FOLLOWING ANEURYSMAL
SUBARACHNOID HEMORRHAGE
Tiffany R Chang1, Robert G Kowalski2, Juan R Carhuapoma3,4,5, Rafael J Tamargo3,4, Neeraj S Naval3,4,5
1
University of Texas Medical School at Houston Departments of Neurosurgery and Neurology, Houston, TX, USA,
2
Yale School of Medicine Department of Neurology, New Haven, CT, USA, 3Johns Hopkins School of Medicine
Department of Anesthesia and Critical Care Medicine, Baltimore, MD, USA, 4Johns Hopkins School of Medicine
Department of Neurosurgery, Baltimore, MD, USA, 5Johns Hopkins School of Medicine School of Medicine
Department of Neurology, Baltimore, MD, USA
Introduction
The incidence of seizures associated with aneurysmal subarachnoid hemorrhage (aSAH) is unclear and has been
reported to be roughly 6-18%. Seizure prophylaxis is controversial and is often based on risk stratification- MCA
aneurysms, associated intracerebral hematoma (ICH), poor neurological grade, increased clot thickness and
cerebral infarction are considered highest risk for seizures. The impact of recent cocaine use on seizures following
aSAH has not been well studied.
Methods
Prospectively collected data of aSAH patients admitted to 2 institutional NCCUs between 1991-2009 were
reviewed. We analyzed factors that potentially affected the incidence of seizures, including patient demographics,
poor clinical grade (Hunt-Hess 4/5), medical comorbidities, associated ICH, intraventricular hemorrhage (IVH),
hydrocephalus, aneurysm location, surgical clipping and cocaine use. We further studied the impact of each of
these factors on 'early' and 'late' seizures (defined as pre- and post- clipping/coiling respectively).
Results
Of the 1134 aSAH patients studied, 182 (16%) had seizures. 81 patients (7.1%) had early and 127 (11.2%) had
late seizures, with 26 patients having both. Of 142 cocaine users, 37 (26%) had seizures compared to 15.2% noncocaine users (p=0.001). 18 cocaine-positive patients (12.7%) had early seizures compared to 6.6% cocainenegative patients (p=0.003); 27 cocaine users (19%) had late seizures compared to 10.5% non-cocaine users (p
=0.001). Other factors that impacted aSAH seizures included younger age (p=0.009), poor clinical grade (p=0.029),
associated ICH (p=0.007) and MCA aneurysm location (p< 0.001); surgical clipping impacted late seizures
(p=0.004). Following multivariate analysis, age < 40 (OR 2.04, p=0.001), poor clinical grade (OR 1.62, p=0.01), ICH
(OR 1.95, p=0.011), MCA location (OR 3.3, p< 0.001) and cocaine use (OR 2.06, p=0.001) were associated with a
significantly higher incidence of seizures.
Conclusions
Cocaine use is independently associated with a higher incidence of seizures following aSAH and should be
considered during risk stratification for seizure prophylaxis.
Financial Support: None
25
ePoster 14
___________________________________________________________________________________
EARLY NEURONAL INJURY IN PATIENTS WITH GOOD GRADE SUBARACHNOID HEMORRHAGE
Halinder S. Mangat1, Dikoma Shungu2, Xiangling Mao2, Philip E. Stieg3
1
Weill Cornell Medical College / Department of Neurology, New York, NY, USA, 2Weill Cornell Medical College /
Citigroup Biomedical Imaging Center, New York, NY, USA, 3Weill Cornell Medical College / Department of
Neurological Surgery, New York, NY, USA
Introduction
Aneurysmal subarachnoid hemorrhage (SAH) causes high morbidity and mortality. Survivors suffer cognitive
dysfunction, which goes undetected during the acute illness, as neuropsychological testing at this time is
unfeasible. No biomarkers exist to detect early subclinical neurological injury that may be responsible for noninfarct related neurological deficits.
Methods
We performed MRI and spectroscopy (MRS) on SAH patients in the first two weeks. Good clinical grade patients
with no neurological deficit were included. Patients with hydrocephalus requiring ventriculostomy and those with
visible blood products on imaging at 7 days, were excluded to reduce artifacts on MRS. Patients with delayed
cerebral ischemia, perfusion deficits or angiographic spasm were also excluded. Routine MRI was performed with
FLAIR, DWI, ADC and SWI sequences. Multi-slice 1H MRS imaging was performed and raw data was processed
slice-by-slice according to standard fast Fourier transform algorithm. Resulting spectral data was fitted to derive
metabolite peak areas using software developed in-house. Total NAA, NAA/Creatine, Choline/Creatine data were
acquired from multiple voxels in bilateral frontal subcortical white matter.
Results
Ten patients with SAH had MR imaging done for clinical indications. MRI showed no infarcts or FLAIR hyperintensities. MRS from 3 patients had degraded images due to motion artifact while another patient had artifact from
subarachnoid blood. The MRS spectra showed significantly decreased NAA peaks and concentrations in bilateral
frontal lobes in SAH patients. tNAA in SAH patients was 11.11±3.8 vs. 18.82±1.2 in controls (healthy volunteers)
(p=0.01); NAA/Cr was 1.92±0.16 in SAH patients vs. 2.65±0.23 (p=0.001) in controls; Cho/Cr was 1.16±0.19 in
SAH vs. 1.35±0.01 (p=0.12).
Conclusions
This study provides preliminary evidence that tNAA and NAA/Cr are decreased early after good-grade SAH. This
may represent early subclinical neuronal injury. A larger study as well as further neuropsychological examination of
these patients will help determine association with functional deficits.
Financial Support: None
SUBARACHNOID HEMMORAGE
Neurocrit Care
SUBARACHNOID HEMMORAGE
26
Neurocrit Care
ePoster 15
___________________________________________________________________________________
CSF MICRORNA-181B IS ASSOCIATED WITH POOR 6-MONTH OUTCOME FOLLOWING SUBARACHNOID
HEMORRHAGE
Sherry H-Y Chou1, 2, 3, Basak Icli1, 2, Meghan Cahill1, Rose Du1, 2, Galen V Henderson1, 2, Farzaneh A Sorond1, 2,
Philip L De Jager1, 2, 4, Steven K Feske1, 2, Eng H Lo2, 3, MingMing Ning2, 3, Mark Feinberg1, 2
1
Brigham and Women's Hospital, Boston, MA, USA, 2Harvard Medical School, Boston, MA, USA, 3Massachusetts
General Hospital, Boston, MA, USA, 4Broad Institute of MIT and Harvard, Boston, MA, USA
Introduction
Release of pro-inflammatory cytokines such as TNFĮ is associated with vasospasm and brain injury following
subarachnoid hemorrhage (SAH). Emerging data suggest microRNAs (miR) may be candidate biomarkers
because they can regulate inflammation and have good stability in biological fluids. We have previously
demonstrated that elevated blood TNFĮ is associated with poor SAH outcome. Because TNFĮ regulates miR-181b
expression and miR-181b can regulate inflammatory signaling and exacerbate ischemic brain injury, we
hypothesize that miR-181b may be present in SAH CSF and may be associated with SAH outcome.
Methods
We prospectively enrolled consecutive SAH subjects, banked serial CSF samples, and evaluated their outcome
every 3 months using modified Rankin scores (mRS). Poor functional outcome was defined as mRS>2.
Angiographic vasospasm was defined as >50% caliber reduction in any cerebral artery on post-SAH day 7 cerebral
angiogram. In 54 SAH subjects, we compared CSF miR-181b and miR-26a (as control) levels on post-SAH day 3
by vasospasm and by outcome status. Log-transformation was applied to data with skewed distribution.
Associations were measured using Pearson's or Spearman's correlation depending on data distribution.
Results
27/54 subjects (50%) developed vasospasm and 21/54 (39%) had poor 6-month outcome. MiRs-181b and miR-26a
were consistently measurable in SAH CSF. MiR levels were not associated with Hunt and Hess or Fisher grades.
Elevation of CSF miR-181b was associated with poor 6-month outcome in SAH (p=0.04). CSF miR-181b correlated
negatively with blood TNFĮ (r=0.74, p=0.0001). CSF miR-181b was not associated with vasospasm. CSF miR-26a
was not associated with either vasospasm or with SAH outcome.
Conclusions
MiR-181b is consistently detectable in human CSF after SAH and early elevation of CSF miR-181b is associated
with poor 6-month SAH outcome but not with vasospasm. Future studies are necessary to determine the source
and role of miR-181b in CSF and validate it as a biomarker for SAH outcome.
Financial Support: This work is supported by The Harvard Clinical and Translational Science Center, the
American Heart Association (10CRP2610341, Chou) and the National Institute of Health - NINDS (K23NS073806 Chou, R21NS52498 - Ning, R01NS48422 - Ning, R37NS37074 - Lo, P01NS55104 - Lo).
27
ePoster 16
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DO MARKERS OF PREMORBID NUTRITIONAL STATUS PREDICT COGNITIVE OUTCOMES IN
ANEURYSMAL SUBARACHNOID HEMORRHAGE?
Neha S. Dangayach1, Harpreet S. Grewal2, Jens Witsch1, Emma Meyers1, Christina M. Falo1, Michael J. Schmidt1,
Sachin Agarwal1, Sander Connolly1, Stephan Mayer3, Jan Claassen1
1
Columbia University Medical Center/Neurology, New York, NY, USA, 2Metrohealth campus of Case Western
Reserve University/Internal Medicine, Cleveland, OH, USA, 3Columbia University Medical Center/Neurology, New
York, NY, USA, 4Columbia University Medical Center/Neurology, New York, NY, USA, 5Columbia University
Medical Center/Neurology, New York, NY, USA, 6Columbia University Medical Center/Neurology, New York, NY,
USA, 7Columbia University Medical Center/Neurology, New York, NY, USA, 8Columbia University Medical
Center/Neurosurgery, New York, NY, USA, 9Icahn School of Medicine at Mount Sinai/Neurology, New York, NY,
USA, 10Columbia University Medical Center/Neurology, New York, NY, USA
Introduction
The evidence to support the role of nutritional status in the prevention of cognitive decline during normal aging and
in patients with Alzheimer's dementia is increasing and has great implications for the prevention of dementia.
However, the impact of premorbid nutritional status on cognitive outcomes in patients with subarachnoid
hemorrhage is not known.
Methods
Adult patients >=18 with aneurysmal subarachnoid hemorrhage were enrolled in a single center, prospective,
observational cohort database. Clinical, radiographic and outcomes data were collected prospectively. Admission
albumin and BMI were assessed as markers of pre-morbid nutritional status. Univariate and multivariate logistic
regression analysis were performed and controlled for known markers of cognitive outcomes in patients in SAH.
Cognitive outcomes were assessed using the validated Telephone Interview for Cognitive Status (TICS) at 3
months which was dichotomized at 30; < 30 was defined as poor cognitive outcome while >=30 was defined as
good cognitive outcome.
Results
Over a period of 18 years from July 1996 to April 2014, 1617 patients were admitted to our neurological intensive
care unit with subarachnoid hemorrhage and prospectively enrolled in our subarachnoid hemorrhage outcomes
project (SHOP) database. We conducted a binary logistic regression analysis to examine the impacts of surrogate
markers of nutritional status; admission albumin and BMI on cognitive outcomes. Predictors included age, sex,
severity of SAH, presence of vasospasm, hydrocephalus, re-bleed, albumin and BMI. In the multivariate model
after controlling for known predictors of cognitive outcomes in patients with SAH, albumin and BMI were not found
to be significantly associated with cognitive outcomes at 3 months (BMI OR 0.99, 95% CI 0.96-1.035; albumin OR
1.068, 95% CI 0.939-1.214).
Conclusions
Premorbid nutritional status does not influence cognitive outcomes in patients with SAH.
Financial Support: None
SUBARACHNOID HEMMORAGE
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Neurocrit Care
ePoster 17
___________________________________________________________________________________
EARLY AND PROLONGED HYPOTHERMIA IN POOR-GRADE-SAH REDUCES DEGREE OF VASOSPASM
AND RATE OF DELAYED CEREBRAL INFARCTIONS
Joji B. Kuramatsu1, Rainer Kollmar1, Stefan T. Gerner1, Stephan P. Kloska2, Arnd Dörfler2, Ilker Y. Eyüpoglu3,
Stefan Schwab1, Hagen B. Huttner1
1
University of Erlangen/ Dept. of Neurology, Erlangen, Germany, 2University of Erlangen/ Dept. of Neuroradiology,
Erlangen, Germany, 3University of Erlangen/ Dept. of Neurosurgery, Erlangen, Germany
Introduction
Therapeutic hypothermia [TH] is an established neuroprotective strategy after cardiac arrest and growing evidence
supports TH as supportive treatment in stroke. In subarachnoid hemorrhage [SAH] only few data exists comprising
heterogeneous TH-strategies. Therefore, this study evaluates for the first time the influence of early and prolonged
TH on the key complications in poor-grade SAH - vasospasm and delayed cerebral infarction [DCI].
Methods
This observational matched-controlled investigation included n=36 poor-grade SAH-patients (Hunt & HessScale>3, WFNS-Scale>3). Mild TH (35°C) was initiated early (< 48h) in 12 patients for a prolonged period
(7±1days). Twenty-four patients were matched from our prospective SAH-database by neuro-status, imagingscales, and age. Vasospasm was evaluated by serial Doppler-examinations and DCI was defined as new infarction
on follow-up CT. Functional outcome was assessed at 6-months using the modified-Rankin-Scale and categorized
as favorable-(mRS=0-2) versus unfavorable-(mRS=3-6) outcome.
Results
Doppler-based vasospasm were present in 86.1% of patients. TH neither influenced occurrence nor duration of
vasospasm, but its degree was significantly reduced over 5 days, as well were peak-vasospastic velocities
decreased over 7 days (p< 0.05). The frequency of DCI was 87.5% in non-TH versus 50% in TH-treated patients,
translating into a risk reduction of 44% (OR:7.1(CI:1.3-36.7);p=0.022). Favorable functional outcome was observed
in 33.3% of non-TH versus 66.7% in TH-treated patients (p=0.061).
Conclusions
Early and prolonged TH significantly decreased the degree of vasospasm and the occurrence of DCI, possibly
ameliorating functional outcome. TH may represent a promising therapy targeting the relevant pathways involved in
DCI development, notably vasospasm, which strongly warrants further evaluation of its clinical impact.
Financial Support: None
29
ePoster 18
___________________________________________________________________________________
A 23-YEAR-OLD WOMAN WITH VARIANT NEUROGENIC STUNNED MYOCARDIUM
Elizabeth B Mahanna, Azra Bihorac
University of Florida, Gainesville, FL, USA
Introduction
We report a case of a variant basal form of NSM in a patient with an AVM associated aneurysmal SAH.
Methods
The patient is a 23-year-old woman who presented with sudden severe headache, left facial droop and left
extremity weakness. CT showed SAH, right temporoparietal hemorrhage and subfalcine herniation. Angiogram
showed a complex AVM with associated anterior choroidal aneurysm. She underwent onyx embolization. This was
complicated by partial occlusion of right MCA, re-bleeding and eventual decompressive craniotomy for intractable
ICPs. She developed sudden pulmonary edema and shock. ECG showed sinus tachycardia with no ST-T
abnormalities. An echocardiogram revealed LV dysfunction with severe circumferential basal hypokinesis and
hyperkinetic apical segments. The ejection fraction was 25-30%. The patient was diagnosed with variant NSM.
Results
Neurogenic stunned myocardium is an important complication of SAH with wall motion abnormalities associated
with worse outcome. There are 66 cases of SAH-induced NSM reported. Like classical SCM, SAH-induced forms
predominate in women (85%) with a mean age of 57 years. Among these, all but 6 showed changes on ECG and
mildly elevated cardiac biomarkers. Even among the small number of reported cases our patient is an outlier. Her
heart failure occurred after embolization when she developed re-bleeding and elevated ICP. She represents 1 of 4
cases, which exhibited no changes on ECG; her diagnosis was made after developing pulmonary edema. NSM
was unexpected given her young age. Our patient is the only reported case of AVM associated NSM and the only
woman in her 20s where SAH-induced NSM was present.
Conclusions
In conclusion, to aid in better recognition of NSM in the neurosurgical ICU we presented a unique case of a young
woman with variant NSM precipitated by SAH from rupture of a complex AVM and associated aneurysm. Although
rare, this case represents the variability in neurogenic stunned myocardium.
Financial Support: None
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ePoster 19
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EFFECT OF DEXMEDETOMIDINE ON CEREBRAL AUTOREGULATION IN PATIENTS WITH ANEURYSMAL
SUBARACHNOID HEMORRHAGE
Emma E Meyers1, JM Schmidt1, Fawaz Al-Mufti1, Sachin Agarwal1, E. Sander Connolly2, Jan Claassen1
1
Department of Neurology, Columbia University Medical Center, New York, NY, USA, 2Department of
Neurosurgery, Columbia University Medical Center, New York, NY, USA
Introduction
Dexmedetomidine (DEX) may be associated with alpha2B-mediated alteration of vasoreactivity leading to
decreased cerebral blood flow, which could have deleterious consequences acutely brain injured patients. Little is
known about the effects of DEX on brain physiology in acute brain injury. Here we tested whether initiation of DEX
infusion was associated with changes in cerebral pressure reactivity index (PRx), intracranial pressure (ICP), and
partial pressure of oxygen in brain tissue (PbtO2).
Methods
We identified all aneurysmal subarachnoid hemorrhage patients admitted between 2006-2013 that had continuous
PRx, ICP, and PbtO2 data available prior to, during, and following DEX infusion. A generalized estimating equation
(GEE) model was used to determine changes in PRx, ICP, and PbtO2 during the six hours immediately before and
after drug administration and discontinuation.
Results
We identified 18 patients with a total of 77 DEX initiations. All had Hunt and Hess Grade 4 and 5 subarachnoid
hemorrhage. The median age was 46 years (range 31-66IQR 42-54). The average duration of DEX administration
was 36 +/- 49 hours. During DEX administrations patient were also administered propofol(N=17), fentanyl(N=15X),
pentobarbital(N=3), and midazolam(N=2). The average PRx across the entire duration of monitoring was 0.13+/0.4. Dexmedetomidine DEX was associated with a brief increase in average PRx of 0.151(p=0.002) in the initial
two hours at the start of the infusion(p=0.018). TSimilarly, the cessation of DEX infusion is associated with a
transient decrease in average PRx(p< 0.001) of 0.192(p=0.007) for two hours. There was no change in ICP or
PbtO2 with starting (p=0.3, p=0.09, respectively) or stopping (p=0.46, p=0.17) DEX.
Conclusions
In acute brain injury, DEX is associated with a transient disruption in cerebral autoregulation, the opposite effect
can be seen when discontinuing the medication. This effect on autoregulation in brain-injured patients is, however,
only transient and not associated with alterations of brain tissue oxygenation or ICP.
Financial Support: None
31
ePoster 20
___________________________________________________________________________________
ACCURACY OF NIMODIPINE CAPSULE GEL EXTRACTION
Doug R Oyler1, Sarah Stump2, Aaron M Cook1,2
1
University of Kentucky Healthcare, Pharmacy Services, Lexington, KY, USA, 2University of Kentucky College of
Pharmacy, Department of Pharmacy Practice & Science, Lexington, KY, USA
Introduction
Two formulations of nimodipine are currently available in the US: a 30 mg liquid filled capsule (Nimotop®) and a
recently developed oral solution (Nymalize®). Traditionally, the drug has been given to patients who could not
swallow the capsules by extracting the liquid from the capsule with a syringe and needle and administering
enterally. Despite the reports of inadvertent administration linked to this method of extraction and the associated
FDA Black Box warning, many institutions across the country continue to prepare doses at the bedside. The
accuracy of bedside extraction has not been determined, but may yield considerable variability in the dose
administered. The aim of this study is to evaluate accuracy of nurse extraction of nimodipine from intact capsules.
Methods
This study included nurses who commonly work in a neurological critical care ICU. The nurses extracted liquid from
nimodipine 30 mg capsules using a syringe and 16-gauge needle. The mean weight of extracted nimodipine liquid
from each capsule was compared to batch pharmacy prepared syringes and a pre-calculated weight of 30 mg
nimodipine liquid.
Results
Twenty-eight nurses participated in the study. Nurse extraction yielded a mean of 0.91gm/capsule (SD 0.19gm)
nimodipine liquid or the equivalent of 22.61mg (SD 4.6mg) nimodipine. This equates to a total nimodipine dose of
approximately 45mg (or a 24.65% reduction in dose associated with bedside extraction).
Conclusions
Comparison of simulated bedside extraction of nimodipine to controls suggests bedside extraction is a less
accurate method of nimodipine dose preparation which exhibits marked variability. Our data suggests that
approximately 25% of the prescribed dose of nimodipine is unintentionally omitted with nurse extraction. Given the
available data and relevant safety concerns, bedside extraction of nimodipine has no role in clinical practice. Use of
batch pharmacy preparation or the commercially available solution is recommended.
Financial Support: Dr. Cook has received consulting honoraria from Arbor Pharmaceuticals
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ePoster 21
___________________________________________________________________________________
ACCURACY OF SCREENING LUNG ULTRASOUND FOR THE DETECTION OF PULMONARY EDEMA
FOLLOWING SUBARACHNOID HEMORRHAGE
Venkatakrishna Rajajee1,2, Craig A Williamson1,2, Aditya S Pandey1
1
University of Michigan, Department of Neurosurgery, Ann Arbor, MI, USA, 2University of Michigan, Department of
Neurology, Ann Arbor, MI, USA
Introduction
Pulmonary edema occurs in 8-23% of patients following subarachnoid hemorrhage (SAH). Early detection of
pulmonary edema is vital to appropriate fluid management, particularly during the risk period for Delayed Cerebral
Ischemia (DCI). Lung ultrasound (LUS), which is inexpensive and noninvasive, has been shown to rapidly and
accurately differentiate common causes of acute respiratory failure. Our objective was to determine the accuracy of
daily screening LUS for the detection of pulmonary edema following SAH.
Methods
Lung ultrasound is routinely performed in conjunction with daily Transcranial Doppler (TCD) evaluation in our
neuroICU for SAH patients within the DCI risk period. We reviewed records of SAH patients admitted 7/20125/2014 who underwent at least 5 consecutive days of screening with bilateral LUS. Ultrasound videos were
reviewed for the presence of B+lines by an investigator blinded to the final diagnosis. B+lines were defined as >= 3
B-lines in any anterior intercostal space. A second investigator blinded to ultrasound results determined whether
radiographic pulmonary edema (RPE) as well as pulmonary edema with acute respiratory failure (PE-ARF) were
present during the period of evaluation on the basis of chart review and direct examination of radiographic images.
The diagnostic accuracy of B+lines for the detection of PE-ARF and RPE was determined.
Results
Of 54 patients meeting criteria for inclusion in the study, 20(37%) had PE-ARF, 23(43%) had RPE and 18(33%)
had B+lines. The presence of B+lines demonstrated sensitivity 90%(95%CI 68-99%), specificity 79%(62-91%),
positive predictive value (PPV) 72%(51-88%) and negative predictive value (NPV) 93%(77-99%) for PE-ARF and
sensitivity 78%(56-92%), specificity 79%(62-91%), PPV 72%(51-88%) and NPV 84%(67-95%) for RPE. Median
days from B+lines onset to PE-ARF was 1(IQR 0-1).
Conclusions
Screening LUS was a sensitive and moderately specific test for the detection of symptomatic pulmonary edema
following SAH. Screening LUS may be a useful adjunct to daily TCD evaluation.
Financial Support: None
33
ePoster 22
___________________________________________________________________________________
EARLY CARDIAC UNCOUPLING ASSOCIATED WITH THREE-MONTH MORBIDITY AND MORTLITY AFTER
SUBARACHNOID HEMORRHAGE
J. Michael Schmidt1, Konstantin Popugaev1, Daby Sow3, Emma Meyers1, Michael Crimmins1, Sachin Agarwal1, E.
Sander Connolly2, Jan Claassen1,2
1
Columbia University, Department of Neurology, New York, NY, USA, 2Columbia University, Department of
Neurosurgery, New York, NY, USA, 3IBM T.J. Watson Research, Ossining, NY, USA
Introduction
Cardiac uncoupling has been shown to be associated with poor outcome after intracerebral hemorrhage and
traumatic brain injury. We sought to determine the frequency of cardiac uncoupling after subarachnoid hemorrhage
and its relationship to the development of secondary complications and poor outcome.
Methods
Continuous EKGs recorded from 327 of 449 consecutively admitted SAH patients between 2006 and 2011 were
analyzed. Cardiac uncoupling is defined as a five second integer heart rate standard deviation between 0.3 and 0.6
over a five minute period. Patients with any periods of cardiac uncoupling in SAH days 0-3 were labelled at risk.
Logistic regression was used to test the relationship of cardiac uncoupling to secondary complications and threemonth morbidity and mortality (modified Rankin Score >= 4). We performed multiple imputation using Bayesian
methods to account for outcome scores lost to follow-up.
Results
Episodes of cardiac uncoupling (median time of monitoring: 13%, IQR: 2% to 45%) during SAH days 0-3 was
present in 167 (51%) patients. Cardiac uncoupling was associated with myocardial infarction (P=0.01) and
infarction from delayed cerebral ischemia from vasospasm (P=0.01). Patients with cardiac uncoupling during SAH
days 0-3 were at significantly higher risk for poor outcome (OR: 2.7; 95% CI: 1.2 to 3.5) after controlling for age
(OR: 1.06; 95% CI: 1.03 to 1.09), Hunt and Hess grade (OR: 4.0; 95% CI: 4.6 to 41), APACHE-II Physiological
subscore (OR: 1.2; 95% CI: 1.1 to 1.3), aneurysm size greater than 10mm (OR: 6.0; 95% CI: 1.9 to 19), and
infarction secondary to cerebral vasospasm (OR: 5.9; 95% CI: 1.1 to 31).
Conclusions
Cardiac uncoupling may serve as an early injury severity marker to help differentiate patients with similar clinical
grades. Further research is needed to determine its prognostic value whether it may represent a modifiable factor
that can be targeted for treatment.
Financial Support: Support was provided by the Charles A. Dana Foundation and by the National Center for
Advancing Translational Sciences, National Institutes of Health, through Grant Number KL2 TR000081, formerly
the National Center for Research Resources, Grant Number KL2 RR024157. The content is solely the
responsibility of the authors and does not necessarily represent the official views of the NIH.
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ePoster 23
___________________________________________________________________________________
EFFECT OF ORAL NIMODIPINE ON CEREBRAL BLOOD FLOW AND BRAIN TISSUE OXYGENATION
FOLLOWING SAH
Huy Tran, Mark Krasberg, Kim Olin, Howard Yonas
University of New Mexico, Department of Neurosurgery, Albuquerque, NM, USA
Introduction
Nimodipine is the only pharmacologic neuroprotectant that has been shown to improve outcome in SAH patients by
reducing the incidence of delayed cerebral ischemia (DCI). However, Nimodipine is known to cause hypotension,
which in some patients following SAH may potentially have deleterious effects. We seek to study the effects of
Nimodipine by evaluating CBF and brain tissue oxygenation changes that occur after administration.
Methods
We prospectively collect data in SAH patients admitted to our neuroscience critical care unit at a tertiary academic
center from late 2013 to May 2014. High grade SAH patients with GCS < 9 undergo multimodality monitoring as
part of standard practice at our institution. CBF (Hemedex) and brain tissue oxygenation (Licox, Integra)
measurements were obtained from sensors fixed in proximity, inserted through a Hummingbird Duo (Innerspace)
bolt. All data, including intracranial monitoring data as well as basic ICU vital signs are recorded in a digital system
(CNS, Moberg Research) and are time-locked.
Results
We had 6 patients who were receiving Nimodipine for prophylaxis against DCI with a full complement of
multimodality monitoring. This analysis focused on the initial days post SAH prior to any evidence of DCI. Mean
arterial pressure (MAP) dropped in all patients. (Range 3-20 mmHg). There was a concomitant drop in CBF
(range3-20) in 4/5 patients and drop in PbtiO2 (range 0.2-8) in 5/5 patients.
Conclusions
A decrease in CBF in response to a decrease in MAP is consistent with a loss of cerebral autoregulation. The
concomitant decrease in tissue oxygen defines a severe loss of vascular reserve. These results suggest
Nimodipine can cause ischemia in a subset of SAH patients. Further study with a larger patient sample is
warranted.
Financial Support: Last author has a minor stock position with Innerspace
35
ePoster 24
___________________________________________________________________________________
INTER-RATER AGREEMENT FOR DELAYED ISCHEMIC EVENTS AFTER ANEURYSMAL SUBARACHNOID
HEMORRHAGE
Sahar F. Zafar1, Kathryn O'Connor1, Nicolas Gaspard2, M. Brandon Westover1, Eric S. Rosenthal1
1
Massachusetts General Hospital/Department of Neurology, Boston, MA, USA, 2Yale School of
Medicine/Department of Neurology, New Haven, CT, USA
Introduction
Delayed cerebral ischemia (DCI) and delayed ischemic neurologic decline (DIND) are frequent and significant
complications of aneurysmal subarachnoid hemorrhage (SAH). Discrepancies in the definitions of DCI and DIND,
however, make outcome studies problematic. A recent consensus statement advocated standardized definitions for
DCI and DIND events in clinical trials of SAH. We sought to evaluate the inter-rater agreement (IRA) of these
definitions.
Methods
Based on consensus definitions, we assessed for: 1. delayed cerebral ischemia (DCI), defined as radiographic
cerebral infarction; 2. delayed ischemic neurologic decline Type 1 (DIND1), defined as focal neurological decline;
and 3. DIND2, defined as global decline in arousal. Four neurologists retrospectively reviewed detailed electronic
records of 59 SAH patients. Three reviewers had access to and reviewed neuroradiology imaging. IRA was
assessed using Gwet's kappa statistic.
Results
There was almost perfect agreement (k=95.67%) on the overall presence or absence of DCI, DIND1 and DIND2
events. Agreement was "fair" for DIND1 (k=36.86%) events identified by at least one rater, but "substantial" for
DIND2 (69.66%) events. We observed greater agreement for DIND1 events when there was a significant focal
motor decline of at least 1 point in the motor strength exam. There was poor agreement (k=3.12%) on DCI events;
CT imaging was the predominant radiology modality.
Conclusions
Consensus definitions for DCI and DIND after SAH yield good agreement for events involving a global decline in
arousal (DIND2). However, ascertainment of focal DIND events and DCI based on CT is unreliable. In addition to a
strict process of adjudication, both an explicit threshold for determining focal neurologic decline and use of MRI
imaging to discriminate edema from infarction may improve the inter-rater reliability of DIND and DCI
determination. These improvements are critical for success in clinical trials and quality improvement interventions.
Financial Support: This study was supported by the Andrew David Heitman Foundation for Neuroendovascular
Research (PI,Eric Rosenthal, Michael Brandon Westover). Michael Brandon Westover was funded by a grant from
the American Brain Foundation
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MEDICAL ISSUES
ePoster 25
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ACUTE BLOOD PRESSURE REDUCTION IN STROKE PATIENTS WITH CLEVIDIPINE OR NICARDIPINE
Teresa A. Allison1, Stephanie Bowman1, Heather Hartman1, H. Alex Choi2, Sophie Samuel1, Kiwon Lee2
1
Memorial Hermann- Texas Medical Center, Department of Pharmacy, Houston, TX, USA, 2University of Texas
Health Science Center, Departments of Neurosurgery and Neurology, Houston, TX, USA
Introduction
Clevidipine is an alternative to nicardipine for acute blood pressure (BP) reduction in stroke patients secondary to
its rapid onset of action. The purpose of this study was to determine whether the time to systolic blood pressure
(SBP) goal is reduced with the use of clevidipine leading to improved patient outcomes.
Methods
A retrospective analysis was conducted in patients with acute ischemic stroke (AIS) or spontaneous intracranial
hemorrhage (ICH) from 11/2011 to 12/2013 at a tertiary care facility. Blood pressure management was evaluated in
the first 24 hours of patients who initially received either nicardipine (NIC) or clevidipine (CLEV). Secondary
endpoints included percent time below SBP goal, door-to-needle time for alteplase administration, number of
hypotensive episodes, and outcomes.
Results
A total of 210 patients were included; 140 NIC and 70 CLEV patients. Except for diagnosis, baseline demographics
were similar between groups: AIS: 28.6%; NIC vs. 52.9%; CLEV (p=0.001). Admission SBP was NIC; 194 ± 34
mmHg vs. CLEV; 199 ± 30 mmHg (p=NS). Median time to SBP goal of 150 mmHg (ICH) or 180 mmHg (AIS) from
first reported reading > goal was 119 (IQR; 60 - 249) min; NIC vs. 60 (IQR; 38 - 153) min; CLEV. (p = 0.0001). In
AIS, CLEV was able to maintain SBP goal < 180 mmHg 85% of time vs. 78%; NIC (p=0.001). In ICH, CLEV was
able to maintain SBP goal < 150 mmHg 67% of time vs. 64%; NIC (p =0.001). Time to alteplase administration was
NIC; 59.1 ± 24.8 min. vs. CLEV; 56 ± 22.1 min (p=NS). Three patients in each group had significant hypotension.
There was no difference in outcome variables.
Conclusions
Clevidipine appears to reduce time to SBP goals faster. Additionally, it may be able to maintain SBP goal more
often. A prospective analysis is required.
Financial Support: None
Neurocrit Care
37
COMPARATIVE EVALUATION OF LOCAL CNS ANTIBIOTIC THERAPY WITH OR WITHOUT CONCOMITANT
SYSTEMIC ANTIBIOTICS
Krishna C. Bolla1, Karen Berger2, Seami Park1, Angela Loo2, Shwetha Chiluveru1, Jehun Sung1, Koeun Choi1,
Thomas J. Walsh3, Axel Rosengart1
1
Departments of Neurology, Neurosciences and Neurosurgery Weill Cornell Medical College-New York
Presbyterian Hospital, New York, NY, USA, 2Department of Pharmacy New York Presbyterian Hospital, New York,
NY, USA, 3Department of Medicine/Infectious Diseases Weill Cornell Medical College-New York Presbyterian
Hospital, New York, NY, USA
Introduction
High-dose intravenous antibiotics remain the first-line treatment for bacterial CNS infections. However, in patients
with complicated, persistent or recurrent CNS infections, intraventricular or intrathecal (IVT/IT) antibiotics may be
considered due to the poor blood-brain-barrier penetration of antibiotics for deep-seated CNS infections. We
analyzed the English literature to compare outcomes between the use of local (IVT/IT only) or combined systemic
and local antibiotic therapy.
Methods
Publications on IVT/IT antibiotic therapy from 1946-2014 were identified. Data for demographic features, treatment
regimen, and clinical/microbiological outcome were collected. Of 1,166 citations retrieved, 204 studies met
inclusion criteria. Review of all individual patients within each publication resulted in 567 eligible patients. After
excluding uncommon antibiotics used in < 5 patients, 147 studies with 298 patients remained available for analysis.
Stata 12 statistical program was used for chi square and Fisher's exact tests.
Results
In decreasing frequency, the most commonly IVT/IT studied antibiotics included vancomycin (94 patients combined
group; 43 local therapy group), gentamicin (37; 27), amikacin (18; 11), colistin (27; 28) and teicoplanin (7; 6). Most
treatment indications (>80%) were ventriculitis and meningitis. Microbiological clearance and clinical cure for
vancomycin given combined IVT/IT/IV were 55% and 84% respectively, compared to 44% and 75% for IVT/IT
alone. Successful sterilization and clinical cure rates for combined IVT/IT/IV with gentamicin were 84% and 70%
and for IVT/IT 85% and 82%, respectively. Similar microbiological and clinical cure rates among the IV/IVT/IT and
IVT/IT groups were observed in patients treated with amikacin, colistin, and teicoplanin. None of the group
differences were statistically significant.
Conclusions
Microbiological and clinical cure rates in bacterial ventriculitis/meningitis infections were similar between patients
treated with direct local antibiosis (IVT/IT) alone or combined with IV therapy. However, as these results were
obtained from retrospective analyses of published data, only prospective, randomized controlled trials would
provide definite conclusions.
Financial Support: None
MEDICAL ISSUES
ePoster 26
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Neurocrit Care
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ePoster 27
___________________________________________________________________________________
CEREBRAL TOXEMIA FROM HYPERAMMONEMIA: ADULT-ONSET DISORDERS OF UREA CYCLE
METABOLISM
Mekhala Chandra, Alan H. Yee
California Pacific Medical Center, San Francisco, CA, USA
Introduction
Severe hyperammonemia may have catastrophic neurologic consequences. The initial neurologic manifestations
are often non-specific but can range from mild encephalopathy to rapidly progressive coma. Left untreated,
profound elevation in serum ammonia may lead to catastrophic cerebral edema and death. Prompt recognition is
critical regardless of etiology, as early treatment may be lifesaving.
Methods
We report two consecutive cases of severe hyperammonemia from adult onset inborn errors of urea cycle
metabolism and review their clinical course, imaging findings, and available literature.
Results
Two 27-year-old patients, one female, presented with rapidly progressive encephalopathy leading to coma. Initial
cranial imaging was unremarkable; however, subsequent serologic studies demonstrated marked elevation of
ammonia concentration. Progressive hernation syndromes developed and one underwent bifrontal decompressive
craniotomy despite hyperosmolar therapy and emergent hemodialysis for hyperammonemia. Multifocal myoclonus
was common, and one developed refractory status epilepticus. Repeat cranial imaging demonstrated characteristic
severe bihemispheric cortical changes suggestive of ischemia. Urine and serum studies of organic and amino acids
were compatible with adult onset urea cycle defects of metabolism for both. Despite maximum medical and surgical
therapy, one patient progressed to brain death while the other remained in a persistent vegetative condition
Conclusions
Inherited disorders of urea cycle metabolism are rare causes of hyperammonemia in adulthood. Progressive
neurologic decline with the accompanying characteristic neuroimaging changes should prompt appropriate
diagnostic testing, while urgent empiric therapy should be initiated to lower concentrations. Persistently elevated
ammonia may lead to permanent cortical injury, independent of the pathology and rise in intracranial pressure may
ensue. Routine hyperosmolar therapy may be of limited benefit, and early surgical decompression should be
considered.
Financial Support: None
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39
A CASE REPORT OF LISTERIA MONOCYTOGENES ABSCESSES PRESENTING AS CORTICALLY
PREDOMINANT RING ENHANCING LESIONS
Indira De Jesus, Amedeo Merenda
University of Miami/Jackson Memorial Hospital, Miami, FL, USA
Introduction
Listeria monocytogenes, a common cause of community-acquired meningitis, can rarely involve the central
nervous system (CNS) in the form of multiple cerebral ring enhancing lesions.
Methods
An 81-year-old woman presented with a rapidly progressive decline in mental status in the setting of multiple
cortically predominant ring enhancing lesions. A few days earlier, she had developed symptoms of a mild upper
respiratory tract infection, as well as diarrhea. Her past medical history was significant only for type 2 diabetes
mellitus. Prior to her transfer to our unit, she had been empirically treated with Acyclovir and Ciprofloxacin at
another hospital. Brain imaging, CSF studies, brain biopsy and continuous electroencephalogram were obtained at
our institution. In light of the patient's age, presence of hyponatremia and history of diabetes mellitus, empiric
antimicrobial treatment was modified to include Ampicillin, Meropenem, Vancomycin, Voriconazole and
Pyrimethamine/Sulfadiazine, to cover for opportunistic infections. IV dexamethasone was added due to significant
perilesional vasogenic edema.
Results
The patient presented with stupor, but neither fever nor leukocytosis. CSF results were significant only for a mildly
elevated protein level; special studies, stains, and cultures were unremarkable. The report of a repeat brain MRI,
with and without gadolinium, was as follows: "large areas of high flair signal and tubular/lobulated/ring enhacement
in bifrontal regions with a smaller focus in the left anterior midbrain; overall these findings are concerning for
underlying multicentric glioma or multicentric primary CNS lymphoma." Brain biopsy, however, revealed early
abscess formation caused by Listeria monocytogenes infection.
Conclusions
Listeria brain abscesses are rare. High index of suspicion in patients with risk factors for this infection (e.g.
advanced age, diabetes mellitus) is key to ensure timely initiation of appropriate empirical antibiotic therapy in the
setting of cerebral ring enhancing lesions. IV ampicillin is considered the treatment of choice, but meropenem
represents a valid alternative.
Financial Support: None
MEDICAL ISSUES
ePoster 28
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ePoster 29
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CASE REPORT: TUBERCULOUS MENINGITIS IN AN ELDERLY PATIENT WITH INITIAL CONCERNS FOR
METASTATIC CEREBRAL DISEASE
Bryan M Krueger, MD1,2, Simona Ferioli, MD1,3, William A Knight IV, MD1,2,4
1
University of Cincinnati Neuroscience Institute, Cincinnati, OH, USA, 2University of Cincinnati Department of
Neurosurgery, Cincinnati, OH, USA, 3University of Cincinnati Department of Neurology and Physical Medicine and
Rehabilitation, Cincinnati, OH, USA, 4University of Cincinnati Department of Emergency Medicine, Cincinnati, OH,
USA
Introduction
Tuberculosis meningitis is the most severe form of tuberculosis and is rarely encountered in the midwest United
States. Diagnosis is challenging due to the non-specific presentation and limited diagnostic methods. We present a
case of tuberculous meningitis diagnosed in an elderly man with initial concerns for metastatic cerebral disease.
Methods
This is a case presentation of 80-year-old Caucasian male with a history sick sinus syndrome (status post
pacemaker) who presented to from a community hospital with worsening altered mental status and tetraplegia
requiring mechanical ventilation after five months of progressive failure to thrive. He had no recent travel history
and had been living in care facilities on and off since presentation. Spinal fluid revealed neutrophilic-predominant
pleocytosis, elevated protein and hypoglycorrhachia with negative cultures. He was started on broad spectrum
antibiotics before transfer for presumptive meningitis without improvement.
Results
MRI could not be obtained due to the pacemaker. Head CT with contrast revealed small enhancing lesions with
surrounding edema in the frontal white matter, cervical spinal cord and pons interpreted as metastatic disease.
Work-up for primary source was initiated. However, sputum QuantiFERON-TB Gold Test returned positive after six
days and repeated spinal fluid studies confirmed TB. Treatment was initiated and his mental status improved. He
regained ability to follow commands two weeks after therapy initiation.
Conclusions
Tuberculous meningitis is rare in developed countries and diagnosis is difficult due to its indolent presentation and
limits in laboratory studies available. Interestingly, our case was initially interpreted as metastatic brain disease due
to similar spinal fluid and CT imaging characteristics that both diseases share. This highlights another challenge in
the diagnosis of TB meningitis in immunocompentent hosts, stressing the importance of spinal fluid and sputum
surveillance for TB in cases of subacute meningitis despite misleading radiographic features.
Financial Support: None
Neurocrit Care
41
A MULTI-FACETED PROGRAM TO REDUCE THE RATES OF CATHETER-ASSOCIATED URINARY TRACT
INFECTIONS
Martha Lusby, Michelle Harris Williams, Brigid Blaber, Patricia Woltz, Joseph Haymore, Atul Kalanuria, Neeraj
Badjatia
The University of Maryland Medical Center, Baltimore, MD, USA
Introduction
Catheter-associated urinary tract infections (CAUTIs) are a major contributor to morbidity in critically ill patients. We
developed a multi-faceted approach towards CAUTI reduction after our Neurocritical Care Unit (NCCU) was
identified with a high incidence of CAUTIs.
Methods
We analyzed CAUTI rates over a 10-month period prior to and after implementation of practice guidelines which
focused on daily chlorhexidine baths, daily electronic medical record reminders for urinary catheter (UC) removal
and standardized protocols for bladder scanning and intermittent catheterization after UC removal. We
hypothesized that many of the CAUTIs were due to asymptomatic bacteriuria rather than active infection so a new
2-step practice was implemented whereby cultures were only obtained if the urinalysis demonstrated pyuria defined
as 10 WBC/mm3. CAUTIs were defined using criteria established by the Centers for Disease Control. Data was
tracked daily by infection control staff. We calculated monthly UC days by dividing the total number of UC days by
patient days. UC days were defined as the total number of days of exposure to a UC for all patients during the
implementation period. UC days included the number of patients in the NCCU with UCs each day.
Results
There was no difference in age (57 years old), gender (48% women) or diagnoses. There was no difference in
monthly patient days (626 days v. 640 days, P=0.2) but there was a trend towards a reduction in mean monthly UC
days (306 days v. 279 days, P=0.08), and a reduction in the monthly UC days (0.49 v. 0.44, P=0.03). The new
urine culture policy reduced the mean number of urine cultures analyzed monthly from 53 to 28 (P=0.004). Overall,
monthly CAUTI rates were reduced from 8.6 to 3.7 per 1,000 patient days (P=0.01).
Conclusions
Implementation of a unit-based CAUTI reduction program successfully lowered the incidence of CAUTIs in our
NCCU.
Financial Support: None
MEDICAL ISSUES
ePoster 30
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42
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ePoster 31
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ANTI-N-METHYL-D-ASPARTATE RECEPTOR ENCEPHALITIS (NMDARE) INDUCED AUTONOMIC
INSTABILITY NECESSITATING PACEMAKER PLACEMENT: A CASE STUDY
Stephanie R. Mehr, Melissa A. Wiley, Roy C. Neeley
Vanderbilt University Medical Center, Nashville, TN, USA
Introduction
Anti-N-methyl-D-aspartate receptor encephalitis (NMDARE) is a rare autoimmune encephalitis affecting primarily
young women. It often manifests as a paraneoplastic syndrome with clinical features that include progressive
behavioral changes, psychosis, central hypoventilation, seizures, and autonomic instability. Although cardiac
arrhythmias often accompany NMDARE, they are rarely detailed in literature. We seek to describe the course of a
previously healthy female who was positive for Anti-NMDAR antibodies but was negative for primary tumor. Her
course was complicated by intermittent bradyarrhythmias which progressed at times to asystole, and ultimately
warranted permanent pacemaker implantation. Our patient was a 31-year-old African American female with no
significant past medical history. She initially presented to the psychiatric portion of our hospital with new onset
psychosis. She was transferred to our neurologic intensive care unit after a seizure and persistent altered mental
status likely secondary to catatonia. The severity of her catatonia and the frequency of her seizures contributed to
respiratory failure requiring mechanical ventilation. Her course was then further complicated by hemodynamically
significant bradycardia induced by vasovagal maneuvers. The episodes were initially self-limited, with spontaneous
return to hemodynamic stability. However, they eventually necessitated pharmacologic intervention for resolution.
Initial therapy was thus targeted at preventing vasovagal episodes, such as intravenous fentanyl and endotracheal
lidocaine for cough suppression. As her disease progressed, the hemodynamically significant bradycardia began to
occur independently of vagal stimuli. It also became refractory to pharmacologic intervention. Cessation only
occurred by chest compressions or transcutaneous pacing, thus warranting implantation of a permanent
pacemaker.
Neurocrit Care
43
A PREDICTIVE MODEL FOR ASSESSMENT OF PULMONARY EMBOLISM IN NEURO-INTENSIVE CARE
UNIT PATIENTS
Debra E. Roberts, Rajat Dhar
Washington University School of Medicine, Department of Neurology, St. Louis, MO, USA
Introduction
Pulmonary embolism (PE) remains a significant risk in critically ill patients, but detection is obscured by nonspecific
signs like tachycardia and tachypnea that are common and overlap with other cardiopulmonary disorders seen in
this population. Predictive models, validated in the Outpatient/Emergency setting, perform poorly in hospitalized
patients. We evaluated factors predictive of PE in patients with acute cardiopulmonary deterioration, in order to
develop a model of which patients require further testing.
Methods
All Neuro-ICU patients who underwent CT pulmonary angiography (CTPA) for suspicion of PE in 2013 were
retrospectively reviewed. Vital signs, labs, radiologic/ Doppler testing, and risk factors for PE were ascertained.
Relationship between these findings and presence/ absence of PE was evaluated using the Chi-square test for
discrete and T-test for continuous data. Variables with p < 0.1 were entered into multivariate analysis using
stepwise logistic regression.
Results
Tachycardia and tachypnea were present in over 90% of the 40 patients undergoing CTPA testing, while acute
hypoxia (SaO2< 90%) was seen in 57%; these variables did not predict the 13 (33%) who were positive for PE.
Instead, PE was associated with active malignancy, acute DVT, normal chest x-ray, and not being on DVT
chemoprophylaxis. These factors were independently associated with PE in multivariate analysis (R2= 0.68) while
fever and acute respiratory failure (intubation within 48 hours) were more likely in those with diagnoses other than
PE (e.g. pneumonia, mucous plugging).
Conclusions
Tachycardia, tachypnea, and hypoxia, while sensitive markers of PE in ICU patients are not specific enough to aid
in its diagnosis. We identified other risk factors that better distinguish PE from competing diagnoses in those with
acute cardiopulmonary instability. A predictive model incorporating these variables may allow refinement of who
requires CTPA testing while avoiding unnecessary testing in low-risk patients.
Financial Support: None
MEDICAL ISSUES
ePoster 32
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44
Neurocrit Care
MEDICAL ISSUES
ePoster 33
___________________________________________________________________________________
A COMPARISON OF GCS AND APACHE III SCORING SYSTEMS IN PREDICTING MORTALITY OF PATIENTS
IN THE NEUROLOGIC INTENSIVE CARE UNIT
Farid Sadaka1,2, Margaret A Cytron1, Kimberly Fowler1, Victoria M Javaux1, Jacklyn O'Brien1
1
Mercy Hospital St Louis/Critical Care Medicine/Neurocritical Care, St Louis, MO, USA, 2St Louis University, St
Louis, MO, USA
Introduction
The most widely used and most studied coma scale to date is the Glasgow Coma Scale (GCS). The GCS was
incorporated into several scoring systems, like the Acute Physiology, Age and Chronic Health Evaluation
(APACHE) III score. APACHE III score is used mainly for critically ill patients of all disease categories admitted to
the intensive care unit (ICU). APACHE III looks at 27 variables for each patient. In addition to GCS, these variables
include the patient's diagnosis, age, vital signs, and laboratory values. These two scoring systems have not been
compared in predicting hospital mortality in patients admitted to NeuroICU.
Methods
We retrospectively identified all patients admitted to our 16 bed NeuroICU between 06/2009 and 2/2014 using the
APACHE Outcomes database. We calculated correlation coefficients for GCS and APACHE III scores in predicting
hospital mortality. Receiver-operating characteristic (ROC) curves were also used to assess mortality predictions.
Results
We identified a total of 2025 patients. Patient characteristics included average age of 61 ± 18 years, 51 % males,
average GCS score of 13 ± 4, and average APACHE III score of 48 ± 21. Hospital mortality was 8.8 %. Both GCS
(r = 0.43) and APACHE III scores (r = 0.45) had very good correlations with hospital mortality (p < 0.01). There was
no statistically significant difference between the 2 correlations (p = 0.4). ROC area under the curve (AUC) was
0.85 (95 % CI = 0.82 - 0.88) for GCS, and 0.84 (95 % CI = 0.81 - 0.87) for APACHE III, suggesting that both scores
have very good discriminative powers for predicting hospital mortality.
Conclusions
This study shows that both GCS and APACHE III scores were very strong predictors of hospital mortality in
NeuroICU patients. GCS was as good as APACHE III in predicting hospital mortality in NeuroICU patients.
Financial Support: None
Neurocrit Care
45
ANTIFACTOR XA LEVELS VERSUS ACTIVATED PARTIAL THROMBPLASTIN TIME FOR MONITORING
UNFRACTIONATED HEPARIN. WHICH ONE TO BELIEVE? A PILOT STUDY
Sophie Samuel1, Teresa A Allison1, Gin Yau1, Sherouk Sharaf1, Natalie Mckaig1, Ghazaleh Ranjbar1, Kiwon Lee2,
Andy Nguyen2, Huimahn A Choi2, Miguel Escobar2
1
Memorial hermann medical center, Houston, TX, USA, 2Department of Neurosurgery and Neurology. The
University of Texas Medical School at Houston, Houston, TX, USA
Introduction
The purpose of this study was to compare outcomes with regard to efficiency of monitoring intravenous
unfractionated heparin infusion using activated partial thromboplastin time(aPTT) and antifactorXa(anti-Xa), we
then analyzed the correlation between paired values of anti-Xa and aPTT.
Methods
This is a single center prospective cohort pilot study.
Results
85 patients met the criteria for heparin continuous infusion;aPTT monitoring(n=48),anti-Xa monitoring(n=37).The
number of times aPTT and anti-Xa test performed were (median, IQR)14(2-34)vs7(2-76);p=0.23. The time to reach
therapeutic range for both groups were (mean,SD)22(20)vs15(13)in hours; p=0.08. 5(10%) in the aPTT group
versus 21(57%) in the anti-Xa group were within the therapeutic range>50-100% of the time (p=< 0.01). 38(78%)
patients in the aPTT group versus 14(38%) in the anti-Xa group had supratherapeutic reading >50-100%of the time
(p< 0.01). There were no differences in the number of days on heparin or bleeding complication during infusion
between groups. Discordant aPTT and anti-Xa values were reported from 230 paired values of 37 patients. 131
anti-Xa values were less than 0.3 IU/mL. When simultaneous aPTTs were examined, 49% correlated with an
aPTT< 60s, 28% with an aPTT between 60-80s and 24% with an aPTT>80s. 98 anti-Xa values were between 0.30.7 IU/mL; simultaneous aPTT values were 12%< 60s, 34% between 60-80s,51%>80s. Supratherapeutic anti-Xa
levels were from 5 readings; correlating a 100% with an aPTT>80s. 3/37 pts had bleeding complications. 1 pt
required blood transfusion. 1 pt required discontinuation of the pilot protocol.
Conclusions
aPTT and anti-Xa values are frequently discordant in monitoring heparin infusion. 57% of time there was
discordance between anti-Xa values and aPTT. The clinical significance of this finding is unclear. Anti-Xa levels
remained within range more often than aPTT levels. However, it's still unclear if a therapeutic anti-Xa level is an
adequate indicator of thrombosis risk versus bleeding risk in the face of discordant aPTT values.
Financial Support: None
MEDICAL ISSUES
ePoster 34
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46
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MEDICAL ISSUES
ePoster 35
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AN UNUSUAL CASE OF SHOCK IN A PATIENT WITH ANEURYSMAL SAH
Ishwara R. Sankara, Venkatesh Aiyagari
University of Texas- Southwestern Medical Center/ Division of Neurocritical Care, Department of Neurology and
Neurotherapeutics, Dallas, TX, USA
Introduction
A 30-year-old Hispanic male who was admitted to the hospital with an aneurysmal SAH. He underwent clipping of
his Anterior communicating artery aneurysm. He had an IVC filter placed for a right Popliteal vein deep vein
thrombosis. He developed an acute massive Inferior venacaval thrombosis (IVC) thrombosis from propagation of
clot trapped within the filter, causing severe shock and multi-organ failure.
Methods
A case report discussing the acute complications of IVC filter placement, but importantly talks about the risks of
Post IVC filter DVT, PE and Phlegmasia Cerulea Dolens (PCD).
Results
This poster specifically discusses the pathophysiology of shock in patients with an acute total IVC thrombosis after
IVC filter placement, and also discusses the rare but fatal complication Phlegmasia Cerulea Dolens (PCD)
Conclusions
As a neurointensivist, it is very important to know the potential complications of IVC filter. Certain complications
such as PE despite previous filter implantation, acute total IVC thrombosis from propagation of clot trapped within
the filter, and PCD can be fatal if not early detected and aggressively treated. Filters should be removed once the
patients risk of DVT is reduced, and prompt initiation of chemoprophylaxis should be considered (even in patients
with IVC filter in place) once the bleeding risk has decreased
Financial Support: None
Neurocrit Care
47
CHARACTERISTICS OF TERMINAL EXTUBATION IN THE NEUROINTENSIVE CARE UNIT
Linda C Wendell, Corey R Fehnel, N. Stevenson Potter, Bradford B Thompson
Rhode Island Hospital/Brown University, Departments of Neurology and Neurosurgery, Providence, RI, USA
Introduction
Prognostication in brain-injured patients can be challenging. Physicians and families want to avoid early withdrawal
of care in those who may have a chance at good outcome. However, overly hopeful prognostication can leave
patients with unwanted poor functional outcomes.
Methods
This is a subanalysis of a prospective observational cohort of patients with primary brain injury admitted to a
neurointensive care unit (NeuroICU) at a tertiary care center who were intubated for airway protection,
mechanically ventilated for >24 hours and expected to have a trial of extubation from March 2012 to January 2014.
Results
Thirty-three patients were enrolled. Nine patients (29%) were terminally extubated and 24 patients had a trial of
extubation or tracheostomy. Sixteen patients had intracerebral hemorrhage, seven patients had traumatic brain
injury, seven patients had subarachnoid hemorrhage and three patients had ischemic stroke. Terminally extubated
patients were older (median age 64 years [IQR 55-80] vs. 53 years [33.5-60], p=0.034). Enrollment Glasgow Coma
Scale (GCS) scores were similar between terminally and non-terminally extubated patients (7 [7-8] vs. 8 [7-9.5],
p=0.12); however, terminally extubated patients had significantly lower enrollment Four Scores, a tool to assess
level of consciousness and brainstem function (8 [6-8] vs. 9 [8-12], p=0.021). Adjusted for age, patients with lower
eye opening scores by GCS and by Four Score were at increased risk for terminal extubation [OR 12.77 (95% CI
1.26-129.74), p=0.031 and OR 2.87 (95% CI 1.08-7.65), p=0.034, respectively].
Conclusions
A large percentage of patients are terminally extubated in the NeuroICU. Among patients ventilated for >24 hours,
aggressive medical care was continued for a similar number of days before the decision to extubate terminally.
Despite similar coma scores, lack of eye opening is a predictor of terminal extubation in the NeuroICU.
Financial Support: None
MEDICAL ISSUES
ePoster 36
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HEAD AND SPINE TRAUMA
48
Neurocrit Care
ePoster 37
___________________________________________________________________________________
ABILITY TO PREVENT K CHANNEL MEDIATED VASODILATOR IMPAIRMENT AS A DETERMINANT IN SEX
DEPENDENT PRESSOR CHOICE TO PROTECT CEREBRAL AUTOREGULATION AFTER PEDIATRIC TBI
William M Armstead1, John Riley1, Monica S Vavilala2
1
University of Pennsylvania Department of Anesthesia, Philadelphia, PA, USA, 2University of Washington
Department of Anesthesia, Seattle, WA, USA
Introduction
Hypotension and low cerebral perfusion pressure (CPP) are associated with low cerebral blood flow (CBF),
ischemia, impaired autoregulation and poor outcomes after traumatic brain injury (TBI). TBI is the leading cause of
death in children, and boys and younger children have poor outcomes compared to girls and older children. CPP is
often normalized by use of inotropes and vasopressors to increase MAP and optimize CBF. Since ethical
considerations constrain mechanistic studies in children, we use an established porcine model of fluid percussion
brain injury (FPI). Phenylephrine (Phe) prevented in female but exacerbated impairment of autoregulation in male
piglets after FPI. In contrast, dopamine (DA) prevented impairment of autoregulation in both sexes after FPI,
suggesting that pressor choice impacts outcome. Activation of Katp and Kca channels is an important mechanism
for vasodilation, including autoregulation. K channel mediated dilation is blunted after FPI via upregulation of ERK
mitogen activated protein kinase (MAPK). Phe protected impairment of K channel mediated dilation in females but
aggravated impairment in male piglets after FPI. We hypothesized that DA protected autoregulation in both males
and females because it equally protected K channel mediated dilation in both sexes after FPI.
Methods
Lateral FPI was produced in anesthetized piglets. Pial artery reactivity was measured via a closed cranial window.
Results
Cromakalim (Katp agonist) and NS 1619 (Kca agonist) produced dilation which was blunted by FPI in males and
females. DA (30 min post FPI) elevated MAP and CPP equally in male and female piglets after FPI. DA protected
cromakalim and NS 1619 induced dilation and blocked upregulation of ERK MAPK equivalently in males and
females after FPI.
Conclusions
These data indicate that DA protects K channel mediated cerebrovasodilation equally in both male and female
piglets because of equivalent blockade of ERK MAPK upregulation in both sexes after FPI.
Financial Support: None
49
ePoster 38
___________________________________________________________________________________
ACTIVATED PARTIAL THROMBOPLASTIN TIME (APTT), NOT PROTHROMBIN TIME (PT), IS MORE
CLOSELY CORRELATED WITH MORTALITY AFTER SEVERE TRAUMATIC BRAIN INJURY (TBI)
Richard K. Choi1, Unmesha Roy-Paladhi2, Kelsey Nawalinski2, Suzanne G. Frangos2, Sean M. Grady2, Eileen
Maloney-Wilensky2, James M. Schuster2, Scott E. Kasner1, Monisha Kumar1
1
Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA, 2Department of
Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
Introduction
Coagulation changes after traumatic brain injury (TBI) are common, but whether these changes are associated with
mortality remains unclear. We sought to determine whether the prothrombin time (PT), activated partial
thromboplastin time (aPTT) and/or platelet count correlate with mortality after severe TBI.
Methods
143 patients with severe TBI admitted between January 1, 2006 and December 31, 2009 were identified from the
Brain Oxygen Monitoring and Outcome (BOMO) registry at a University-affiliated, level-1 trauma center. Admission
demographic variables and laboratory parameters were collected upon admission. Patients taking anticoagulant
medications were excluded. Coagulation abnormalities were dichotomized at PT >13.8s; aPTT >34.4s, and
thrombocytopenia < 150,000/mL. Modified Rankin scores were obtained at 3-months after discharge. Logistic
regression analysis was performed to determine the effect of coagulation abnormalities on 3-month mortality.
Results
100/143 (70%) of all study patients were men; mean age was 44 (range 15 - 91) years. 43/143 (30.1%) died. The
mechanism of trauma was falls in 59 (41%) patients. The incidence of PT prolongation was 47/143 (32.9%) and
aPTT prolongation was 27/143 (18.9%). Thrombocytopenia occurred in 15 (10.5%) of patients. In univariate
analysis, an elevated PT was associated with increased mortality [21/43 versus 21/100; p=0.001]. In step-wise
multivariable logistic regression accounting for age, coma, hematoma expansion, surgical intervention and
mechanism of injury, the only coagulation parameter that was associated with mortality was the aPTT [1.15 (1.041.28); p< 0.01]. Age [OR=1.05 (1.02-1.08); p< 0.01] and surgical intervention [OR=3.91 (1.40 - 10.90); p=0.03]
were also significantly associated with 3-month mortality. Any coagulopathy increased the odds of death by 3.0
[95% CI(1.2-7.40; p=0.02].
Conclusions
The aPTT was more closely correlated with 3-month mortality than the PT, although the incidence of aPTT
prolongation was lower than PT prolongation. Any coagulation abnormality on admission was associated with
increased 3-month mortality. Neither admission nor nadir platelet count correlates with mortality.
Financial Support: None
HEAD AND SPINE TRAUMA
Neurocrit Care
HEAD AND SPINE TRAUMA
50
Neurocrit Care
ePoster 39
___________________________________________________________________________________
ANTIPLATELET AGENT USE IS ASSOCIATED WITH INCREASED INTRACRANIAL HEMORRHAGE
VOLUMES, BUT NOT PROGRESSIVE HEMORRHAGIC INJURY, AFTER TRAMATIC BRAIN INJURY
Richard K. Choi1, Rajanandini Muralidharan2, Kelsey Nawalinski3, Unmesha Roy-Paladhi1, Connie Ju1, Francis
Quattrone3, Suzanne G. Frangos3, Eileen Maloney-Wilensky3, Patrick K. Kim4, Joshua M. Levine1, William A.
Kofke3, 5, Scott E. Kasner1, James M. Schuster3, Monisha Kumar1
1
Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA, 2Department of
Neurology, Winthrop University Hospital, Mineola, NY, USA, 3Department of Neurosurgery, Hospital of the
University of Pennsylvania, Philadelphia, PA, USA, 4Department of Trauma/Emergency Surgical Services, Hospital
of the University of Pennsylvania, Philadelphia, PA, USA, 5Department of Anesthesiology and Critical Care,
Hospital of the University of Pennsylvania, Philadelphia, PA, USA
Introduction
Use of antiplatelet agents may be associated with worse outcomes after Traumatic Brain Injury (TBI). We sought to
determine whether pre-injury use of antiplatelet agents was associated with larger initial hematoma volumes or
progressive hemorrhagic injury (PHI) after TBI.
Methods
A retrospective cohort of severe TBI patients who underwent brain oxygen monitoring at an academic level-1
trauma center between January 1, 2006 and December 31, 2009 was identified. Hematoma volumes were
calculated manually from initial and 24-hour head CT using the maximal width for subdural (SDH) or epidural
hematoma (EDH) and ABC/2 for the volume of an intra-cerebral hematoma. PHI was defined as >25% increase in
SDH/EDH width or ICH volume.
Results
138 patients were included in our analysis. Median age was 41 (21.1). Mean GCS score was 6.6 (4.5) and mean
APACHE II score was 22.6 (5.3). Eighteen patients (12.6%) were taking antiplatelet agents and 36 patients died
(25.2%). Seventy-one percent of patients had SDH, 11.6% had EDH, 62.3% had contusions and 87.7% had SAH.
Antiplatelet use was associated with larger initial (9.5 vs 1.9cc, p=< 0.01) and maximum contusion volumes (21 vs
5cc, p=< 0.01), as well as initial SDH width (11 vs. 6.1mm, p=< 0.01), but not maximum SDH width (8.8 vs. 6.9mm,
p=0.14). In univariate analysis, maximum hematoma volume and initial SDH width were associated with mortality
(p=0.02 and 0.01 respectively) although these associations did not hold in a multivariate model. PHI occured in 88
patients (63.7%); there was no difference in PHI rates between the two groups (p=0.6). Mortality in the antiplatelet
group was significantly higher (55.6% vs. 20.8%, p=< 0.01).
Conclusions
Antiplatelet use is associated with larger initial contusion and SDH volumes. Mortality is higher in the antiplatelet
group, but this is not likely mediated through PHI after initial head CT.
Financial Support: None
ePoster 40
___________________________________________________________________________________
ADHERENCE TO GUIDELINES FOR MANAGEMENT OF CEREBRAL PERFUSION PRESSURE AND
OUTCOME IN PATIENTS WHO HAVE SEVERE TRAUMATIC BRAIN INJURY
Donald E Griesdale1,2,3, Victoria Örtenwall4, Monica Norena5, Hubert Wong2,5, Mypinder Sekhon1,2, Leif Kolmodin2,
William Henderson1,2, Peter Dodek1,5
1
University of British Columbia, Vancouver, BC, Canada, 2Vancouver General Hospital, Vancouver, BC, Canada,
Center for Clinical Epidemiology, Vancouver, BC, Canada, 4Lund University, Lund, Sweden, 5Center for Health
Evaluation & Outcome Sciences, Vancouver, BC, Canada
3
Introduction
The Brain Trauma Foundation (BTF) recommends that cerebral perfusion pressure (CPP) be kept between 50 - 70
mm Hg for patients who have severe traumatic brain injury. The main objective of this study was to assess
adherence to this CPP target and to determine if adherence to this target is associated with hospital mortality.
Methods
Retrospective cohort study 127 patients who had a TBI that required ICP monitoring admitted to the ICU between
April 2006 and May 2012. Adherence to BTF guidelines was measured as the time that the CPP was within 50 - 70
mm Hg divided by the total time of CPP monitoring (CPP time index). Using logistic regression, we modelled the
association between CPP time index and hospital mortality.
Results
The percentage of time that the CPP was within the recommended range was 31.6% (SD 22.2) whereas patients
had a CPP greater than 70 mm Hg for 63.9% (SD 26.2) of the time. Patients had a CPP < 50 mm Hg for an
average of 4.5% of the time (SD 16.3). After adjustment for covariates, CPP time index inside 50 - 70 mm Hg was
not associated with hospital mortality (OR 1.2, 95%CI 0.98 - 1.6, p=0.079). CPP time index for CPP 70mm Hg
and < 50mm Hg were associated with decreased (OR 0.66, 95%CI: 0.52 - 0.82, p< 0.0001) and increased (OR 9.9,
95%CI: 1.4 - 69.6, p=0.021) mortality, respectively.
Conclusions
CPP was greater than 70 mm Hg for most of the time. This level of CPP was associated with decreased mortality.
Financial Support: None
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ePoster 41
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HEMOGLOBIN TIME INDEX ABOVE 90G/L IS ASSOCIATED WITH IMPROVED 6 MONTH FUNCTIONAL
OUTCOMES IN PATIENTS WITH SEVERE TRAUMATIC BRAIN INJURY
Donald E Griesdale1,2,3, Mypinder Sekhon1,2, David K Menon4,5, Chiara Robba4, Andrea Lavinio4, Indeep Sekhon4,
Andrew Taylor4, Karyn McMurray4, Arun Gupta4,5
1
University of British Columbia, Vancouver, BC, Canada, 2Vancouver General Hospital, Vancouver, BC, Canada,
Center for Clinical Epidemiology, Vancouver, BC, Canada, 4Addenbrooke's Hospital, Cambridge, United Kingdom,
5
Cambridge University, Cambridge, United Kingdom
3
Introduction
Prior observational studies suggest that a mean hemoglobin concentration below 90 g/L is associated with
increased mortality. However, these studies are limited by possible exposure misclassification and lack of
standardized functional outcomes. The purpose of this study was to determine if hemoglobin above 90 g/L was
associated with improved 6 month functional outcomes in patients with severe traumatic brain injury.
Methods
Retrospective cohort study 116 patients who had a TBI and underwent multimodal neuromonitoring between 2006 2013. A hemoglobin time-index (HTI) was calculated for each patient by dividing the total number of hours where
the hemoglobin was 90g/L by the total number of hours where hemoglobin was measured. Using a generalized
linear model, we modelled the association between HTI and 6 month favourable neurologic outcome (Glasgow
Outcome Score 4 or 5).
Results
Retrospective cohort study 116 patients who had a TBI and underwent multimodal neuromonitoring between 2006 2013. A hemoglobin time-index (HTI) was calculated for each patient by dividing the total number of hours where
the hemoglobin was 90g/L by the total number of hours where hemoglobin was measured. Using a generalized
linear model, we modelled the association between HTI and 6 month favorable neurologic outcome (Glasgow
Outcome Score 4 or 5).
Conclusions
Percentage of time with a hemoglobin 90 g/L was associated with improved 6 month neurologic outcomes in
patients with severe TBI.
Financial Support: None
53
ePoster 42
___________________________________________________________________________________
ACUTE MICROGLIAL ACTIVATION IN TRAUMATIC BRAIN INJURY: A [11C](R)PK11195 POSITRON
EMISSION TOMOGRAPHY STUDY
Alessandra Lombardo1,2, Young T Hong3,4, Joanne G Outtrim1, Roberto Canales3,4, Nazneen Sudhan1, Terhi
Huttunen5, David Williamson3,4, Rob Smith3,4, Adel Helmy6, Franklin I Aigbirhio3,4, Peter J Hutchinson4,6, Olli
Tenovuo7, Tim D Fryer3,4, Jonathan P Coles1, David K Menon1,3
1
Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom,
Department of Physiopathology and Transplant, Milan University, Neuro ICU, Fondazione IRCCS Cà Granda
Ospedale Maggiore Policlinico, Milan, Italy, 3Wolfson Brain Imaging Centre, University of Cambridge, Cambridge,
United Kingdom, 4Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom,
5
Department of Neurosurgery, Kuopio Neurocenter, Kuopio University Hospital, Kuopio, Finland, 6Division of
Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom,
7
Division of Clinical Neurosciences, Department of Rehabilitation and Brain Trauma, Turku University Central
Hospital and University of Turku, Turku, Finland
2
Introduction
Neuroinflammation is a key secondary injury mechanism following traumatic brain injury (TBI). While measurement
of inflammatory mediators in jugular venous blood and brain microdialysate can characterize global and focal
inflammation in TBI, they do not provide a means of mapping spatial variations in neuroinflammation across the
brain. A recent study used [11C](R)PK11195 positron emission tomography (PET) to demonstrate persistent
thalamic inflammation years after TBI, which was related to outcome. We have applied [11C](R)PK11195 to map
the spatiotemporal patterns of microglial activation in acute moderate/severe TBI.
Methods
Six patients (4 male, admission Glasgow Coma Score: 3-11) underwent [11C](R)PK11195 PET (including
metabolite-corrected plasma kinetic modelling) and magnetic resonance imaging (MRI) at two time points (3-9 days
and 13-22 days) following TBI. [11C](R)PK11195 binding potentials were calculated in the core, in the perilesional
area and in normal appearing areas of the brain.
Results
Two patients with contusions showed a pattern consistent with microglial activation in ischaemic stroke, with early
perilesional increases in [11C](R)PK11195 binding, which increased and included the lesion core at the later time
point. However, the spatial and temporal progression of microglial activation did not conform to this pattern in other
patients. None of the studies showed significant thalamic binding of [11C](R)PK11195.
Conclusions
There is marked variability in patterns of microglial activation in early TBI, which may relate to differences in injury
type and severity, host response characteristics, and possibly therapy. However, the late thalamic microglial
activation reported in past studies does not appear to be a feature of acute TBI, and may represent a late
neuroinflammatory response with a long therapeutic window. Further studies are needed to better characterize
microglial activation in vivo and its meaning in the context of TBI.
Financial Support: None
HEAD AND SPINE TRAUMA
Neurocrit Care
HEAD AND SPINE TRAUMA
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Neurocrit Care
ePoster 43
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ACUTE TIME-COURSE OF UBIQUITIN C-TERMINAL HYDROLASE-L1 AND 145 KDA SPECTRIN
BREAKDOWN PRODUCT IN SERUM AFTER SEVERE TRAUMATIC BRAIN INJURY IN CHILDREN
Ryan R. Metzger1,2, Michelle E. Schober2,3, Brandon Zielinski2,4, Xiaoming Sheng5, Christian Niedzwecki2,6, Denise
Morita2,4, Kimberly S. Bennett2,3
1
Division of Pediatric Surgery, University of Utah, Salt Lake City, UT, USA, 2Primary Children's Hospital, Salt Lake
City, UT, USA, 3Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT, USA, 4Division of
Pediatric Neurology, University of Utah, Salt Lake City, UT, USA, 5Department of Pediatrics, University of Utah,
Salt Lake City, UT, USA, 6Division of Physical Medicine & Rehabilitation, Salt Lake City, UT, USA
Introduction
Blood and cerebrospinal fluid (CSF) levels of brain injury markers may serve as useful diagnostic and prognostic
indicators for traumatic brain injury (TBI). Levels of Ubiquitin C-terminal hydrolase-L1 (UCH-L1) and the 145 kDa
spectrin breakdown product (SBDP145) have been shown to correlate with outcome after severe TBI. The
response profiles of these biomarkers in children after TBI have not been characterized. We examined the acute
time-course of serum and CSF levels of UCH-L1, as well as serum SBDP145, in pediatric patients with severe TBI.
Methods
Patients aged 0-17 years admitted for severe TBI from September 2011 to October 2013 were prospectively
enrolled. Blood and CSF were collected at up to 5 time-points from 12 to 120 hours after injury, and a single timepoint for non-injured control patients.
Results
Nineteen TBI patients (median age = 8 years; range 0.42-15) were evaluated. Serum UCH-L1 levels were greater
than control levels (median across all time-points = 361 versus 147 pg/ml, p < 0.001). Serum SBDP145 showed a
similar overall magnitude of increase (172 vs 69 pg/ml, p < 0.001). Serum and CSF UCH-L1 levels correlated well
(r=0.70; p < 0.001). In both serum and CSF, the overall trend across time-points was a decreasing one (p < 0.001
and p = 0.003, respectively). In contrast, serum SBDP145 levels peaked at a later time-point (overall comparison p
= 0.011). ROC analysis on serum UCH-L1 revealed a cut-off value for distinguishing TBI of 400 pg/ml, with AUC =
0.74. The optimal cut-off value for serum SBDP145 was 100 pg/ml, with AUC = 0.81.
Conclusions
Blood and CSF levels of UCH-L1 display a rapid and transient time-course in children after TBI, while serum
SBDP145 follows a more sustained response. These findings are discussed in relation to clinical characteristics
and EEG markers evaluated concurrently in these patients.
Financial Support: None
55
ePoster 44
___________________________________________________________________________________
ACUTE ADRENAL INSUFFICIENCY IN CERVICAL SPINAL CORD INJURY
Joel Pellot1, Emil Pastrana2, Fanor Saavedra1, Samuel Estronza1
1
University of Puerto Rico, San Juan, PR, USA, 2Swedish Neuroscience Institute, Seattle, WA, USA
Introduction
Adequate adrenal response is fundamental for maintenance of physiological homeostasis in the setting of trauma
and severe illness. Patients with neurogenic shock are at risk of severe consequences if adrenal insufficiency is not
rapidly identified and treated. Our objective was to analyze the incidence of adrenal insufficiency in patients with
acute cervical spinal cord injury and its effect on in-hospital complications and mortality at 6 and 12 months.
Methods
The medical records of patients older than 18 years who were admitted to the adult neurosurgery service at the
University District Hospital due to neurogenic shock following acute cervical spinal cord injury from January 2004 to
December 2009 were reviewed retrospectively. Patients were re-evaluated at 6 and 12 months.
Results
One hundred and ninety-nine patients were admitted with acute cervical spinal cord injury. 37 patients met the preestablished criteria for neurogenic shock. The incidence of adrenal insufficiency (AI) in patients with neurogenic
shock was 22%. The average random cortisol was 9.3 μg/dL in patients with AI vs. 29.2 μg/dL in Non-AI. The
presence of AI was positively correlated with complications and an increase in the risk of intubation (P = 0.01
and P = 0.002). The 30-day mortality rate in patients with AI was 13% compared with the 3% in the Non-AI group
(P = 0.39). Two patients died in the post-hospitalization period at 3 month and 5 months respectively. The overall
survival rate at 1 year was 78% in the AI group as compared with the NON-AI group which as 95% (P>0.05).
Conclusions
Adrenal insufficiency is a poorly recognized complication in patients with acute cervical spinal cord injury and its
aggressive treatment is of utmost importance to avoid further neurological injury. At follow up at 1 year the
occurrence of adrenal insufficiency does affect the survival of patients with acute cervical spinal cord injury.
Financial Support: None
HEAD AND SPINE TRAUMA
Neurocrit Care
HEAD AND SPINE TRAUMA
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Neurocrit Care
ePoster 45
___________________________________________________________________________________
EFFECT OF TRANSFUSION THRESHOLD ON EARLY CEREBRAL HEMODYNAMICS AFTER SEVERE
TRAUMATIC BRAIN INJURY
Claudia S. Robertson1, Jose-Miguel Yamal2, H. Julia Hannay3, Shankar Gopinath1, J. Clay Goodman1, Barbara C.
Tilley2
1
Baylor College of Medicine, Houston, TX, USA, 2University of Texas School of Public Health, Houston, TX, USA,
3
University of Houston, Houston, TX, USA
Introduction
Maintaining an adequate hemoglobin concentration has been thought to minimize early cerebral ischemia after
severe traumatic brain injury. The goal of this analysis was to examine the effect of maintaining hemoglobin
concentration at two randomized transfusion thresholds, at least at 10 gm/dl (10TT group) or 7 gm/dl (7TT group),
on pre-specified early hemodynamics.
Methods
Cerebral hemodynamics, including intracranial pressure (ICP), mean arterial pressure (MAP), and brain tissue
hypoxia (brain tissue PO2 less than 10 mmHg), were compared among the two transfusion threshold groups in a
randomized clinical trial.
Results
Median ICP was 15.6 mmHg in 7TT, and 15.6 mmHg in 10TT. There was no difference in the median time that ICP
was greater than 30 mmHg (0 hours in 7TT, 1 hour in 10TT, p=0.07) or in maximum ICP treatment score (p=0.10)
in the two transfusion threshold groups. Average MAP was 88.8 mmHg in 7TT, and 92.3 mmHg in 10TT (p=0.001).
The proportion of patients who never had a MAP below 70 mmHg was 37.1% in 7TT and 35.0% in 10TT (p=0.76).
For all patients, there was no difference in the occurrence of brain tissue hypoxia. However, when location of the
probe was considered, there were significant differences. When the probe was located in normal appearing brain,
brain tissue hypoxia occurred in 25% of patients in 7TT, compared to 10.2% of patients in 10TT (p=0.04). No
difference in the incidence of brain tissue hypoxia was observed when the probe was placed in abnormal brain.
Conclusions
A small increase in MAP and fewer episodes of global tissue hypoxia (probe in normal appearing brain) were
observed when hemoglobin concentration was maintained at least 10 g/dl. However, these effects were small and
may not outweigh the potential adverse consequences of the transfusions needed to maintain hemoglobin
concentration.
Financial Support: NIH grant #P01-NS38660
ePoster 46
___________________________________________________________________________________
EVALUATION OF A NOVEL CEREBRAL BIO-IMPEDANCE MONITOR TO NON-INVASIVELY MEASURE
INTRACRANIAL PRESSURE IN SEVERE TBI PATIENTS
Guy Rosenthal1, Jean Soustiel2, Alex Furmanov1, Ramez Abu Shkara1, Jacob Zauberman3, Sagi Har Nof3
1
Department of Neurosurgery, Hadassah-Hebrew University Hospital, Jerusalem, Israel, 2Department of
Neurosurgery, Rambam Medical Center, Haifa, Israel, 3Department of Neurosurgery, Sheba Medical Center,
Ramat Gan, Israel
Introduction
Development of a non-invasive intracranial pressure (ICP) monitor has long been a goal in neurocritical care. The
Orsan CPM monitor is a novel use of cerebral bio-impedance technology that is sensitive to changes in fluid
content of the brain and also to pressure and volume changes induced by the pulsatility of the cardiac cycle. We
studied the feasibility of using the Orsan CPM monitor to non-invasively measure ICP in severe TBI patients.
Methods
We studied consecutive severe TBI patients admitted to 3 neurointensive care units in Israel who underwent ICP
monitoring and did not undergo surgical intervention during the time of monitoring. We compared invasive and noninvasive ICP waveforms and measurements.
Results
We studied 30 patients with a mean age of 40 ± 20 years and a median GCS of 5 (IQR 3-8). We analyzed 1338
hours of validated data. Waveform analysis revealed a very strong correlation between the invasive and noninvasive ICP (nICP) waveform (r=0.95, p< 0.0001). Mean error between invasive and nICP measurements on an
hourly basis was 0.38 ± 4.5 mm Hg. The correlation between mean hourly ICP from the invasive and non-invasive
monitors was robust (r = 0.7, p< 0.0001). Importantly, when ICP was intractably elevated (>25 mm Hg for > 90% of
a given hour) mean nICP was 49 ± 16 versus a mean invasive ICP of 52 ± 15 mm Hg, indicating that the noninvasive monitor is able to reliably detect very high ICP. In patients that never experienced elevated ICP mean
nICP was 12 ± 4 mm Hg (invasive ICP 10 ± 3 mm Hg).
Conclusions
The results of this preliminary study suggest that cerebral bio-impedance is a promising technology that may offer
continuous non-invasive estimation of ICP, and is able to accurately detect significant elevations of ICP. Further
investigations using this technology are warranted.
Financial Support: The presenting author has served as a scientific advisor for Orsan and has received consulting
fees.
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EFFECTS OF DOCOSAHEXAENOIC ACID ON MICROGLIAL AND MACROPHAGE M1/M2 MARKER
EXPRESSION IN RAT PUP BRAIN AFTER TRAUMATIC BRAIN INJURY
Michelle E Schober1, Daniela F Requena1, Sydney Maves1, Mathew Cusick 2
1
University of Utah/Pediatric Critical Care Medicine, Salt Lake City, UT, USA, 2University of Utah, Immunology, Salt
Lake City, UT, USA
Introduction
Dietary Docosahexaenoic Acid (DHA) decreased lesion volume and cognitive impairment in our controlled cortical
impact (CCI) model of developmental TBI, associated with decreased oxidative stress and inflammation.
Mechanisms of DHA's neuroprotection are poorly understood. In systemic macrophages, DHA decreases
inflammatory (M1) activation while promoting reparatory (M2) activation. DHA is a peroxisome proliferator gamma
(PPARȊ) ligand. Effects of DHA on M1/M2 activation of resident microglia or infiltrating macrophages after TBI are
unknown. We hypothesized that DHA would decrease mRNA levels of M1 activation markers in microglia and
infiltrating macrophages after CCI in the 17 day old rat, associated with increased PPARȊ1 mRNA.
Methods
CCI or SHAM surgery was delivered to 17 day old male rats exposed to 0.1% DHA (DHA) or otherwise equivalent
chow (REG). At post injury day (PID) 3, M1 (IL-1ȕ, IL-12p35, IL-18, CCL2, INFȊ, TNFĮ, iNOS) and M2 marker (IL1RĮ, IL-12p40, CD206, IL-10, TGFȕ, Arg2) and PPARȊ1 mRNA were measured in microglia/macrophages isolated
using flow cytometry and CD11b/ CD45 antibodies. IL2, 4 and 6 mRNA levels were measured in injured tissue.
Results
Preliminary results suggest DHA did not affect total CD11b+ cells but decreased infiltrating macrophages (30±3 vs
22±3% total, p=0.04); decreased microglial M1 marker mRNA (TNFĮ to 43±2% and INF Ȋ to 25±6% REG, p< 0.05
for both; iNOS to 33±8% and IL-1ȕ to 30±1%, trend of p< 0.1 for both). Increased CD206 in DHACCI microglia
approached significance (362±37% REG, p=0.05).
Conclusions
Exposure to a 0.1% DHA diet after CCI may be associated with decreased infiltrating macrophages and decreased
microglial M1/M2 mRNA ratio. We anticipate that DHA will decrease M1/M2 mRNA ratios in microglia and
macrophages, associated with increased PPAR Ȋ1 mRNA. We speculate that DHA improves neurologic outcomes
in rat pups after CCI via immunomodulation.
Financial Support: None
59
ePoster 48
___________________________________________________________________________________
ASSOCIATION BETWEEN OPTIC NERVE SHEATH DIAMETER AND MORTALITY IN PATIENTS WITH
SEVERE TRAUMATIC BRAIN INJURY
Mypinder S Sekhon1, Paul McBeth1, Jie Zou1, Lu Qiao1, Kolmodin Leif1, Henderson R William1, Reynolds Steven2,
Griesdale E Donald1
1
Critical Care Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada,
Critical Care Medicine, Royal Columbian Hospital, University of British Columbia, New Westminster, BC, Canada
2
Introduction
Increased intracranial pressure (ICP) is associated with worse outcomes following traumatic brain injury (TBI).
Studies have confirmed that ICP is correlated with optic nerve sheath diameter (ONSD) on ultrasound. The aim of
our study was to assess the independent relationship between ONSD measured using CT and mortality in a
population of patients admitted with severe TBI.
Methods
We conducted a retrospective cohort study of patients with a TBI requiring ICP monitoring admitted to the ICU
between April 2006 and May 2012 to two neurotrauma centers. ONSD was independently measured by two
physicians blinded to patient outcomes. Multivariable logistic regression modeling was used to assess an
association between ONSD and hospital mortality.
Results
A total of 220 patients were included in the analysis. Overall, the cohort had a mean age of 35 (SD 17) years and
171 of 220 (79%) were male. The median admission GCS was 6 (IQR 3 - 8). Intra-class correlation coefficient
between raters for ONSD measurements was 0.92 (95%CI: 0.90 - 0.94, P< 0.0001). On multivariable analysis,
each 1 mm increase in ONS was associated with a two-fold increase in hospital mortality (OR 2.0, 95%CI: 1.2 3.2, P=0.007). Using linear regression, ONSD was independently associated with increased ICP in the first 48
hours after admission (ȕ=4.4, 95%CI: 2.5 - 6.3, P< 0.0001).
Conclusions
In patients with TBI, ONSD measured on CT scanning was independently associated with ICP and mortality.
Financial Support: None
HEAD AND SPINE TRAUMA
Neurocrit Care
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ICU ORG AND TECH
ePoster 49
___________________________________________________________________________________
ADVANCED PRACTICE PROVIDERS IN NEUROCRITICAL CARE: AN EVIDENCED-BASED REVIEW
Johanna Aparicio CRNP, Megan Lange CRNP, Julie Wubs CRNP, Emily Kay CRNP, Neeraj Badjatia MD, Christan
Bartsch PA
University of Maryland Medical Center/Neurocritical Care, Baltimore, MD, USA
Introduction
Existing evidence suggests that the utilization of Advanced Practice Providers (APPs) in critical care settings is
safe, cost effective, yields significant benefit in continuity/quality of care and improves patient outcomes. We aimed
to identify published literature regarding the role of Acute Care Nurse Practitioners (ACNPs) and Physician
Assistants (PAs) specific to Neurocritical Care (NCC) and to identify implications for practice.
Methods
A systematic search of PubMed and CINAHL was carried out using the terms "Neurocritical Care", "Acute Care
Nurse Practitioner", "Physician Assistant", "Neurosurgery", "Neuroscience" and "24 hour models" from 1999
through May 2014.
Results
A preliminary review of the literature revealed over 100 articles referencing APPs in critical care settings. A total of
7 articles focused on APPs in the NCC setting. Of those, three articles focused on the role and scope of practice for
ACNPs in a NCC unit, one focused on a potential NP orientation competency for a 24-hour NP coverage model,
one focused on the tandem collaborative practice of NP-Physician colleagues in a neurosurgical practice and only
one focused on the significant clinical and financial outcomes with care provided by ACNPs. The most current
study was a survey of Neurocritical Care Society (NCS) members that focused on intensivist and staff perceptions
of ACNPs and PAs. None of these studies addressed issues related to contemporary scope of practice, patient
satisfaction or the long term financial consequences of sustaining such a program.
Conclusions
There is currently a very low level of evidence in the literature to support the impact of APPs in NCC. Further
research is needed to explore the impact of NCC APPs on quality of care measures and patient outcomes.
Additionally, evaluation of the economic ramifications of creating and maintaining such models are needed to
improve APP utilization.
Financial Support: None
Neurocrit Care
61
BRAINS ON BEETHOVEN, A FEASIBILITY STUDY OF MUSIC THERAPY IN THE NEURO ICU
Aimee Aysenne, Nerissa Ko, Shelia Chan, Mohan Kottapally, Wade Smith
University of California, San Francisco/ Department of Neurocritical Care, San Francisco, CA, USA
Introduction
This study is to determine the feasibility of evaluating the effect of music therapy, specifically Beethoven's Ninth
Symphony on brain-injured patients in the neurointensive care unit. A secondary aim of this study is to evaluate the
feasibility of commercially available wrist accelerometers (Fitbit ®) as non-invasive neurologic monitors.
Methods
Patients with a GCS score 5- 12 admitted > 24 hours and < 7 days were recruited from the Neuro ICU. The study
design is a 3-part randomized cross-over study consisting of daily 67-minute sessions: Beethoven's Ninth
Symphony via MP3 player with noise cancelling ear-buds, noise cancelation only, or control group with ear-buds
and music turned off. Outcome measurements included sedation and pain medication requirements, FOUR score,
NIHSS and activity with Fitbits ® placed on each wrist.
Results
Seven patients were identified and met study criteria. Three patients were excluded after consent was obtained: 2
due to an improvement in GCS after extubation and one due to incorrect date of onset. Four patients completed the
study protocol. Neurologic exam changed during the intervention for 75% patients (3/4). Anecdotal observations
during suggest patients appear to be more restful during the music session compared to other sessions. Analysis
of the Fitbit® data failed to show any lateral differences even when the patient had a hemiplegic exam. There were
no observed complications from this study.
Conclusions
Studying the effects of music on brain injured patients is feasible. Anecdotal evidence during the intervention
periods suggests music may be a safe and effective method of inducing restfulness in this patient population.
Future studies are needed to determine significance. This study was not powered to do so. Due to medical
necessity, all patients were restrained during the study period, which likely affected the results of Fitbit®. Fitbits®
do not appear to be useful neurologic monitors.
Financial Support: None
ICU ORG AND TECH
ePoster 50
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ICU ORG AND TECH
ePoster 52
___________________________________________________________________________________
AN INTERDISCIPLINARY COLLABORATIVE APPROACH TO IMPLEMENTING CRRT IN NEUROCRITICAL
CARE
Danielle M. Jaskulski, RN, Paul McCarthy, MD, Neeraj Badjatia, MD, Brigid Blaber, MS RN, Mary Ann Bautista,
RN, Rebecca Horrell, NP, Jennifer Miller, MD, Mehrnaz Pajoumand, Pharm MD, Deborah Stein, MD, Paul
Thurman, RN
University of Maryland Medical Center/ NeuroCare ICU, Baltimore, MD, USA
Introduction
Continuous renal replacement therapies (CRRT) are preferred to intermittent therapies in the critical care setting for
patients with hemodynamic instability or acute neurologic injury. The management of CRRT is often led by
consulting nephrologists. We describe the development of a neurocritical care driven CRRT program.
Methods
In July 2012 a team of neurointensivists, nurse practitioners, nurses, and pharmacist, developed a comprehensive
plan for a neurocritical managed CRRT program. Needs surrounding education, quality improvement, and research
were identified. Team members completed an 8-hour competency course, on-line training, a 4-hour simulation, and
precepting by experienced clinicians. The program started in February 2013.
Results
Between February 2013 and April 2014, nineteen patients (median age 60, median GCS 11) have undergone
CRRT. Primary diagnoses included subarachnoid hemorrhage (n = 3), ischemic stroke (n =2), intracerebral
hemorrhage (n = 7), status epilepticus (n = 4), subdural hematoma (n = 2), and anoxic brain injury (n = 1).
Indications for CRRT included acute kidney injury (n = 7), ESRD (n = 3), CHF/volume overload (n = 5), and
acidosis (n = 4). The median duration of therapy was 4 days (range: 1 - 21 days). The median ICU length of stay
was 7 days with a mortality rate of 26%. The majority of patients have been managed with CVVH without
anticoagulation. Nursing, pharmacy and advanced practitioners have been satisfied with the program and feel it
has contributed to care. Early in our program, filter clotting was problematic, largely attributed to CRRT prescription
management.
Conclusions
Our neurocritical care team has successfully managed a variety of patients on CRRT. Antibiotic and antiepileptic
drug utilization and biomarkers are areas for future study. The incidence of filter clotting is being addressed with
modifications in our prescription and the addition of a citrate protocol. The program will include therapeutic plasma
exchange in the future.
Financial Support: None
Neurocrit Care
63
ESTIMATED RADIATION EXPOSURE IN THE NEURO ICU: A RETROSPECTIVE SNAPSHOT OF PATTERNS
OF EXPOSURE IN A LARGE ACADEMIC MEDICAL CENTER
Avinash Kumar1, Cari Buckingham2
1
Dept of Anesthesia & Critical Care, vanderbilt University, Nashville, TN, USA, 2Dept of Radiology, Vanderbilt
University, Nashville, TN, USA
Introduction
The exposure to ionizing radiation has increased significantly with the wide availability of CT scans and portable
imaging technology. We examine the pattern of use of inpatient diagnostic imaging and radiation exposure in the
Neuro ICU patient population at a large academic medical center.
Methods
We retrospectively evaluated all patients admitted to the Neuro ICU at Vanderbilt University Medical Center from
Jan to Dec 31, 2013. We focused on CT scans since they contribute the maximum radiation exposure. Data was
electronically mined and cross-referenced to the patients EMR and radiology records. Radiation dose estimates
were calculated based on published reference values and conversion factors (primarily CT head w/wo contrast
(2msv), CT angio (7-10mSv), Ct Chest Abd, pelvis (10mSv), CT cerebral perfusion analysis (3.3 mSv).
Results
In the calendar year 2013, we had a total of 2154 admission encounters (F=1078). The mean age on admission
was 56.55Y ± 16.7. The mean length of ICU stay was 6.3 days. Mechanical ventilation was initiated on 420 with a
mean length on mechanical ventilation was 5.09 days. 2028 CT based scans were completed of which the vast
majority were Head CT without contrast (n=1209). 379 patients had multiple CT based studies. The mean number
of studies was 3.8 ± 2. The maximum number of studies on a single patient was 21. The number of patients with
more than 3 studies during their ICU stay was 159. The mean radiation exposure in all patients with more than one
CT study was 7.71 mSv±5.2 with a median exposure of 6mSv. This increased to a mean exposure of 10.11 ±
5.4mSv with a median of 8mSv.
Conclusions
Patients in the Neuro ICU are at a risk for significant exposure to ionizing radiation. Radiation exposure must be
factored into the culture of quality and patient safety in the ICU.
Financial Support: None
ICU ORG AND TECH
ePoster 53
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64
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ICU ORG AND TECH
ePoster 54
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CHALLENGES IN THE TREATMENT OF ACUTE NEUROLOGICAL ILLNESSES IN A TEACHING HOSPITAL IN
TANZANIA
Halinder S. Mangat1, Luke R. Smart2,3, Bahati M. Wajanga3, Robert N. Peck2,3
1
Weill Cornell Medical College / Department of Neurology, New York, NY, USA, 2Weill Cornell Medical College /
Center for Global Health, New York, NY, USA, 3Bugando Medical Center / Department of Medicine, Mwanza,
Tanzania
Introduction
There is a significant shortage of neurologists in sub-Saharan Africa. While this impacts management of chronic
diseases such as epilepsy, movement disorders, dementias, the impact on acute neurological illnesses is also
significant and under-recognized.
Methods
Educational visits were made by a neurologist over three years with participation in clinical and educational
activities. Patients were examined on ward rounds and teaching conferences. Medical residents were tested on
neurological examination and localization.
Results
Acute stroke, ischemic and hemorrhagic, meningitis, myelopathy and tetanus formed the most common
neurological diagnoses. Initial clinical examination from medical residents was limited for neurological details and
localization of lesion was not performed. Skull x-rays were performed in all trauma patients, while spine x-rays were
routinely performed in patients with para- or tetraplegia. CT scan was frequently non-functional and MRI
unavailable in the area. Lumbar punctures were performed routinely while myelograms were rarely performed.
Patients with tetanus were admitted to the ICU while patients with other acute illnesses were admitted to the ward.
Patients with tetanus were aggressively treated with benzodiazepenes and occasionally mechanical ventilation. No
treatment was available for patients with acute stroke and myelopathy. They were discharged home with residual
neurological deficit. We have developed an educational curriculum for medical residents, with emphasis on clinical
examination as a cornerstone in making clinical diagnoses. Utilisation of locally available techniques such as
myelography has been encouraged, while expeditious use of resources such as CSF analysis has been classified
as essential. Protocols for safe performance of lumbar puncture have been developed for patients with altered
mental status, based on clinical examination.
Conclusions
While intermittent visits and teaching by visiting specialists are helpful, there is an immense need to develop
educational programs for neurologists locally. Establishing robust patient databases may assist in estimating
burden of acute neurological illness in areas with scarcity of specialists.
Financial Support: None
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DECLINING POST-CARDIAC ARREST MORTALITY: WHERE DO PATIENTS DIE AND WHERE DO THEY
SURVIVE?
Yogesh Moradiya1, Santosh B Murthy1, Sneha Modi2, Romergryko G Geocadin1
1
Johns Hopkins University School of Medicine/Division of Neurosciences Critical Care, Baltimore, MD, USA,
2
MedStar Franklin Square Medical Center/Department of Medicine, Baltimore, MD, USA
Introduction
Large population-based studies show declining mortality after cardiac arrest (CA) in hospitalized patients, but the
impact of the components of "chain of survival" of cardiac arrest on changing mortality is unclear. To explore this
further, we studied trends in mortality of all cardiac arrests treated in emergency departments in the US.
Methods
We searched the Nationwide Emergency Department Sample (NEDS) from 2006-2011, a 20% stratified sample of
all ED visits in the US for adults with diagnosis of cardiac arrest (ICD-9 427.5). Trends in ED-mortality, inpatient
mortality among hospitalized patients, and overall survival to discharge were calculated by using logistic regression
using calendar year as a predictor variable. Population estimates were calculated using complex sample analysis
that accounts for weighting, clustering and stratification used for NEDS sampling design.
Results
Of the 1,623,940 (median age 68 year, 58.9% males) cases with CA, 53.7% died in the ED, and of the 618,928
patients surviving to admission, 62.4% died during hospitalization. The annual incidence of CA increased by 5,353
(95% CI: 3,649-7,075, P=0.001) cases with each calendar year. There was a statistically non-significant trend
toward increased ED-mortality from 52.4% (95% CI: 51-53.8%) in 2006 to 54% (52.7-55.3%) in 2011 (P=0.064). In
contrast, inpatient mortality among hospitalized patients decreased from 67.5% in 2006 (66.4-68.6%) to 59.3%
(58.3-60.3%) in 2011 resulting in 6.9% decreased odds of mortality (95% CI: 5.9-7.9%, P< 0.001) each year.
Overall survival after CA increased from 20.9% in 2006 (19.9-21.9%) to 23.9% (22.9-24.9%) in 2011, a 3.3% (95%
CI: 2-3.7%, P< 0.001) yearly increase in survival.
Conclusions
Recent improvement in post-CA mortality is largely limited to patients surviving to hospital admission, possibly
highlighting improving post-resuscitation care. The lack of improvement in ED-mortality suggests the need to revisit
and improve pre-hospital and active resuscitative components of the survival chain.
Financial Support: None
ICU ORG AND TECH
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ICU ORG AND TECH
ePoster 56
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CEREBRAL CRITICAL CLOSING PRESSURE: CAN WE OVERCOME NON PHYSIOLOGICAL RESULTS?
Corina Puppo1, Georgios V. Varsos2, Marek Czosnyka2
1
Emergency and Critical Care Departments, Clinics Hospital, Universidad de la República, Montevideo, Uruguay,
2
Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of
Cambridge, UK, Cambridge, United Kingdom
Introduction
Cerebral critical closing pressure (CrCP) is a value of arterial pressure at which brain small vessels collapse and
cerebral circulation ceases. It is theoretically equal or higher than intracranial pressure (ICP). The difference
between CrCP and ICP represents wall tension, a parameter expressing vasomotor tone of small arteries. The
value of CrCP is used in several models describing cerebral hemodynamics. Its accurate calculation is important
for assessment of continuity of cerebral blood flow. However, methods in use for calculation of CrCP (first harmonic
or systolic-diastolic values of Flow Velocity and Arterial Blood Pressure) often show non-interpretable negative
values, limiting the clinical use of this concept.
Methods
A data set of 35 severe TBI patients acquired between 2000 and 2009 at Addenbrooke's Hospital, Cambridge,
which showed negative CrCP values with the first harmonic method, was re-analysed. The recorded variables
were: transcranial Doppler cerebral blood flow velocity, invasive arterial blood pressure, and intracranial pressure.
Data were acquired at a frequency of 50 Hz, with a computer data acquisition system ICM+
(www.neurosurg.cam.ac.uk/icmplus) . The data, which showed negative values with the first harmonic method
(M1), were compared with a new impedance based estimator (M2). It takes into account systemic and cerebral
hemodynamic variables, as compliance and resistance of cerebral arterioles. Mean, minimum, and maximum CrCP
values, SD, percentage of values below zero, were studied and compared with M1 results. Continuous values were
also graphically analysed and compared.
Results
The median values of CrCP M1/M2 in these 35 patients, were -15/20.The lowest values were -168/0 mm Hg
respectively. With M2 all the values were positive and higher than ICP. There was a significant difference between
M1 and M2 values attributed to absence of negative values on M2.
Conclusions
This paper reinforces the fact that the impedance model renders physiologic values for CrCP, enhancing its
promise for use in clinical reality.
Financial Support: Financial Support: Conflict of interest: MC has a share of licensing fee for a software ICM+
distributed by Cambridge Enterprise Ltd.
Neurocrit Care
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BRAIN TISSUE OXYGEN MONITORING: EVALUATION OF A NOVEL MULTIPARAMETRIC BRAIN TISSUE
PROBE APPLYING NEAR INFRARED SPECTROSCOPY AND INDOCYANINE GREEN DYE DILUTION
Martin Seule1,2,3, Edgar Santos2, Berk Orakcioglu2, Emanuela Keller1, Gerhard Hildebrandt3, Andreas Unterberg2,
Oliver Sakowitz2
1
Neurointensive Care Unit/University Hospital Zurich, Zurich, Switzerland, 2Department of Neurosurgery/University
Heidelberg, Heidelberg, Germany, 3Department of Neurosurgery/Kantonsspital St. Gallen, St. Gallen, Switzerland
Introduction
Brain tissue oxygen (ptiO2) monitoring is widely accepted as a diagnostic tool for early detection of secondary
ischemia. We aimed to investigate the relationship between ptiO2 monitoring and specific parameters obtained by a
novel multi-parametric brain tissue probe (NeMo Probe).
Methods
Neuromonitoring including a ptiO2-probe (Licox, Integra LifeScience, USA) and NeMo Probe (NeMoDevices AG,
Switzerland) was performed in two patients with subarachnoid hemorrhage. Changes of oxygenated and
deoxygenated hemoglobin (Hboxy and Hbdeoxy) were measured using the NeMo Probe with integrated optical
fibers for near infrared spectroscopy. After intravenous injection of indocyanine green (ICG), the mean transit time
of ICG (mttICG), cerebral blood volume (CBV), and cerebral blood flow (CBF) were calculated. The Pearson
correlation was generated for statistical analysis.
Results
During the total monitoring period (217 hours) there was a significant correlation between ptiO2 and both Hboxy
and Hbdeoxy (p< 0.0001). In 59% of 66 analyzed intervals of 30 minutes duration with ptiO2 changes >5mmHg, a
strong correlation (r > 0.6) between ptiO2 and Hboxy was observed. In 30% of intervals there was still a significant
correlation (0.3 < r < 0.6). A similar trend existed for the correlation between ptiO2 and Hbdeoxy, but the frequency
of intervals with no correlation was lower for Hboxy compared to Hbdeoxy (11% vs. 30%; p=0.009). A total of 24
ICG-measurements were performed. Mean values were for mttICG 6.1 ± 0.8 s, CBV 3.6 ± 0.2 ml/100g and CBF
38.0 ± 7.2 ml/100g/min. There was a strong correlation between ptiO2 and both mttICG (p< 0.001) and CBF
(p=0.006).
Conclusions
This preliminary report indicates a good correlation between conventional ptiO2 monitoring and parameters of
cerebral blood flow and oxygenation changes obtained by the NeMo Probe. Further development of new algorithms
is necessary to estimate Hboxy and Hbdeoxy as absolute values and to define hypoxic thresholds.
Financial Support: NeMoDevices provided technical equipment for this clinical trial. M. Seule received grant
support by the "Stiefel-Zangger Foundation" of the University Zurich, Switzerland. E. Keller has a financial interest
as founder and member of board of NeMoDevices AG.
ICU ORG AND TECH
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ePoster 58
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CEREBRAL HYPOXEMIA DETECTION USING NEAR INFRA-RED SPECTROSCOPY AND OUTCOME IN
PATIENTS WITH ACUTE NEUROLOGICAL INJURY
Sameer Sharma, Dani Choufani, Mina Lobbous, Iulia Movileanu, Julius Gene Latorre
Upstate University hospital, Syracuse, NY, USA
Introduction
Secondary brain damage in acute brain injury occurs due to low cerebral perfusion and cerebral oxygenation.
Impaired cerebral autoregulation occurs during acute phase and maintenance of cerebral perfusion pressure
between 50-70mmHg has been advocated to prevent cerebral hypoxemia. Cerebral oximetry using near infrared
spectroscopy is a novel monitoring method to detect cerebral hypoxemia. We hypothesize that cerebral hypoxemia
detected by 7600 Equanox is associated with outcome in patients with acute brain injury
Methods
Patients with acute brain injuries admitted to Neuro-ICU were included in study after informed consent from
surrogate decision maker. Cerebral oximetry using 7600 Equanox was started and continued until 7 days or
discharge, whichever came first. Patients who were younger than 18 years, expected survival less than 48 hours,
being considered for withdrawal of care were excluded from enrollment.CPP and cerebral oxygenation values were
used for analysis. Aberrant values of oximetry were discarded prior to data analysis. The association between
outcome was analysed using chi-square against percentage of CPP values between 50-70 and cerebral
oxygenation values above 60%
Results
Data for 6 patients and 541 hours of recording was available for analysis of CPP.5 patients had combination of
traumatic SDH,IPH and SAH.1 patients had malignant MCA stroke.3/6 patients died. Survivors had greater time
within the target CPP compared with non-survivors(49.51%vs30.15%,chi-square=20.82,p< 0.001).Data for 14
patients was available for analysis of oximetry values with 980 hours of data.10 patients had a combination of
traumatic SDH,IPH and SAH,3 patients had malignant MCA stroke and 1 patient had non-convulsive status.7/14
patients died. Cerebral hypoxemia (defined as oximetry value below 60% measured by 7600 Equinox) was
detected in 2.83% of monitoring time in survivors compared with 7.96% in non-survivors (chi-square=24.53,p<
0.001)
Conclusions
Cerebral hypoxia detected by 7600 Equinox were more common among nonsurvivors in acute brain injury.
Whether cerebral oximetry-guided cerebral perfusion optimization strategy will affect outcome in acute brain injury
is unknown. Further studies using longer monitoring and more patients are needed to confirm these findings
Financial Support: 7600 Equanox was provided by Nonin Inc.
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DEVELOPMENT OF THE NEUROCRITICAL CARE NURSE PRACTITIONER
Erin E Silva1,2, Kathleen Ballman1,2, Jordan Bonomo1
1
University of Cincinnati Medical Center, Cincinnati, OH, USA, 2University of Cincinnati College of Nursing,
Cincinnati, OH, USA
Introduction
The growth of Neurocritical Care (NCC), restrictions placed on resident work-hours, and the need for consistent,
competent care providers all have increased the need for nurse practitioners (NPs) with specialized training in
NCC. While this need is present the description of how to adequately prepare NCC NPs is yet to be consistently
established. The purpose of this abstract is to understand available literature to support post-graduate education
for NPs and to explore competencies and training required to adequately prepare NPs to provide specialized care
in a NCC environment.
Methods
A literature review to assess existing post-graduate training for NPs was conducted. The programs were
qualitatively reviewed for content including program structure and competency and curriculum utilization.
Results
While mostly qualitative program evaluations exist describing individual programs it supports post-graduate
education for NPs. The review suggests with a structured post-graduate education program there is a decrease in
time to independent practice, increase in job satisfaction and confidence, increase in retention, and improved
compliance with practice guideline (Bahouth & Esposito-Herr, 2009; Brown, Besunder, & Bachmann, 2008; Flinter,
2011; Harrington, 2011a). Only 2 reviews include NCC NP evaluations and none describe standardizing
competencies for training in NCC.
Conclusions
The lack of standardized NCC NP competencies weakens the ability to effectively evaluate and compare NCC NP
residency programs throughout the country. The proposed solution is the development of an NCC NP residency
structured within a Doctorate of Nursing Practice (DNP) program with support from national societies in
neuroscience such as the Neurocritical Care Society (NCS) and the American Association of Neuroscience Nurses
(AANN) in order to collaborate and establish minimal competence required to safely practice NCC.
Financial Support: None
ICU ORG AND TECH
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ICU ORG AND TECH
ePoster 60
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ENHANCING STROKE TEAM CARE AND COMMUNICATION THROUGH AUTOMATION: IMPLEMENTATION
OF A MULTIDISCIPLINARY "ESTROKE DOC FLOWSHEET"
Jaime R Thomas1, Jeannette M Hester1, Peggy R Guin1, Joan M Drane1, Amy L Fullerton1, Michael F Waters2
1
UF Health Shands, Gainesville, FL, USA, 2UF Health Shands, Gainesville, FL, USA, 3UF Health Shands,
Gainesville, FL, USA, 4UF Health Shands, Gainesville, FL, USA, 5Uf Health Shands, Gainesville, FL, USA,
6
University of Florida, Neurology, Gainesville, FL, USA
Introduction
Healthcare providers today are under an unprecedented amount of pressure to efficiently deliver safe and effective
care despite challenging healthcare environments and limited resources. For stroke care providers, this presents a
unique challenge. Acute stroke interventions mandate effective communication across multiple disciplines, settings
and phases of care. These challenges have been appreciated by professional and regulatory agencies that are
charged with improving patient safety and quality outcomes via consistent implementation of evidence-based
guidelines, "meaningful use", and integration of information technology with clinical practice.
Methods
An interdisciplinary team involving nursing, physicians, speech language pathology (SLP), pharmacy and
information technology built an electronic stroke flowsheet in EPIC to facilitate timely communication and
documentation of stroke care across the continuum. Several barriers, including difficulties with Primary Stroke
Center metrics compliance, served as catalysts for the implementation of this change. The final product consisted
of a separate stroke doc flowsheet with integrated clinical decision support in the form of "Best Practice Advisories
(BPAs)", automated consults and targeted clinical prompts. The expectation was that the stroke doc flowsheet
would be completed for all patients presenting with suspected acute stroke or who were designated as "stroke
alert" status during their hospital stay.
Results
As a result, compliance with stroke metrics improved over a six month time frame (November 2012 through April
2013): documentation of post IV t-PA vital signs and neurological assessments (14.3% to 100%), adherence to
safe blood pressure parameters (78.6% to 100%), swallow screen evaluations prior to PO intake (69.8% to 90.4%).
In addition, real-time data capture enhanced the ability to maintain door-to-needle times less than sixty minutes in
at least 50% of eligible patients.
Conclusions
Well-designed, interdisciplinary electronic medical record enhancements promote quality and patient safety. In
addition, having stroke metrics captured in a consistent manner facilitates documentation and subsequent data
abstraction.
Financial Support: None
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ePoster 61
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INTERLEUKINS EXPRESSION IN A MODEL OF ISOLATED CONTROLLED HYPOTHERMIA FOLLOWED BY
REWARMING TO NORMOTHERMIA
Valeria Burgos1, Foda Rosciani2, Pablo Argibay1, Eduardo San Roman2, Fernando D Goldenberg1,2
1
Medical Research Institute, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina, 2Section of Neurocritical
Care, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
Introduction
Rewarming to normothermia is an important step in induced therapeutic hypothermia (TH). Several models have
shown that mild TH has anti-inflammatory effects but the molecular changes during subsequent rewarming are not
clearly understood. We have previously shown that rats exposed to TH for 2 h show a significant decrease in the
mRNA level of IL-6, a pro-inflammatory cytokine. Here, we analyze the gene expression of pro- and antiinflammatory cytokines after rewarming in a model of isolated controlled hypothermia.
Methods
Male rats were subjected to TH (32°C for 2 h) followed by a rewarming phase (37°C for 2 h) vs. Control rats (37°C).
Gene expression analysis was performed using real-time PCR in samples of peripheral blood taken at the end of
the rewarming phase or control.
Results
Rewarming from hypothermia led to a significant decrease in the mRNA levels of both IL-2 (p < 0.05) and IL-6 (p <
0.01) and an increase in the mRNA levels of TNF-RI (p < 0.05) as compared to the normothermic control. The rest
of the pro- and anti-inflammatory genes were not significantly different among groups (p > 0.05).
Conclusions
Our data show that exposing rats to TH followed by rewarming to normothermia is associated to a significant
decrease in the genetic expression of two pro-inflammatory cytokines, IL-2 and IL-6 and an increase in the genetic
expression of the anti-inflammatory cytokine TNF-RI. These findings if reproduced in a larger group of animals
exposed to TH and rewarming for longer periods of time, could explain some of the potential neuroprotectant
effects of TH in human clinical models.
Financial Support: None
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GLYCEMIC CONTROL IN CONTROLLED NORMOTHERMIA FOR ACUTE BRAIN INJURY
Kathryn A. Morbitzer1, Juinting Chiang1, Corey J. Witenko1,2, J. Dedrick Jordan3, Emily A. Durr1,2, Denise H.
Rhoney1
1
UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA, 2University of North Carolina Hospitals, Chapel Hill,
NC, USA, 3University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
Introduction
Short-term therapeutic hypothermia has been linked with higher blood glucose (BG) levels, increased BG
variability, and greater insulin requirements. However, no data exists investigating glycemic control in patients
undergoing controlled normothermia (CN). The purpose of this study was to analyze BG levels, variability, and
insulin requirements during CN.
Methods
This was a retrospective cohort study of adult patients with acute brain injury admitted to UNC Hospitals between
May 2010 and September 2013 who underwent CN for >24 hours. Data was collected at baseline, 48-hours prior to
CN, throughout CN, and 48-hours post-CN.
Results
Twenty-one patients comprising 1119 BG concentrations met inclusion criteria. The mean age was 50 (±17) years
and aneurysmal subarachnoid hemorrhage accounted for 48% of admitting diagnoses. The mean days from injury
to cooling was 4.4 (±2.4). Median BG was higher during pre-cooling (150±34 mg/dL) compared to CN (130±41
mg/dL) and post-cooling (134±40.5 mg/dL), while BG variability was similar during pre-cooling (51±34 mg/dL)
compared to post-cooling (51±37 mg/dL) and lower during CN (44±34.5 mg/dL). Fifteen patients pre-CN, 16
patients during CN, and 12 patients post-CN required insulin. Among patients who required insulin, median BG was
higher during pre-CN (160.5±28 mg/dL) compared to CN (150±35 mg/dL) and post-CN (147±40 mg/dL) while BG
variability was similar among all groups (Pre:56±31 vs. CN:54±32 vs. Post:55±27 mg/dL). Daily insulin usage was
higher during CN (27±47.5 units/day) compared to pre-CN (9±26 units/day) and post-CN (13±42 units/day).
Conclusions
Higher median BG levels occurred during pre-CN, suggesting the acute phase after injury has the greatest impact
on elevated BG concentrations. In patients who received insulin, greater insulin requirements during CN compared
to post-CN were required to achieve similar median BG concentrations, suggesting an altered response to insulin
during CN.
Financial Support: None
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ePoster 63
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DIFFUSION-WEIGHTED IMAGING IMPROVE PROGNOSTICATION POWER IN PATIENTS WITH
THERAPEUTIC HYPOTHERMIA AFTER CARDIAC ARREST
Yang-Je Cho1, Sung Soo Ahn2, Byung In Lee1
1
Department of Neurology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea, 2Department
of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
Introduction
MRI is a good prognosis tool in the various neurological disorders. However, the role of MRI in the prognostication
has not been confirmed. We evaluated the possible role of diffusion-weighted imaging (DWI) in the comatose
patients who received therapeutic hypothermia after cardiac arrest.
Methods
Integrated, team-based therapeutic hypothermia was set on September 2011 and MRI was performed in the
comatose patients 72 hours after cardiac arrest per protocol. Clinical outcome was assessed with cerebral
performance category. DWI findings, laboratory data, and outcomes of the patients between September 2011 and
October 2013 were analyzed. The voxels below different ADC thresholds was calculated at 50 x 10-6 mm2/sec
intervals, and % brain volume cut -off was estimated. Qualitative analysis of various brain region was compared.
Results
54 patients (out of 81 patients) received MRI per protocol was included. When the volume less than ADC value 550
x 10-6 mm2/sec was bigger than 7.5% of brain volume or the volume less than ADC value 650 x 10-6 mm2/sec was
bigger than 17.8% of brain volume, the sensitivity was 67.7% and 64.5%, respectively with specificity of 95.7% for
all (by ROC analysis; AUC, 0.804 and 0.794). Positive predictive value of poor outcome was 100% when ADC
value 550 x 10-6 mm2/sec was bigger than 10.9% or ADC value 650 x 10-6 mm2/sec was bigger than 27.6% or ADC
value 700 x 10-6 mm2/sec was bigger than 38.2% of brain volume. Analysis of diffusion restriction in the different
cortical and subcortical structures revealed basal ganglia, thalami, and occipital lobe as most appropriate target
(sensitivity, 74.9%, 71%, 77.4%; specificity 91.3%, 91.3%, 82.6%, respectively; AUC, 0.806 to 0.841) for poor
prognosis.
Conclusions
Using both quantitative and qualitative analysis, DWI can improve power of prognostication in patients with
therapeutic hypothermia after cardiac arrest.
Financial Support: None
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EARLY ABSENT PUPILLARY REFLEXES AFTER CARDIAC ARREST TREATED WITH THERAPEUTIC
HYPOTHERMIA
Laxmi P. Dhakal1, Ayan Sen 2, William D. Freeman 1
1
Mayo Clinic, Jacksonville, FL, USA, 2Mayo Clinic, Phoenix, AZ, USA
Introduction
Even under optimal conditions, cardiopulmonary resuscitation (CPR) generates no more than 20% of normal
cardiac output1. Low cardiac output, and medications could lead to brainstem reflex depression similar to cardiac
tissue stunning2.
Methods
After IRB approval, we retrospectively reviewed a consecutive series of cardiac arrest (CA) patients treated with
therapeutic hypothermia at Mayo Clinic Florida (January2006 to January 2012) and Arizona (August 2010 to March
2014). Cerebral Performance Category (CPC) was dichotomized into good outcome 1-2 and poor outcome 3-5.
Results
We identified 99 patients who had successful resuscitation after cardiac arrest. The mean age 60.5 years (IQR 4874), male 57 (57.5%) and ventricular fibrillation (VF) 34 was the most common code rhythm. Good outcome was
present in 15 of VF and 8 of asystole patients. 29 (29%) had non-reactive pupils at admission exam, of which 8
later had return of pupil reactivity by day 3 of hospitalization (D3). Two of these patients had good outcome
Conclusions
Early absent pupillary reflexes on the first day after resuscitation may result from transient brainstem reflex
stunning or possibly code drugs given during CPR. Caution is advised during the first 24 hours in neurological
prognostication since a minority of patients ultimately had a good neurological outcome
Financial Support: None
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ePoster 65
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EFFECT OF ANTIBIOTIC PROPHYLAXIS ON PNEUMONIA IN CARDIAC ARREST SURVIVORS TREATED
WITH TARGETED TEMPERATURE MANAGEMENT
David J. Gagnon1, Gilles L. Fraser1, Richard R. Riker1, John T. Dziodzio1, Niklas Nielsen2, David B. Seder1
1
Maine Medical Center, Portland, ME, USA, 2Helsingborg Hospital, Helsingborg, Sweden
Introduction
Early onset pneumonia affects up to 65% patients undergoing targeted temperature management (TTM) after
cardiac arrest. Prophylactic antibiotics (PRO) reduce the incidence of early-onset pneumonia in intubated patients
with diffuse brain injuries and coma but have yet to be examined in TTM. We investigated the effect of PRO on the
development of pneumonia in cardiac arrest survivors undergoing TTM.
Methods
This retrospective study interrogated the multinational Northern Hypothermia Network registry (2004-2008).
Patients were 18 years old, had a GCS < 8 at hospital admission, and were treated with TTM. There were no
formal exclusion criteria. Differences between the PRO and no PRO cohorts were analyzed through a univariate
analysis using standard parametric testing. Logistic regression models were created to evaluate the independent
effects of various clinical and demographic factors on the risk of developing pneumonia and on the incidence of
good functional outcome (CPC 1-2 at 6-12 month follow-up).
Results
Of the 1,240 patients, 416 (34%) received PRO and 824 (66%) did not. Groups were similar in age, gender, arrest
location, initial rhythm, and time to return of spontaneous circulation. More PRO patients were cooled via
endovascular methods (22.2% vs. 11.5%, p< 0.001). PRO patients had a lower incidence of pneumonia (12.6% vs.
54.9%, p< 0.0001), less severe sepsis (1.2% vs. 5.7%, p< 0.001), and a shorter ICU stay (121 vs. 152 hours,
p=0.001) but a similar incidence of good functional outcome (41.1% vs. 36.6%, p=0.19). In the multivariable
models, stepwise logistic regression demonstrated PRO was independently associated with a lower incidence of
pneumonia (OR 0.09, p< 0.0001) but was not associated with good functional outcome.
Conclusions
Prophylactic antibiotics in patients treated with TTM after cardiac arrest was associated with a reduced incidence of
pneumonia but not with improved functional outcome. Further prospective studies on the impact of prophylactic
antibiotics are warranted.
Financial Support: None
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STATUS EPILEPTICUS DOES NOT ALWAYS INDICATE POOR OUTCOME IN THERAPEUTIC HYPOTHERMIA
AFTER CARDIAC ARREST
Kyung Min Kim, Byung In Lee, Kyoung Heo, Yang-Je Cho
Department of Neurology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
Introduction
Status epilepticus (SE) after cardiac arrest has been known as a predictor of grave prognosis. However, SE is not
a definite predictor of poor prognosis favoring the withdrawal of life supports, and small percentage of the patients
may benefit from the aggressive treatment. We studied the benefit of aggressive antiepileptic treatments in patients
with SE who received therapeutic hypothermia after cardiac arrest.
Methods
Integrated, team-based therapeutic hypothermia was set to start on September 2011. SE was aggressively
managed with intravenous midazolam and various antiepileptic drugs as soon as possible under continuous EEG
monitoring. Clinical characteristics, laboratory data, and outcomes of the SE patients after cardiac arrest between
September 2011 and October 2013 were used in analysis.
Results
Total 81 patients (65 men, mean age 55.8 years) were included in the study. SE was present in 23 patients
(28.4%), and 78.3% of them (18 out of 23) had myoclonic SE. Good prognosis (CPC 4-5) was found in 17.4% (4
out of 23) of the SE patients, which was in contrast with 40.7% of good prognosis in entire study population.
Mortality was found in only two patients (8.7%), although most patients were remained in CPC 4 outcome (16 out
of 23, 69.6%). Five patients recovered to fully communicable status were all in cardiac origin (60% non-shockable
rhythm), and had 41.8 minute of arrest time. Three of the five good survivors had non-myoclonic SE and
successfully treated with antiepileptic drugs. One patient with myoclonic SE had persistent myoclonic seizure, and
one patient showed only generalized spikes on EEG without clinical myoclonus.
Conclusions
Considerable number of the SE patients regained their consciousness and 60% of them suffered from nonmyoclonic SE, indicating the importance of identifying myoclonic or non-myoclonic SE. Further study to delineate
the positive effect of aggressive antiepileptic treatment should be considered.
Financial Support: None
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SYSTEMATIC QUALITY ASSESSMENT OF PUBLISHED ANTISHIVERING PROTOCOLS
Taehoon Lee1, Bomi Park1, Krishna C. Bolla1, Jehun Sung1, Shwetha Chiluveru1, Seami Park1, Karen Berger2, Axel
Rosengart1
1
Departments of Neurology, Neuroscience and Neurosurgery Weill Cornell Medical College-New York Presbyterian
Hospital, New York, NY, USA, 2Department of Pharmacy New York Presbyterian Hospital, New York, NY, USA
Introduction
Shivering is a common and problematic side effect of targeted temperature modulation and general anesthesia.
Antishivering strategies often employ a combination of pharmacological and physical interventions utilized in a
stepwise approach according to institutional treatment protocols. We evaluated the quality of antishivering
protocols and guidelines with respect to reliability and strength of evidence-based recommendations.
Methods
A total of 3,062 publications were retrieved from four medical databases and 2,445 excluded due to lack of
relevance. After applying predefined eligibility criteria with respect to minimal protocol standards, 16
protocols/guidelines remained. Each was assessed using the modified Appraisal-of-Guidelines-for-Research-andEvaluation-II (mAGREEII). Each of the 23 quality items within 6 domains was applied using a nominal scale
(Yes=1, No=0 point; total score range 0-23).
Results
Among the 16 protocols/guidelines, only one embodied systematically reviewed recommendations; the remaining
15 aimed at establishing standardized protocols. 14/16 protocols/guidelines focused on therapeutic cooling in
which skin counterwarming and meperidine were most commonly cited. Of all 14 protocols a variety of individual
and combination treatments were recommended and their mAGREEII scores were within the lowest quartile
ranging from 1 to 6 (median 5). Most commonly unaddressed domains were stakeholder involvement (Domain 2),
rigor of development (Domain 3) and editorial independence (Domain 6). 2/16 protocols/guidelines addressed
postanesthetic antishivering strategies. Of these two, the ASA (American Society of Anesthesiologists) guideline
containing recommendations of forced-air warming device and meperidine received the highest mAGREE II score
(14 points); the other protocol suggesting the combination of warming device with clonidine or meperidine had a
lower mAGREE II score (4 points).
Conclusions
Current published antishivering protocols/guidelines lack evidence-based recommendations. Only one guideline
fulfilled more than fifty percent of the quality items. To be consistent with the most up-to-date, evidence-based
practice, future antishivering treatment protocols should optimize methodological rigor and transparency.
Financial Support: None
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RETROSPECTIVE COMPARISON OF IV VERSUS ENTERAL IBUPROFEN FOR FEVER CONTROL IN
NEUROCRITICALLY ILL PATIENTS
Christine A. Lesch1, Yousaf Ajam2, Abdullah Mohammed2, Angela G Velasquez2, Jan Claassen2, Michael J
Schmidt2, Sachin Agarwal2
1
NewYork-Presbyterian Hospital, Columbia University Medical Center, Department of Pharmacy, New York, NY,
USA, 2Columbia University College of Physicians and Surgeons, Departments of Neurology and Neurosurgery,
New York, NY, USA
Introduction
Fever in neurologically injured patients is associated with poor outcome. Pharmacokinetics studies have
demonstrated comparable bioavailability of enteral (PO) and intravenous (IV) ibuprofen in healthy adults. We
hypothesized that fever control in critically ill patients is comparable between IV and PO ibuprofen.
Methods
A single-center, retrospective study on patients admitted at Columbia University Medical Center NeuroICU from
2011-2013 and received at least 4 doses of PO or IV ibuprofen in a 24 hour time period. Fever burden was
calculated hourly by subtracting each patient's recorded temperature from 37°C. Complications were collected only
for the period of drug administration.
Results
There were 39 patients (median age 56; 49% women) with 1505 hours of data (PO: 1090; IV: 450) on brain
hemorrhages (54%), ischemic stroke (13%), meningo-encephalitis (18%), and other diagnoses (15%). Median
dose of ibuprofen and acetaminophen were 2200 and 650 mg respectively. Mean fever burden was statistically
lower with IV vs PO ibuprofen (0.59+/-0.7 vs 0.75+/-0.8, p=0.001). Acetaminophen when administered with
ibuprofen regardless of ibuprofen dose or route, resulted in a lower fever burden compared to those who didn't
receive acetaminophen for both PRN (0.13+/-0.05 p=0.01) and standing doses of acetaminophen (0.4+/-0.06, p<
0.01). Higher doses of acetaminophen taken with ibuprofen regardless of ibuprofen dose or route resulted in a
lower fever burden (0.36+/-0.06, p< 0.01) compared to lower doses (0.16+/-0.05, p=0.002). Complications from
ibuprofen included 5 (13%) patients with hemoglobin drop > 2 g/dL, 7 (18%) developed a serum creatinine (mg/dL)
>1.5 times from baseline and 7 (18%) developed a platelet drop > 20% from the prior day lab.
Conclusions
Intravenous ibuprofen resulted in better fever control compared to enteral. The combination of acetaminophen to
ibuprofen regardless of ibuprofen route or dose results in better fever control than ibuprofen alone. The high
complication rates warrant caution with use.
Financial Support: The presenting author has received research support for a different study by Cumberland
Pharmaceuticals
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IMPACT OF BODY TEMPERATURE ON OUTCOME AFTER TBI
Lori K. Madden1,2, Shelley Blozis3, Ava Puccio4, Holli DeVon5
1
University of California Davis, Betty Irene Moore School of Nursing, Sacramento, CA, USA, 2University of
California Davis, Department of Neurological Surgery, Sacramento, CA, USA, 3University of California Davis,
Department of Psychology, Davis, CA, USA, 4University of Pittsburgh, Neurological Surgery, Pittsburgh, PA, USA,
5
University of Illinois at Chicago, College of Nursing, Chicago, IL, USA
Introduction
Treatment goals for patients with traumatic brain injury (TBI) address minimizing the effects of primary injury and
avoiding secondary injury. Targeted temperature management is a strategy to avoid secondary injury following TBI.
The purpose of this study was to examine the association between body temperature and neurologic outcome in
adults after moderate or severe TBI.
Methods
Secondary analysis of 340 patients with moderate or severe TBI (GCS < 13) was completed. Aberrant
temperatures were defined as < 36.5°C (hypothermia) or > 37.5°C (fever). Temperature profiles were evaluated in
24 hour increments (0 to < 24; 24 to < 48; 48 to < 72; 72 to 96 hours). Neurological outcome was measured at six
months after injury using the Extended Glasgow Outcome Scale (GOS-E).
Results
Eighty-six percent of those patients with any temperature < 36.5°C and 79% with any temperature > 37.5°C in the
first 24 hours died. Variability in body temperature over the 96-hour period was significantly associated with GOS-E
both in univariate (p=0.000) and multivariate (p=0.035) assessment. When stratified by temperature severity, both
mild fever (37.6-38.2°C; p=0.046) and high fever (>39.0°C; p=0.038) were significantly associated with GOS-E.
Hypothermia in the first 24-hour period (p=0.018) and fever in the first 24 hours (p=0.012) or the 24 to < 48-hour
period (p=0.006) were all significantly associated with GOS-E. Controlling for known predictors of neurologic
outcome, fever in the first 48 hours after injury, hypothermia in the first 24 hours after injury, minimum and
maximum temperature in the 48-72 hour period, and variation in temperature across the 96-hour period were all
predictors of GOS-E.
Conclusions
Body temperature in the 96 hours after moderate to severe TBI significantly influenced neurologic outcome.
Controlled normothermia may be a beneficial approach in reducing secondary injury following TBI. Further
research is necessary to confirm these findings in a controlled prospective environment.
Financial Support: National Institute of Nursing Research, NIH, Grant #F31NR013813 Gordon and Betty Moore
Foundation
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SOCIO-ECONOMIC DISPARITIES AND TRENDS IN THERAPEUTIC HYPOTHERMIA UTILIZATION AFTER
CARDIAC ARREST IN THE UNITED STATES, 2006-2011
Yogesh Moradiya1, Santosh B Murthy1, Sneha Modi2, Romergryko G Geocadin1
1
Johns Hopkins University School of Medicine/Division of Neurosciences Critical Care, Baltimore, MD, USA,
2
MedStar Franklin Square Medical Center/Department of Medicine, Baltimore, MD, USA
Introduction
Therapeutic hypothermia (TH) has been strongly recommended for post-cardiac arrest (CA) comatose patients by
the American Heart Association and the International Liaison Committee on Resuscitation since 2003 but it
remains underutilized in the United States (US). With accumulating evidence of benefit, improving techniques,
attitudes toward therapy, we studied recent trends and epidemiologic predictors of TH utilization after CA.
Methods
We searched the Nationwide Inpatient Sample (NIS) 2006-2011, a stratified random sample of 20% of all
hospitalizations in non-federal US hospitals for adults with CA (ICD-9 code 427.5) who underwent therapeutic
hypothermia (code 99.81). Logistic regression analysis was performed to identify independent predictors of TH
utilization. We calculated TH utilization trends using Mantel-Haenszel test for linear association. Population
estimates and variance were calculated using complex sample analysis that accounts for weighting, clustering and
stratification used for NIS sampling design.
Results
861,890 cases (median age 69 year, 54.7% males) of CA were included, of whom 10,421(1.21±0.08% [SE])
underwent TH. The adjusted rates of TH utilization were lower among elderly (P< 0.001), Black (P< 0.001) and
Hispanic (P< 0.001) vs. White, and female vs. male (P=0.009), and were higher among patients with private
insurance vs. Medicare (P=0.002) and highest vs. lowest income quartile (P=0.003). The overall TH utilization rate
increased from 0.25±0.1% of all CA cases treated in 2006 to 2.65±0.21% in 2011 (trend P< 0.001). After controlling
for confounders, the odds of TH utilization in CA increased by 60% (95% CI: 54-66%) with each calendar year.
Conclusions
There exist significant socio-economic disparities in TH utilization after CA with lower rates of utilization among
elderly, females and non-white patients and those with Medicare insurance and low income. Though TH utilization
has increased in recent years, a substantial proportion of eligible patients do not receive this treatment. Barriers to
the TH utilization need further study.
Financial Support: None
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EFFICACY OF NON-PHARMACOLOGICAL ANTISHIVERING INTERVENTIONS: A SYSTEMATIC
ASSESSMENT/ANALYSIS
Bomi Park1, Taehoon Lee1, Karen Berger2, Krishna C. Bolla1, Koeun Choi1, Seami Park1, Axel Rosengart1
1
Departments of Neurology, Neuroscience and Neurosurgery Weill Cornell Medical College, New York, NY, USA,
2
Department of Pharmacy New York Presbyterian Hospital, New York, NY, USA
Introduction
Shivering is a frequent complication observed in the perioperative and induced hypothermia (IH) settings. Despite
effective antishivering pharmacological treatment options, non-pharmacologic (physical) interventions are often
employed in order to reduce the risk for adverse drug effects associated with many of these medications. Our
objective was to critically evaluate the published evidence of non-pharmacologic antishivering interventions.
Methods
4,258 clinical trials on non-pharmacological antishivering methodologies were retrieved as of April 2014 from
several medical databases using predefined search terms. After applying exclusion criteria, 62 trials (3,146
subjects) studied non-pharmacological interventions on patients without thermoregulatory dysfunction. Publications
were descriptively analyzed by types of clinical setting, comparison of intervention, and study design, and then
underwent a quality assessment.
Results
Physical interventions identified were a) active cutaneous warming (forced-air warming, electric heating
pad/blanket, radiant heating, and water-circulating mattress), b) body core warming (fluid or gas warming system),
c) passive cutaneous warming (space blankets, towels), and d) electroacupuncture. Comparisons against controls
were most common (57/72) while 15 studies compared treatments against each other. Clinical settings included a)
perioperative setting without IH (55/72) and b) with IH (9/72) and c) IH without anesthesia (8/72). Active cutaneous
warming was most commonly studied (32/72) and consistently reported better outcomes than controls in all three
settings. In contrast, results from studies investigating passive cutaneous warming and body core warming were
contradicting. Evidence for the usefulness of electroacupuncture was lacking. Comparison evaluations among
different interventions were inconclusive due to the paucity and heterogeneity of studies comparing directly
different interventions against one another.
Conclusions
Comparative assessment of the effectiveness of non-pharmacological antishivering methods delineates active
cutaneous warming as the most effective non-pharmacologic intervention. However, the heterogeneity of the
published evidence, lack of adequately designed studies, and relatively low number of intervention comparison
trials precluded statistically appropriate analysis for definitive evidence-based recommendations.
Financial Support: None
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GLYCEMIC CONTROL IN PROLONGED THERAPEUTIC HYPOTHERMIA FOR ACUTE BRAIN INJURY
Corey J. Witenko1,2, Kathryn A. Morbitzer2, Juinting Chiang2, Emily A. Durr1,2, J. Dedrick Jordan3, Denise H.
Rhoney2
1
University of North Carolina Hospitals, Chapel Hill, NC, USA, 2UNC Eshelman School of Pharmacy, Chapel Hill,
NC, USA, 3University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
Introduction
Short-term therapeutic hypothermia (TH) has been linked with higher blood glucose (BG) levels, increased BG
variability, and greater insulin requirements. No data exists investigating glycemic control during prolonged TH. The
purpose of this study was to analyze BG levels, variability, and insulin requirements during prolonged TH.
Methods
This was a retrospective cohort study of adult patients with acute brain injury admitted to UNC Hospitals between
May 2010 and September 2013 who underwent TH for >24 hours. Data was collected at baseline, 48-hours prior to
TH, throughout TH, and 48-hours post-TH.
Results
Sixteen patients comprising 1071 BG concentrations met inclusion criteria. The mean age was 41±18 years and
TBI accounted for 56.3% of the admitting diagnoses. The mean days from injury to cooling was 2.8±2.4. Median
BG (143±25.5 vs. 110±35.25 vs. 116.5±28.8 mg/dL) and BG variability (82±71 vs. 46±53 vs. 61±29 mg/dL) were
higher during pre-TH compared to TH and post-TH, respectively. Nine patients during pre-TH and TH and 7
patients during post-TH required insulin. Among patients who required insulin, median BG (147±34 vs. 133±35.5
vs. 132±10.5 mg/dL) and BG variability (96±111 vs. 75±68 vs. 61±22 mg/dL) were higher during pre-TH compared
to TH and post-TH. Insulin usage was higher during TH (34±60 units/day) compared to pre-TH (18±25.5) and postTH (4±4 units/day). More patients who received insulin experienced at least one hypoglycemic event during TH
(33.3%) compared to pre-TH (11.1%) and post-TH (0%) and at least one hyperglycemic event during pre-TH
(77.8%) compared to TH (55.6%) and post-TH (42.9%).
Conclusions
Higher BG levels and increased variability occurred during pre-TH, suggesting the acute phase after injury has the
greatest impact on BG and variability. In patients who received insulin, greater insulin requirements, increased BG
variability and more hyper- and hypoglycemic events occurred during TH compared to post-TH, suggesting an
altered response to insulin during TH.
Financial Support: None
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VANCOMYCIN PHARMACOKINETIC PARAMETERS IN PATIENTS WITH ACUTE BRAIN INJURY
UNDERGOING CONTROLLED NORMOTHERMIA
Kathryn A. Morbitzer1, J. Dedrick Jordan2, Emily A. Durr1,3, Denise H. Rhoney1
1
UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA, 2University of North Carolina at Chapel Hill School of
Medicine, Chapel Hill, NC, USA, 3University of North Carolina Hospitals, Chapel Hill, NC, USA
Introduction
Critically ill patients have been shown to exhibit a hyperdynamic response and sustained elevation of creatinine
clearance, termed augmented renal clearance (ARC). Controlled normothermia (CN) is utilized in patients with
acute brain injury to manage fever. Therapeutic hypothermia has been shown to decrease metabolic rate.
However, no data exists investigating the impact of ARC and controlled normothermia on achieving target
vancomycin therapeutic concentrations. The purpose of this study was to evaluate pharmacokinetic parameters of
vancomycin in patients with acute brain injury undergoing CN.
Methods
This was a retrospective cohort study of adult patients with acute brain injury admitted to UNC Hospitals between
May 2010 and March 2014 who underwent CN and received vancomycin. Predicted PK parameters based on
population data were compared with calculated PK parameters based on serum concentrations.
Results
Seventeen patients comprising 24 vancomycin steady-state serum concentrations met inclusion criteria.
Aneurysmal subarachnoid hemorrhage (47%) and traumatic brain injury (41%) accounted for the majority of
admitting diagnoses. Serum concentrations were obtained a median of 3.5±4 days into CN. Patients had a median
creatinine clearance of 121±70 mL/min and median volume of distribution of 58.1±16.1 L, estimated according to
standard methods. The median dosing regimen was 17.1±5.7 mg/kg every 8±2 hours. The median measured
trough concentration (10.8±5.9 vs. 17.2±11.2 ȝg/mL;p=0.001) and median calculated half-life (4.6±2.3 vs. 6.7±3.3
hr;p=0.043) were significantly lower than predicted values. The median calculated elimination rate constant
(0.15±0.059 vs. 0.105±0.064 hr-1;p=0.044) was significantly higher than the predicted value.
Conclusions
Patients with acute brain injury who underwent CN exhibited PK alterations favoring increased elimination of
vancomycin when compared to predicted PK parameters based on population data. This suggests that the
elevated renal elimination of vancomycin due to ARC outweighs a potential reduction in drug elimination caused by
CN, which may result in serious complications as a consequence of undertreatment of infections.
Financial Support: None
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VANCOMYCIN PHARMACOKINETIC PARAMETERS IN PATIENTS WITH ACUTE BRAIN INJURY
UNDERGOING PENTOBARBITAL INFUSION OR THERAPEUTIC HYPOTHERMIA
Kathryn A. Morbitzer1, J. Dedrick Jordan2, Emily A. Durr1,3, Denise H. Rhoney1
1
UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA, 2University of North Carolina at Chapel Hill School of
Medicine, Chapel Hill, NC, USA, 3University of North Carolina Hospitals, Chapel Hill, NC, USA
Introduction
Critically ill patients have been shown to exhibit a hyperdynamic response and sustained elevation of creatinine
clearance, termed augmented renal clearance (ARC). Pentobarbital infusion and prolonged induced moderate
therapeutic hypothermia (TH) decrease the metabolic rate and are used for complications associated with acute
brain injury. No data exists investigating the impact of ARC, TH, and pentobarbital on achieving target vancomycin
therapeutic concentrations. The purpose of this study was to evaluate pharmacokinetic parameters of vancomycin
in patients with acute brain injury undergoing TH or pentobarbital infusion.
Methods
This was a retrospective cohort study of adult patients with acute brain injury admitted to UNC Hospitals between
May 2010 and March 2014 who underwent pentobarbital infusion or TH and received vancomycin. Predicted PK
parameters based on population data were compared with calculated PK parameters based on serum
concentrations.
Results
Ten patients comprising 14 vancomycin steady-state serum concentrations met inclusion criteria. Traumatic brain
injury accounted for 50% of admitting diagnoses and serum concentrations were obtained a median of 4±4 days
into TH or pentobarbital infusion. Patients had a median creatinine clearance of 122±63 mL/min and median
volume of distribution of 57.8±16.1 L, estimated according to standard methods. The median dosing regimen was
15.7 mg/kg every 8 hours. No significant differences were found for the median measured compared to predicted
trough concentration (15.5±6.3 vs. 15.9±13.2 ȝg/mL;p=0.818), median calculated compared to predicted
elimination rate constant (0.107±0.027 vs. 0.107±0.047 hr-1;p=0.982), and median calculated compared to
predicted half-life (6.5±1.9 vs. 6.5±3.6 hr;p=0.945).
Conclusions
Patients with acute brain injury who underwent pentobarbital infusion or therapeutic hypothermia did not exhibit PK
alterations when compared to predicted PK parameters based on population data. This suggests that the
decreased metabolic rate caused by therapeutic hypothermia and pentobarbital infusions may counterbalance the
augmented renal clearance experienced by patients with acute brain injury.
Financial Support: None
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THE HEART-BRAIN CONNECTION. SUDDEN UNEXPECTED CARDIAC DEATH IN LATERAL MEDULLARY
SYNDROME: A MISSING LINK?
M. Ali Babi M.D, Kiran Rajneesh M.D, M.S, Mark Gorman M.D, Christopher Commichau M.D
Fletcher Allen Healthcare and the University of Vermont, Department of Neurosciences, Burlington, VT, USA
Introduction
Cases of sudden unexpected cardiac death in lower brainstem infarction have been described the literature.
However, the pathogenesis surrounding the mechanism of cardiac arrest is not well understood. We report a case
of sudden death in a patient who presented with acute lateral medullary syndrome.
Methods
This is a case review with review of previously described case reports (Pubmed search). Our patient presented
with a clinical diagnosis of acute lateral medullary (Wallenberg) syndrome with CTangiography notable for occluded
left vertebral artery. As part of stroke evaluation, cardiac biomarkers, electrolytes, echocardiography, and ECG
were all normal and the patient had no previously known cardiac pathology. The patient was monitored on
telemetry during admission, demonstrating no arrhythmias until the time of sudden unexpected cardiac arrest.
Results
Because of prominent dysphagia, we placed a nasogastric tube (NGT) in the gastric antrum under real-time
bedside electromagnetic guidance (Cortrak®). However 15 minutes after placement of the NGT, the patient
developed severe bradycardia, progressing to asystole. Return of spontaneous circulation only occurred after 60
minutes of CPR including transvenous cardiac pacing. Family eventually withdrew care.
Conclusions
This case highlights a rare potential complication of lower brainstem ischemia culminating in sudden cardiac arrest.
This poorly understood manifestation seems different from well-described sudden cardiac arrest in supratentorial
lesions, which usually present as ventricular tachycardia/ ventricular fibrillation followed by asystole and circulatory
collapse. In this case, we speculate that brainstem ischemia influencing cardiac and respiratory centers created
autonomic dysregulation and vagal overtone in the setting of vagal stimulation from NGT placement led to severe
parasympathetic overflow (storm) and culminated in severe bradycardia and asystolic cardiac arrest. In conclusion,
rare, yet fatal arrhythmias occur in acute brainstem ischemia, and particularly in lateral medullary syndrome and
may be potentially avoidable. We suggest avoiding procedures or maneuvers that may be associated with
increased vagal overtone.
Financial Support: None
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PREDICTORS OF HEMORRHAGIC TRANSFORMATION IN PATIENTS TREATED WITH INTRA-ARTERIAL
THROMBOLYSIS AND MECHANICAL THROMBECTOMY: A REAL WORLD EXPERIENCE
Gisele S Silva1,2, Renata A Miranda1, Rodrigo M Massaud1, Andreia M Vacari1
1
Programa Integrado de Neurologia, Hospital Israelita Albert Einstein, São Paulo, Brazil, 2Departamento de
Neurologia e Neurcirurgia, UNIFESP, São Paulo, Brazil
Introduction
Hemorrhagic transformation (HT) is a feared complication of intra-arterial (IA) thrombolytic therapy in patients with
acute ischemic stroke (AIS). Predictors of HT in the era of mechanical thrombectomy are not well established. The
aim of our study was to evaluate the frequency of HT and its predictors in a series of patients with AIS treated with
either IA thrombolysis and/or mechanical thrombectomy outside a clinical trial.
Methods
We evaluated a database of consecutive patients admitted to a Brazilian tertiary hospital with AIS treated with
either IA thrombolysis and/or mechanical thrombectomy from January 2009 to December 2013. Categorical
comparisons were made by the chi-square or Fisher exact test. We used logistic regression analysis to investigate
predictors of any HT.
Results
Forty-eight patients were treated. The median baseline National Institutes of Health Stroke Scale score was 16 [1121], and mean age was 68.8+/-16.5 years. A total of 33.3% of the patients were treated with IA thrombolysis and
mechanical thrombectomy (solitaire and/or penumbra devices used), 22.9% received only IA thrombolysis, 22.9%
only mechanical thrombectomy, 12.5% intravenous (IV) rtPA followed by mechanical thrombectomy, 6.4% IV rtPA
followed by mechanical thrombectomy and IA thrombolysis and 2% of the patients received only IA thrombolysis.
Any HT occurred in 14 patients (29.8%). Systolic blood pressure at admission (OR 1.01 [1.01-1.08, p=0.02),
ASPECTS scores (OR 0.44 [0.23-0.82, p=0.01), platelet count (OR 0.98 [0.97-0.99], history of diabetes (OR 4,5
[1.14-17.73] and hyperthermia in the first 48 hours peri-procedure (OR 5.5 [1.1-27.8], p=.03) were univariate
predictors of HT. On multivariate analysis, only the ASPECTS score remained as an independent predictor of HT.
Conclusions
In this real-world series of patients treated with IA thrombolysis and/or mechanical thrombectomy the burden of
ischemic lesion at admission measured using the ASPECTS scores was the only independent predictor of HT.
Financial Support: None
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RECURRENT ISCHEMIC STROKE AS A FIRST MANIFESTATION OF POORLY DIFFERENTIATED
CARCINOMA (PDC) OF UNKNOWN ETIOLOGY
Dani I Choufani, Julius G Latorre, Mina Lobbous
Upstate University Hospital/ Neurocritical Care, Syracuse, NY, USA
Introduction
We report a case of recurrent ischemic strokes resistant to anticoagulation as the first manifestation of poorly
differentiated carcinoma (PDC) of unknown etiology. It is first case reported in the literature.
Methods
Case Report: A 57-year-old male patient presented to our hospital with non fluent aphasia. Clinical examination
revealed a right inferior quadrantanopsia, a right upper extremity hemiparesis, and aphasia. MRI of the brain
showed acute infarcts in multiple vascular territories. A 4-vessel cerebral angiogram was normal. Work-up for
systemic vasculitis was unremarkable but the hexagonal phase phospholipid neutralization test was abnormal. A
systemic anticoagulation was recommended by Hematology team. While the patient was in rehabilitation, he
started complaining of abdominal pain. A CT of the abdomen showed heterogeneously enhanced lesion within the
lower pole of the right kidney and bulky extensive lymphadenopathy involving the retroperitoneum, gastrohepatic
ligament and retrocrural regions. Prior to scheduled a biopsy, the patient developed dysarthria and worsening of his
language deficit. He was readmitted. Repeat brain MRI showed new areas of acute ischemic infarction scattered
on multiple vascular territories despite adequate anticoagulation. Within 24 hours, the patient's mental status
declined. Repeat Brain MRI showed further development of new ischemic infarction affecting multiple cerebral
vasculature. Lymph node biopsy revealed poorly malignant carcinoma of unknown primary.
Conclusions
Discussion: Recent study showed that infarction in multiple vascular territories in stroke patients associated with
cancer is significantly elevated (34%), compared to 15% of stroke patients not associated with cancer. It may be
prudent to include neoplastic screening in cryptogenic stroke evaluation, especially if multiple vascular territories
are involved without clear embolic source. Despite adequate anticoagulation, our patient continued to have new
embolic infarction leading to his death. Whether early diagnosis and aggressive chemotherapy prior to the
recurrence of the patient's strokes could have made a difference is unknown.
Financial Support: None
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MORTALITY AND LOCATION OF LONG-TERM CARE AMONG OLDER ISCHEMIC STROKE PATIENTS
UNDERGOING DECOMPRESSIVE HEMICRANIECTOMY IN THE UNITED STATES
Corey R Fehnel1,2, Yoojin Lee2, N Stevenson Potter1, Bradford B Thompson1, Linda C Wendell1, Vincent Mor2
1
Rhode Island Hospital/Brown Alpert Medical School Division of Neurocritical Care, Providence, RI, USA, 2Brown
University School of Public Health/Department of Health Services, Policy & Practice, Providence, RI, USA
Introduction
Patients and families frequently inquire about the likelihood severe stroke survivors will ever return home. While a
survival benefit with Decompressive Hemicraniectomy (DHC) in older adults was shown in DESTINY II,
improvement in disability is controversial. To better inform decision-making, we estimated rates of mortality and
location of long-term care with a nationwide retrospective cohort of ischemic stroke patients over the age of 65
following DHC.
Methods
Cases were identified by ICD-9 principal diagnosis codes for Acute Ischemic Stroke (434.x and 436.x) from all
Medicare fee for service hospital discharges from January 1, 2008 to December 31, 2008. Inclusion criteria
consisted of ICD-9 procedure codes for craniectomy within seven days of the index admission. Secondary ICD
codes for traumatic head injuries and spontaneous cerebral hemorrhage were excluded. A per-person
chronological history of health care utilization and location of care, including being a long stay nursing home
resident, was developed using linked Medicare Part A, Part B, Minimum Data Set Assessments, and Online
Survey, Certification and Reporting (OSCAR) files. Mortality rates were calculated from Medicare enrollment files.
Results
Among 397,503 ischemic stroke cases identified, 152(.04%) underwent DHC. Median age was 71, 53% were male,
78% were white. The 30-day acute hospital readmission rate was 25%. One and two year mortality rates were 53%
and 57% respectively. Among survivors, 24% were in a nursing home at 1 year, and 15% at 2 years. One-third of
the total cohort (33.5%) returned home by one and two years after stroke and DHC.
Conclusions
U.S. mortality rates for older persons undergoing DHC are similar those found in DESTINY II. A large proportion of
surviving DHC patients return home. Further study of caregiver quality of life may provide useful insights for
discussing outcomes after DHC with patients and families.
Financial Support: None
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PROGNOSTIC MEANING OF LEFT VENTRICULAR DIASTOLIC DYSFUNCTION IN PATIENTS WITH ACUTE
ISCHEMIC STROKE
Sang-Bae Ko1, Wi-Sun Ryu2, Yang-Ki Minn3, Im-Seok Koh4, H. Alex Choi5, Kiwon Lee5
1
Seoul National University Hospital/ Neurology, Seoul, South Korea, 2Dongguk University/ Department of
Neurology, Ilsan, South Korea, 3Hallym University/ Department of Neurology, Seoul, South Korea, 4National
Medical Center/Department of Neurology, Seoul, South Korea, 5The University of Texas/Department of
Neurosurgery, Houston, TX, USA
Introduction
Diastolic dysfunction (DD) is associated with an increased risk of mortality in subjects with myocardial infarction,
and even in the general population. We hypothesized that DD has a negative impact on functional outcome and
mortality in patients with acute ischemic stroke
Methods
We consecutively included 503 patients with ischemic stroke. Transthoracic echocardiography and tissue Doppler
image were used to evaluate diastolic function and DD grading. We used logistic regression and Cox-regression
analyses to examine an independent relation of DD with functional outcome and mortality, respectively.
Results
Included patients were male dominance (male, 63%) and age was 67.2 ± 11.8. A parameter of diastolic function,
E/e' (Early mitral inflow velocity/early diastolic mitral annulus velocity), was independently associated with
unfavorable outcome at 3 months and mortality after ischemic stroke. The patients with E/e' of > 14 (the highest
quartile) have a 3-fold increased risk of unfavorable outcome (odds ratio, 2.97; 95% confidence interval [CI], 1.615.48) compared to those with E/e' of < 8.8 (the lowest quartile). In addition, corresponding hazard ratio for mortality
was 4.74 (95% CI, 1.64-13.66). Compared with patients having normal diastolic function, those with moderate-tosevere DD had a greater risk of unfavorable outcome (odds ratio, 2.66; 95% CI, 1.10-6.41) and mortality (hazard
ratio, 6.75; 95% CI, 1.81-25.15). Furthermore, these associations were consistent across stroke subtypes and in
sensitivity analyses.
Conclusions
Diastolic dysfunction is associated with poor neurologic outcome and mortality in patients with acute ischemic
stroke.
Financial Support: None
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TWO REPORTS OF SUCCESSFUL ENDOVASCULAR TREATMENT OF CAROTID DISSECTION WITH FLOW
LIMITATION
Lauren Koffman, Muhammad S Hussain
Cerebrovascular Department, Cleveland Clinic, Cleveland, OH, USA
Introduction
Controversy exists as to the management of cervical artery dissection. Medical management with either antiplatelet
agents or anticoagulation is considered first line treatment, but endovascular therapy may be used to manage
patients with carotid dissections that have flow limiting stenosis that fails to respond to medical therapy.
Methods
Case series at a tertiary care medical center.
Results
Patient one was a 55-year-old man that presented two weeks after a MVA with transient neurologic symptoms. MRI
was negative for diffusion restriction but MRA revealed a severe narrowing of the right internal carotid artery
(ICA) lumen extending from the proximal ICA to the distal cervical ICA, consistent with acute right ICA dissection
with flow limitation. Diagnostic angiogram confirmed a flow limited cervical right ICA stenosis. Several hours post
procedure patient developed perfusion dependent symptoms. Repeat angiogram showed delayed anterograde
grade flow through the dissected segment. Five stents were placed from the origin to the petrous segment of the
internal carotid artery and anterograde flow was restored. Patient two was a 53-year-old man that presented after
multiple episodes of neurologic symptoms. MRA showed left ICA dissection immediately distal to the bifurcation
with reduced flow. MRI showed two acute punctuate infarcts in the left MCA distribution. Patient was discharged on
therapeutic coagulation, but returned several days later and repeat MRI showed a new infarct. On re-admission
angiogram showed non opacification of the cervical and proximal petrous segments of the left ICA. Five stents
were placed extending from the origin to the petrous segment of the internal carotid artery and flow was restored.
Post intervention carotid ultrasounds confirmed stent patency in both patients. Both patients did clinically well, with
resolution of their neurological symptoms.
Conclusions
These cases illustrate situations of flow compromise due to cervical artery dissection successfully treated with
stenting. In assessment of dissection patients, flow limitation should be considered during evaluation and stenting
may be considered a therapeutic option.
Financial Support: None
Neurocrit Care
RECANALIZATION AND CLINICAL OUTCOME OF ACUTE ISCHEMIC STROKE PATIENTS WITH MIDDLE
CEREBRAL ARTERY OCCLUSION WHO UNDERWENT NEW GENERATION THROMBECTOMY-A SINGLE
CENTER EXPERIENCE
Yahia M Lodi1,2,3, Varun V Reddy1,2, Ashok Devasenapathy1,2, Karmel Shehadeh3, A Houran3, Joe Chou3
1
Upstate Medical University, Binghamton, NY, USA, 2UHS-Wilson Medical Campus, Johnson City, NY, USA,
3
Binghamton University, Binghamton, NY, USA
Introduction
Thrombectomy is considered an option for all stroke patients who are either not or failed candidate for intravenous
thrombolytic. Objectives: To identify the rate of recanalization and outcome in acute ischemic stroke patients with
MCA occlusion who underwent thrombectomy using Solitaire retrieval device.
Methods
Retrospective review of all consecutive MCA thrombectomy cases from June 2013 to March 28, 2014. Outcomes
were measured using NIHSS and mRS.
Results
18 patients including 2 failed IV tPA patients with MCA occlusion underwent thrombectomy. The mean age was
70±14 years old, mean NIHSS 17.1±1.4, 67% female and 33% were 80 years or older. Conscious sedation was
given to all but two who were intubated due to the initial impact of stroke. Mean time to MCA microcatheter
placement was 30±3 minutes. Compete recanalization (TICI3) was observed in 89% and partial (TICI2a) 11% with
mean time of recanalization from groin puncture of 65±6 minutes. Immediate post procedure 10 point improvement
of NIHSS was observed in 50% cases including 3 with NIHSS 0. 24 hours 10 point improvement was observed in
67% cases including 33% with NIHSS 0. 44% were discharged home directly from critical care unit. 30 days good
outcome (mRS 2 or less) was observed in 12 cases (66%) (mRS 0 = 3, 1=6, and 2=3). Two patients who were
intubated at presentation died due to the withdrawal of care. Poor outcome (mRS 4) was observed in 3 cases Poor
outcome was observed on those who had NIHSS close to 20 or higher and or were intubated at presentation.
Conclusions
Solitaire thrombectomy achieves a very high rate of recanalazitation in MCA occlusion which results in an early
neurological recovery and good clinical outcome irrespective of patient gender, age and site of occlusion.
Therefore, new generation thrombectomy should offer to all ischemic stroke patients who have large artery
occlusion.
Financial Support: None
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MODIFICATION OF POST STROKE CENTRAL NERVOUS SYSTEM EXTRACELLULAR MATRIX WITH
POLYLYSINE PROMOTES NEURITE FORMATION AND INCREASED NEURITE LENGTH
Eric J Marrotte1, Naoir Zaher1, Yi Zhang2, Xian Shuang Liu2, Michael Chopp2, Benjamin Buller 2
1
Henry Ford Hospital/Department of Neurology, Detroit, MI, USA, 2Henry Ford Hospital/Department of Neurology
Research, Detroit, MI, USA
Introduction
Extracellular matrix (ECM) plays a key role in cell function and differentiation of stem/progenitor cells. After stroke,
several changes in the native ECM occur that inhibit regeneration of brain tissue. However, very little is known
about central nervous system (CNS) cell interaction with CNS-ECM. Polylysine is a positively charged molecule
that is widely used in cell culture of CNS cells. We hypothesize, that post stroke CNS-ECM modified with polylysine
will enhance neurite outgrowth.
Methods
Central nervous system ECM was isolated from rat brains 7 days after middle cerebral artery occlusion from the
ipsilateral stroke hemisphere and the non-stroke contralateral hemisphere and used to coat 6 well plates. Five
groups were used; Stroke-ECM, Normal-ECM, 10% Polylysine, and 10% Polylysine-Stroke-ECM and non-coated
wells. Neurons were isolated from E19 rat brains and plated at 2x105 cells/well. Cells were incubated for 10 days.
Each group was blinded and the number of neurites in 10 random fields (10x) were counted. The length of neurites
was then measured for each group.
Results
CNS cells cultured on Normal-ECM compared to CNS cells cultured on Stroke-ECM had significantly more neurite
outgrowths (104.8±7.9 vs.17.2±9.5, n=3, P< 0.05). Additionally, the length of the neurites was significantly longer
with CNS cells cultured on Normal-ECM compared to Stroke-ECM (107.3±8.8 vs.89.0 ±8.0 n=100 Neurites/group,
P< 0.05). CNS cells cultured on Stroke-ECM modified with polylysine demonstrated significantly more neurites with
increased length compared to Stroke-ECM alone (number: 177.6±10.8 vs. 17.2±9.5, n=3, P< 0.05) (length:
131.2±9.1 vs. 89.0±8.0, n=100 neurites/group, P< 0.05). Polylysine coated plates demonstrated the greatest
number of neurites compared to all other groups (695.4±28.3, n=3 P< 0.05).
Conclusions
Polylysine modification rescued the functional ability of stroke-ECM to support CNS cells neurite outgrowth. These
data provide evidence that modification of ECM after stroke may enhance/promote potential novel cell therapies
after stroke.
Financial Support: None
Neurocrit Care
93
SAFETY OF ACUTE REPERFUSION THERAPY IN ACUTE ISCHEMIC STROKE PATIENTS WHO HARBOR
MULTIPLE UNRUPTURED INTRACRANIAL ANEURYSM; A CASE SERIES
Ashkan Mowla1, Mehla Syndhya1, Karanbir Singh1, Mohammad K. Ahmed1, Peyman Shirani1, Chandan Krishna2,
Robert N. Sawyer1, Marilou Ching1, Adnan H. Siddiqui2, Elad I. Levy2, Kenneth V. Snyder2, Annmarie Crumlish1,
L.N Hopkins2
1
Stroke Division, Department of Neurology, State University of New York at Buffalo, Buffalo, NY, USA, 2Department
of Neurosurgery, State University of New York at Buffalo, Buffalo, NY, USA
Introduction
Intracranial aneurysm was considered an exclusion criteria for intravenous (IV) thrombolysis in acute ischemic
stroke in both NINDS and ECASS III studies, possibly due to a hypothetical increase in the risk of bleeding from the
aneurysm rupture. On the other hand, aneurysm multiplicity has been shown to be a significant predictive factor for
rupture of intracranial aneurysms less than 5mm in diameter. We sought to determine the safety of acute
reperfusion therapy in acute ischemic stroke patients with pre-existing multiple intracranial aneurysms.
Methods
We retrospectively examined the medical charts and cerebrovascular images of all patients treated with IV
thrombolysis for acute ischemic stroke in our center from the beginning of 2006 till the end of April 2014. Those
with evidence of multiple unruptured intracranial aneurysms on their cerebrovascular images prior to acute
reperfusion therapy were identified. Post thrombolysis brain imagings were reviewed to evaluate for any aneurysmrelated or distant intraparenchymal or subarachnoid hemorrhages.
Results
A total of 637 patients received IV thrombolysis in our center during a 9.4 years period. 33 (5.1%) were found to
have at least one intracranial aneurysm, out of those 7 (21.2%) had more than one aneurysm. Five patients
received only IV thrombolysis and 2 received combination of IV and intra-arterial thrombolysis. The size of the
largest aneurysm was 7.5 mm in diameter (Range: 2 mm to 7.5 mm). In those 7 patients, a total of 16 aneurysms
were identified. Six were fusiform, 1 was bilobed saccular and the rest were unilobed saccular aneurysms. None
developed any symptomatic intracranial hemorrhage.
Conclusions
Our findings suggests that aneurysm multiplicity does not increase the risk of aneurysmal hemorrhage with acute
reperfusion therapy in acute ischemic stroke patients who harbor unruptured intracranial aneurysm less than 7.5
mm in diameter.
Financial Support: Levy: shareholder/ownership interests–Intratech Medical Ltd., Mynx/Access Closure, Blockade
Medical LLC. Principal investigator: Covidien US SWIFT PRIME Trials. Other financial support–Abbott for carotid
training for physicians. Siddiqui: research grants–National Institutes of Health (co-investigator: NINDS
1R01NS064592-01A1 and NIBIB 5RO1EB002873-07), University at Buffalo (Research Development Award)
financial interests–Hotspur, Intratech Medical, StimSox, Valor Medical, Blockade Medical, Lazarus Effect
consultant–Codman & Shurtleff, Inc., Concentric Medical, Covidien Vascular Therapies, GuidePoint Global
Consulting, Penumbra, Stryker Neurovascular, Pulsar Vascular speakers' bureaus–Codman & Shurtleff,
Genentech National Steering Committees for Penumbra 3D Separator Trial, Covidien SWIFT PRIME Trial,
MicroVenton FRED Trial advisory board–Codman & Shurtleff, Covidien Vascular Therapies honoraria–Abbott
Vascular and Codman & Shurtleff, Inc. for training other neurointerventionists in carotid stenting and for training
physicians in endovascular stenting for aneurysms. Hopkins: grant/research support-Toshiba consultant-Abbott,
Boston Scientific, Cordis, Micrus, Silk Road financial interests-AccessClosure, Augmenix, Boston Scientific, Claret
Medical, Endomation, Micrus, Valor Medical board/trustee/officer position-Access Closure, Claret Medical
speakers' bureau- Abbott Vascular honoraria-Bard, Boston Scientific, Cleveland Clinic, Complete Conference
Management, Cordis, Memorial Health Care System, Society for Cardiovascular Angiography and Interventions
(SCAI). Snyder: Consultant/speakers' bureau/honoraria: Toshiba speakers' bureau/honoraria: ev3/Covidien, The
Stroke Group
ISCHEMIC STROKE
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VOLUMETRIC THRESHOLD FOR MEDICAL INTERVENTION OR SURGICAL DECOMPRESSION AFTER
CEREBELLAR ISCHEMIC STROKE
Amanda K Raya, Andria L Ford, Salah G. Keyrouz
Washington University, St. Louis, MO, USA
Introduction
Cerebellar ischemic strokes are known to carry significant risk of early edema which may lead to brainstem
compression and death. Earlier identification of patients who are likely to need decompression may improve
outcomes. In this study, we aimed to identify clinical and radiographic predictors of medical or surgical intervention
in patients with cerebellar ischemic stroke.
Methods
This was a retrospective study of all patients with cerebellar ischemic strokes on head CT admitted to our ICU from
2010 through 2013. Patients who had withdrawal of care were excluded. The primary outcome was the need for
one or more of these interventions: osmotic therapy, extraventricular drainage (EVD) or surgical decompression.
Binary logistic regression was performed to determine predictors of intervention. Predictors of interest included
age, GCS, time from onset to scan, the presence of bilateral infarcts, volume of infarction, and a ratio of infarct
volume to posterior fossa volume (nVolume).
Results
Forty-six patients with cerebellar ischemic stroke were included. Mean time from stroke onset to CT was 48 hours.
Eighteen patients (39%) required intervention, of whom five needed medical intervention, and 13 received surgical
decompression. The mean infarct volume for those who did not require any intervention was 24.1 ml versus 45.8
ml in those who did (p< 0.001). Age, GCS, time from onset to scan, and the presence of bilateral infarcts were not
significant predictors. Infarct volume did predict intervention, with an OR = 4.0 (95% CI 1.6-10.0) for every 10 ml
increase. In a ROC curve analysis, nVolume achieved an AUC of 0.91 (95% CI 0.82-0.99), and an optimal cutoff of
0.28 had 86% sensitivity and 89% specificity for needing intervention.
Conclusions
Infarct volume is a strong predictor of deterioration. It may be possible to identify a volumetric threshold on initial
head CT that necessitates further intervention.
Financial Support: None
Neurocrit Care
95
THE ROAD TO REHAB IN ACUTE STROKE: USING EARLY NEUROSTIMULANTS TO HELP PAVE THE WAY
Michael E. Reznik1, Ajitesh Ojha1, Joseph Durkin2, Bradley J. Molyneaux1,3, Vivek K. Reddy1,4
1
University of Pittsburgh Medical Center, Department of Neurology, Pittsburgh, PA, USA, 2University of Pittsburgh
Medical Center, Department of Pharmacy Services, Pittsburgh, PA, USA, 3University of Pittsburgh Medical Center,
Department of Critical Care Medicine, Pittsburgh, PA, USA, 4University of Pittsburgh Medical Center, Stroke
Institute, Pittsburgh, PA, USA
Introduction
Discharge to acute rehabilitation (rather than a nursing facility) is known to improve outcomes in patients with acute
stroke. Unfortunately, a number of patients are often excluded because of concerns regarding alertness or
attention. Trials of neurostimulants have sometimes been attempted in such situations; it is the objective of this
retrospective study to see if such practices have affected disposition outcomes.
Methods
A list of all inpatients with ischemic or hemorrhagic stroke who received neurostimulants (amantadine,
bromocriptine, or modafinil) over a one year period was obtained, in addition to their age, initial NIHSS, time to
initiation (TTI) of neurostimulant, and serial rehab evaluations. This cohort was then compared with a control group
of "closest match" pairs (stroke type, NIHSS, age, gender) from our institutional Get With the Guidelines (GWTG)
data over that same year.
Results
48 patients were included in the initial cohort—35 with ischemic strokes (mean NIHSS 16.1, age 75.3, TTI 6.1
days), and 13 with ICH (NIHSS 16.2, age 74.7, TTI 7.9 days). These were matched with 35 ischemic (NIHSS 16.0,
age 75.4) and 13 hemorrhagic strokes (NIHSS 16.3, age 74.2) from the GWTG database. Of ischemic strokes, for
both the neurostimulant cohort and GWTG control, 16/35 qualified for rehab on their first evaluation; of the
remaining 19, 7 in the cohort (36.8%) and 3 in the control (15.8%) subsequently converted to rehab. With ICH, 5/13
and 3/13 initially qualified for rehab in the cohort and control, respectively; of the remaining, 1/8 (12.5%) and 3/10
(30%), respectively, subsequently converted.
Conclusions
This study suggests that early neurostimulant use may aid in transitioning patients with ischemic stroke, but not
ICH, to acute rehab. The patients who did well with neurostimulants had an earlier TTI (4.6 vs. 7.3 days). Further
data is pending from the years 2011 and 2012.
Financial Support: None
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SAFETY OF INTRAVENOUS THROMBOLYSIS FOR ACUTE ISCHEMIC STROKE IN PATIENTS WITH PREEXISTING INTRACRANIAL NEOPLASMS
Karanbir Singh, Ashkan Mowla, Sandhya Mehla, Mohammad K. Ahmed, Peyman Shirani, Haris Kamal, Robert N.
Sawyer, Annmarie Crumlish, Marilou Ching
Stroke Division, Department of Neurology, State University of New York at Buffalo, Buffalo, NY, USA
Introduction
Intracranial neoplasms were an exclusion criteria in NINDS-rtPA trial, possibly due to a hypothetical increase in
bleeding risk within the neoplasm, and are currently considered a contraindication for intravenous (IV) thrombolysis
in acute ischemic stroke patients. Minimal data is available on the safety of IV thrombolysis for acute ischemic
stroke in patients with pre-existing intracranial neoplasm. We sought to determine the safety of IV rtPA in such
patients through a retrospective hospital based study.
Methods
We retrospectively reviewed the medical records and brain imaging of patients who received IV rtPA for acute
ischemic stroke from January 2006 to April 2014 at our center. A subset of patients with intracranial neoplasms
were identified. We looked into the bleeding rate within the neoplasm in those patients after IV rtPA administration.
Results
637 patients received IV rtPA for acute ischemic stroke, 15 (2.3%) were found to have an intracranial neoplasm. 14
were meningiomas and one was an intracranial lipoma. Two patients had more than one meningioma (2 each). The
size of neoplasms ranged from 9 mm to 34 mm in maximum dimension. Among these 15 patients, 13 received only
IV rtPA and 2 received IV rtPA followed by Intra-arterial thrombolysis. Symptomatic intracranial hemorrhage
occurred in only 1 patient (6.6%) who had a 9 mm meningioma in the right cerebello-pontine angle. Hemorrhage
occurred within the area of infarct and was distant from the neoplasm location.
Conclusions
Our findings suggests that IV rtPA administration for acute ischemic stroke does not increase the risk of
hemorrhage within benign neoplasms. Their listing in exclusion criteria for rtPA should be reconsidered to assure
appropriate use of intravenous rtPA. To the best of our knowledge, our study is the largest study on the safety of IV
rtPA for acute ischemic stroke in patients with pre-existing intracranial neoplasms.
Financial Support: None
Neurocrit Care
97
IMPACT OF ICTAL AND EPILEPTIFORM EEG ACTIVITY ON OUTCOME IN CARDIAC ARREST PATIENTS
TREATED WITH THERAPEUTIC HYPOTHERMIA
Sachin Agarwal1, Priyank Patel1, Andres Rodriguez1, Brandon Foreman1, Angela Velasquez1, Sarah Rahal1,
Cristina M Falo1, Stephan A Mayer2, Hyunmi Choi1, Jan Claassen1
1
Columbia University, New York, NY, USA, 2Icahn School of Medicine at Mount Sinai, New York, NY, USA
Introduction
Prognostic value of seizures and other abnormal EEG patterns during and after therapeutic hypothermia (TH) has
been poorly studied.
Methods
This is a retrospective data analysis of consecutive cardiac arrest patients who survived to ICU admission and
underwent both TH with goal temperature of 33 degree Celsius, and continuous EEG monitoring for 72 hours at
Columbia University Medical Center from 2008 to 2013. Outcome measures were collected via the Cerebral
Performance Categories Scale (CPC) at the time of hospital discharge. CPC scores of >3 were considered as bad
outcomes. Known predictors of outcomes were used in the multivariate regression analysis using STATA 13.1.
Results
139 patients included had seizure incidence of 35% (49), generalized periodic discharges (GPD) (N=49; 44%), and
status epilepticus (SE) 30.2% (42), (myoclonic 60%, non-convulsive 35.7%, and convulsive 4.3%). Patients with
seizures, GPD, and SE, in the first 72 hours were approximately 4, 5 and 7 times respectively, more likely to have a
poor outcome at discharge (p value< 0.05). A multivariate model adjusting for 1st day neuron specific enolase
levels (median: 27.5), age (mean: 63±17), time to return of spontaneous circulation (median: 25mins), initial rhythm
(ventricular fibrillation: 21%, pulseless electrical activity: 44%, asystole: 35%) and bystander CPR (48%), was
created and the association for all three patterns remained significant (OR: 5; 6.8, 7.4, p< 0.05) for CPC>3.
Conclusions
Cardiac arrest patients have a very high incidence of abnormal EEG patterns despite treatment with TH. Seizures,
status epilepticus, and GPEDs are highly correlated with poor outcome. Clinical trials of anti-epileptic therapy after
cardiac arrest are well justified.
Financial Support: None
SEIZURES
ePoster 85
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SEIZURES
ePoster 86
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CONTINUOUS EEG ARTIFACTS CAUSED BY TWO NEW CARDIAC OUTPUT MONITORS
Khalid A Alsherbini, Jordan Bonomo, David Ficker, William Knight
University of Cincinnati/ Neurocritical care, Cincinnati, OH, USA
Introduction
Continuous EEG monitoring (cEEG) use is increasing. Advanced cardiovascular monitoring has the potential to
create artifacts on cEEG. It’s important to recognize the artifacts as they may affect cEEG interpretation. The
Edwards LifeSciences Ref/Ox(D750HF75) continuous cardiac output pulmonary artery catheter and the Cheetah
Medical Non-invasive Cardiac Output Monitor(CHEETAH NiCOM) are both electrical impulse generators. The
phase and frequency are modified by the device's intrinsic control systems, but these artifacts are the result of the
electrical signals to the monitors (thermistor and receiver in the Ref/Ox and electromagnetic pulse impulse with the
CHEETAH).
Methods
30 patients who had an Edwards LifeSciences Ref/Ox continuous cardiac output pulmonary artery catheter (7) or
CHEETAH NiCOM (23) were retrospectively identified who had cEEGs. All cEEGs were interpreted by a board
certified epileptologist.
Results
Ref/Ox catheter (Figure 1): This artifact is typically identified with a high-amplitude spike followed by a slow-wave
that spreads over a non-physiologic electrical field across all channels, alternating polarity across the different
channels as well as both hemispheres. This is then followed by a rhythmic monomorphic delta discharge at 2.53Hz frequencies. This is of higher amplitude in the frontal regions, and lasts until the next spike with the repeat
electrical impulse. CHEETAH NiCOM (Figure 2): This artifact is a low-amplitude, rhythmic, monotonous discharge
occurring at frequencies of 16-20Hz that mainly involves the parasagittal channels of both hemispheres. This can
be seen more posteriorly as well.
Conclusions
The Ref/Ox artifact can be falsely considered epileptic in nature, especially in patients with a severely suppressed
background. The Cheetah artifact can be mistaken for a beta discharge in patients who are deeply sedated, which
also can be mistaken for a reactive background. New artifacts are being observed on cEEG with advanced cardiac
monitors. It is important to recognize that these artifacts may mask the cEEG interpretation or be falsely recognized
as epileptic in nature.
Financial Support: None
Neurocrit Care
99
ISOLATED SUPPRESSION-BURST PATTERN ON CONTINUOUS EEG IS NOT ASSOCIATED WITH POOR
NEUROLOGIC OUTCOME FOLLOWING RESUSCITATION FROM CARDIAC ARREST
Edilberto Amorim1, Jon C Rittenberger2, Julia J Zheng3, Maria E Baldwin1, Alexandra Popescu1
1
University of Pittsburgh Medical Center, Department of Neurology, Pittsburgh, PA, USA, 2University of Pittsburgh,
Department of Emergency Medicine, Pittsburgh, PA, USA, 3University of Pittsburgh, Neuroscience Department,
Pittsburgh, PA, USA
Introduction
Early prognostication in cardiac arrest (CA) is challenging. Continuous EEG monitoring provides real-time
evaluation of brain activity. Prior literature has suggested suppression-burst (SB) pattern on EEG is associated with
poor outcome. We explored the association between SB and neurologic outcome. We also explored the
association between myoclonic status epilepticus (MSE) and other malignant EEG patterns with outcome in
patients managed with induced hypothermia (IH).
Methods
From April 2010 to June 2013, medical records and cEEG data from patients undergoing IH after CA were
retrospectively reviewed. Patients with SB not accompanied by MSE, status epilepticus, seizures, or generalized
periodic discharges were classified as "pure" SB. Poor outcome was defined as Cerebral Performance Category
score of 3-5 at discharge.
Results
A total of 294 patients were included, and in-hospital mortality was 74.5% (219/294). Pure SB was not associated
with mortality (p=0.45) or poor outcome (p=0.1), having a false-positive rate of 19% [95% Confidence Interval (CI):
11-30%] and 35% (CI: 18-66%), respectively. MSE was present in 60 (20.4%) subjects, and was associated with
mortality (p< 0.001; FPR 3%; CI:90-99%) and poor outcome (p=0.007; FPR 0%; CI: 84-100%). Two subjects with
MSE survived and were discharged to a rehabilitation facility.
Conclusions
Pure SB was not an accurate predictor of mortality or poor outcome in cardiac arrest patients treated with
hypothermia. MSE was strongly associated with mortality and poor outcome, however not unequivocally.
Financial Support: None
SEIZURES
ePoster 87
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ePoster 88
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AUTOMATIC EVALUATION OF CONTINUOUS EEG FOR NEUROMONITORING OF CRITICAL ILL PATIENTS
Franz Fürbass1, Johannes Koren3, Johannes Herta2, Manfred Hartmann1, Christoph Baumgartner3, Andreas
Gruber2, Tilmann Kluge1
1
AIT Austrian Institute of Technology, Safety & Security Department, Vienna, Austria, 2Medical University of
Vienna, Department of Neurosurgery, Vienna, Austria, Vienna, Austria, 3Neurological Department Rosenhügel at
General Hospital Hietzing, Vienna, Austria, Vienna, Austria
Introduction
Continuous EEG (cEEG) is a non-invasive method to detect metabolic changes of the brain, seizures and status
epilepticus in real time. Manual evaluation of cEEG requires skilled staff with profound knowledge of EEG available
24/7 to optimize treatment gain. A computer based method called NeuroTrend was developed that analyses the
EEG based on the ACNS' critical care EEG terminology to allow objective and automatized surveillance of EEG.
Methods
NeuroTrend scans the EEG for periodic discharges, spike-and-wave, and rhythmic patterns. The detection results
are displayed graphically showing localization, frequency, and amplitude of the EEG patterns. The time extent of
the detected markers relates to the time extent of the EEG patterns wherefore the visualization of results for
several hours or even days per screen becomes feasible. To assess the sensitivity of the method 143 routine and
21 long-term EEGs from 79 patients of an intermediate care unit with a median GCS of 11 (min 3, max 15) were
analyzed manually according to the ACNS terminology. The results of the manual analysis were compared to the
NeuroTrend results in a 10 minute granularity.
Results
The agreement between NeuroTrend and manual review was 91% for periodic patterns, 95% for rhythmic delta
activity and 73% for spike-and-wave patterns. In addition all seizures and stati of the long term EEGs were clearly
visible through rhythmic or spike-wave patterns.
Conclusions
The comparison of automatic and manual evaluation of the EEG showed a high agreement for ACNS patterns. The
ability to detect electrographic seizures and status epilepticus with NeuroTrend was shown. The graphical
representation of automatically detected EEG patterns in combination with other brain monitoring parameters like
i.e. ICP will open new ways in multimodal neuromonitoring.
Financial Support: None
Neurocrit Care
101
CONTINUOUS EEG SIGNIFICANTLY IMPACTS MEDICAL MANAGEMENT OF PATIENTS ADMITTED TO ICU:
A PROSPECTIVE STUDY
Ayaz M Khawaja1, Guoqiao Wang2, Gary Cutter2, Jerzy P Szaflarski1, 3
1
Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA, 2Department of
Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA, 3Division of Epilepsy, University of
Alabama at Birmingham, Birmingham, AL, USA
Introduction
There is limited evidence from retrospective studies how continuous EEG (cEEG) impacts antiepileptic drug (AED)
use. We prospectively investigated the impact of cEEG on AED modifications (n-AED) in patients admitted to ICU.
Methods
Patients who received any cEEG were prospectively identified and matched to patients admitted in the same week
who did not receive cEEG (non-cEEG) for admission diagnosis, age, and gender. Patients admitted with seizures
alone were excluded. The primary outcome was n-AED. Main explanatory variables included demographics,
number of comorbidities, admission Glasgow Coma Scale (GCSA), durations of ICU and hospital stay, and
duration of cEEG. Generalized linear model was used to identify factors associated with AED changes.
Results
222 patients were enrolled, equally divided between cEEG and non-cEEG groups. Mean(SD) number of AED
changes (mean-nAED) for cEEG-group was 2.1(2.9), compared to 0.4(0.9) in non-cEEG-group. Comparison
between these two groups after controlling for age, GCSA, and seizures at admission, showed that cEEG use (p<
0.0001) and comorbidities (p=0.0047) had significant impact on nAED. Mean-nAED of the cEEG group during
hospital stay was 4.3 times that of the non-cEEG group. An increase of 1 comorbidity resulted in 11% decrease in
nAED. Mean ICU stay of 18.0(14.1) days for cEEG-group was significantly different from 13.1(13.7) days for noncEEG-group (p=0.012). Within the cEEG-group, 59.1% had AED changes made before, 43.6% during and 22.9%
after cEEG use. Mean-nAED before, during and after cEEG were 0.7(0.7), 1.2(2.5), and 0.3(0.7), respectively.
Mean-nAED during cEEG was 4.3 times the changes during the period both before and after cEEG (p< 0.0001).
66.4% of cEEG patients had AEDs started, 38% increased, 14.5% decreased, and 14.5% stopped. 25.4% of noncEEG patients had AEDs started, 6.7% increased, 2% decreased and 3% stopped.
Conclusions
In this prospective study, cEEG use leads to significantly more AED modifications when compared to non-cEEG
patients.
Financial Support: None
SEIZURES
ePoster 89
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102
Neurocrit Care
SEIZURES
ePoster 90
___________________________________________________________________________________
NEW ONSET REFRACTORY STATUS EPILEPTICUS (NORSE): A REPORT OF OUTCOMES IN TEN
CONSECUTIVE PATIENTS
Ayaz M Khawaja1, Jennifer L Dewolfe1, 3, David W Miller2, Jerzy P Szaflarski1, 3
1
Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA, 2Department of
Anesthesiology, University of Alabama at Birmingham, Birmingham, AL, USA, 3Division of Epilepsy, University of
Alabama at Birmingham, Birmingham, AL, USA
Introduction
New onset refractory status epilepticus (NORSE) is an uncommon condition characterized by continuous or
intermittent seizures without return to baseline that fail to respond to first and second-line AEDs in patients without
preexisting history of seizures/epilepsy.
Methods
Ten consecutive patients with NORSE were identified from a retrospective chart review of patients admitted with
possible encephalitis. NORSE was defined as continuous or intermittent epileptiform activity on EEG for greater
than a week that did not respond to >2 anti-epileptic agents. Collected variables included age, gender, duration,
number of AEDs, use of immunosuppression, pertinent laboratory and imaging findings, final diagnosis, and
discharge disposition.
Results
9/10 patients were females. Mean age was 37 (range 21-61). Four cases were attributed to Anti-NMDA, Anti-VGKC
or Anti-GAD antibodies. Three patients had neurosyphilis, HSV and VZV encephalitis, and other cases were
secondary to posterior leukoencephalopathy syndrome, cefepime, or cryptogenic causes. The mean duration of
RSE was 62 days (range 10-110). Non-specific encephalopathy and fever were the most common presentations.
7/10 patients exhibited CSF pleocytosis/elevated protein with none having low glucose. Only two patients had
positive CSF microbiology (HSV, VDRL). Limbic hyperintensities/cortical diffusion restrictions were most common
MRI findings (6/10). Acyclovir was the most commonly used antimicrobial (7/10). The mean number of AEDs tried
was 5 (range 4-8). Six patients were treated with high dose steroids and intravenous immunoglobulins, three with
plasmapharesis, and one with rituximab and cyclophosphamide. One patient had oophorectomy (Anti-NMDA).
Patients who received immunotherapy (6/10) had better outcomes (5/6 discharged home). Two patients died
(Neurosyphilis, Anti-VGKC), and three other discharged to nursing home (Anti-GAD, cefepime, HSV).
Conclusions
In addition to AEDs, patients with NORSE may require early aggressive immunotherapy and/or initiation of
immunosuppressants to achieve adequate seizure control. Better outcomes can be expected in younger patients
and patients with autoimmune etiology for NORSE.
Financial Support: None
Neurocrit Care
103
A RARE CAUSE OF ASEPTIC MENINGITIS AND NORSE- NEW ONSET REFRACTORY STATUS
EPILEPTICUS
Sarah H. Peacock2, William D. Freeman1, Lioudmila V. Karnatovskaia1, Laxmi Dhakal2
1
Mayo Clinic Department of Neurology Critical Care, Jacksonville, FL, USA, 2Mayo Clinic Department of Critical
Care, Jacksonville, FL, USA
Introduction
Neurologic paraneoplastic syndromes are rare, occurring in less than 0.01% of patients with cancer. In absence of
known malignancy/apparent imaging findings diagnosis may be missed or delayed. We present a patient with
heavy smoking history who developed progressively altered mental status and new onset seizures.
Methods
A 51-year-old male developed headache several days after fishing that gradually progressed to intermittent
confusion. He developed progressive gait instability, lethargy, followed by witnessed tonic-clonic seizures he was
admitted for treatment of suspected viral encephalitis. The patient had progressive increase in seizures meeting the
definition of status epilepticus; as well as refractory SE. MRI of the brain did show focal intracortical FLAIR signal
abnormality in the right cerebellar hemisphere which enhanced with contrast and a non-enhancing lesion in the
right superior frontal gyrus. EEG demonstrated numerous clinical and electrographic seizures with repeated focal
(left T3) onset electrographic seizures with rapid hemispheric and bihemispheric generalization lasting greater than
1 minute in duration on EEG with > 5minutes of generalized postictal suppression with persistent left hemispheric
suppression consistent with clinical Todd's paralysis. CSF had lymphocytic predominance; gram stain and cultures
were negative. Serum paraneoplastic panel was positive for Ȗ-GABA B-receptor and N-type and P/Q-type calcium
channel antibodies. CT scan of the chest was unremarkable except for an enlarged subcarinal lymph node.
Endobronchial ultrasound-guided lymph node aspiration of the subcarinal lymph node was performed;
histopathology was consistent with small cell lung cancer (SCLC).
Conclusions
Paraneoplastic syndromes and encephalitis that present as NORSE is rare and should be kept in the differential of
'aseptic meningitis' other than viral entities since it has a different prognosis and workup. In patients with acute or
sub-acute neurologic changes in absence of clear alternative etiology evaluation for underlying malignancy even in
absence of obvious imaging findings may therefore be warranted.
Financial Support: None
SEIZURES
ePoster 91
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104
Neurocrit Care
SEIZURES
ePoster 92
___________________________________________________________________________________
CARDIAC ELECTRICAL INSTABILITY ASSESSED BY T-WAVE ALTERNANS IN PATIENTS WITH STATUS
EPILEPTICUS IN THE INTENSIVE CARE UNIT
Andrew C. Schomer, Bruce D. Nearing, Steven Schachter, Richard L. Verrier
Beth Israel Deaconess Medical/Harvard University, Boston, MA, USA
Introduction
T-wave alternans (TWA), a beat-to-beat fluctuation in the amplitude and shape of the T wave in the
electrocardiogram has proven to be a noninvasive marker of risk for sudden cardiac death. Following secondary
generalized tonic-clonic seizures, TWA was shown to be markedly elevated (~70 ȝV) in the post-ictal period
(Strelczyk, Epilepsia 2011:52:2112-7), which exceeds the 47-ȝV criterion for life-threatening cardiac arrhythmia
risk. Our goal was to determine whether there is an elevated level of TWA on cardiac monitoring in patients with
convulsive status epilepticus in the ICU when compared to their ECG during times in which their seizures were
under control.
Methods
Single lead electrocardiogram data was exported from the patient's EEG monitor (Natus system), for patients with
convulsive status epilepticus (N=4) and were analyzed for TWA using the Modified Moving Average method. Study
was approved by BIDMC's Committee on Clinical Investigations.
Results
In patients actively in convulsive status epilepticus, TWA averaged 113 μV. During the times in which the seizures
were better controlled their TWA averaged 35 μV. There was a statistically significant difference of 78 μV (SE ±
22.8; p=0.04).
Conclusions
Patients actively in convulsive status epilepticus show an elevated level of TWA, which was significantly higher
than when their seizures were under control. Despite the small sample size, a significant difference was found
between the level of TWA when in status and when seizures were controlled. These findings are consistent with
earlier studies of TWA following a secondary generalized seizure. This marker of life-threatening cardiac risk may
be a novel way to predict the potential for cardiac injury in patients with status epilepticus and may provide further
understanding of a possible mechanism involved in sudden unexpected death in epilepsy (SUDEP).
Financial Support: None
Neurocrit Care
105
FREQUENCY-DEPENDENT DISSOCIATION BETWEEN BRAIN TISSUE OXYGENATION AND CEREBRAL
BLOOD FLOW OF PERIODIC EPILEPTIFORM DISCHARGES
Jens Witsch1, Emma Meyers1, Angela Velazquez1, Michael J Schmidt1, Maria C Falo1, David Albers2, Soojin Park1,
Sachin Agarwal1, 4, E Sander Connolly4, Jan Claassen1, 4, 5
1
Division of Critical Care Neurology, Department of Neurology, Columbia University, College of Physicians and
Surgeons, New York, NY, USA, 2Department of Biomedical Informatics, Columbia University, New York, NY, USA,
3
Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA, 4Department of
Neurosurgery, Columbia University, College of Physicians and Surgeons, New York, NY, USA, 5Comprehensive
Epilepsy Center, Department of Neurology, Columbia University, College of Physicians and Surgeons, New York,
NY, USA
Introduction
Many abnormal EEG patterns on the ictal-interictal continuum such as periodic epileptiform discharges (PEDs)
have been described following acute brain injury. Most are associated with poor outcome but it is unclear if these
are epiphenomena or cause additional harm. We investigated the frequency-dependent pathophysiological
signature of PEDs using multimodality monitoring (MMM) following subarachnoid hemorrhage (SAH).
Methods
We identified 60 SAH patients with MMM and determined the average PEDs frequency for each minute of cEEG by
visual inspection of the EEG. We performed generalized estimating equation (GEE) analysis to explore the
relationship between PED frequency and MMM data.
Results
We found an increase of CPP between PED-frequencies 0 Hz (mean 91.8, standard deviation (SD) 17.6 mmHg)
and 1.5 Hz (mean 100.7, SD 15.8 mmHg) and saturated CPP-values at 2 Hz (mean 104.2, SD 15.8 mmHg), 2.5 Hz
(mean 104.7, SD 18.6 mmHg) and 3.0 Hz (mean 104.6, SD 17.5 mmHg). PbtO2 was similar at 0 Hz (mean: 28.0,
SD 13.7 mmHg), 0.5 Hz (mean: 27.1, SD 10.8 mmHg) and 1 Hz (mean: 27.9, SD 14.7 mmHg), followed by an
increase at 1.5 Hz (mean 35.0: SD 14.5 mmHg), and a marked decrease at 2 Hz (mean: 16.8 SD 12.7 mmHg), 2.5
Hz (mean 12.3, SD 2.3 mmHg) and 3 Hz (mean 12.5, SD 3.9 mmHg). GEE-analysis revealed significant
differences of all mean CPP values (when compared to mean CPP at 0 Hz) and significant differences of mean
PbtO2 values at 0.5 and 1.5 to 3 Hz (when compared to PbtO2 at 0 Hz).
Conclusions
We confirmed the expected increase in cerebral blood flow with increasing frequency of PED discharges. However,
despite this increase in blood flow brain tissue oxygenation dropped with higher frequencies suggesting that
increased supply did not adequately match the increased demand.
Financial Support: None
SEIZURES
ePoster 93
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106
Neurocrit Care
SEIZURES
ePoster 94
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CLINICAL SPECTRUM OF MALIGNANT NON-CONVULSIVE STATUS EPILEPTICUS (MNCSE) IN
NEUROCRITICAL CARE
Sunghoon Yang, Masao Nagayama, Tomiko Nagayama, Zenji Shiozawa
International University of Health and Wellfare Atami Hospital, Atami, Japan
Introduction
In 2012, Peter W. Kaplan proposed the concept of malignant non-convulsive status epilepticus (mNCSE) which
was preliminarily defined as refractory NCSE which remains uncontrolled for at least 5 days even after an initial
anesthetic agent (Epileptic Disord, 2012). However, its clinical spectrum is not delineated yet.
Methods
We retrospectively investigated the clinical spectrum of consecutive patients with status epilepticus (SE)
[generalized convulsive status epilepticus (GCSE) and NCSE] who were admitted to the Center for Stroke and
Neurocritical Care in our University Hospital from May 2006 to March 2014. We classified NCSE into five
subcategories, that is, 1) mNCSE, 2) recurrent NCSE, 3) protracted NCSE, 4) comatose NCSE, 5) NCSE with
postictal organ dysfuctions.
Results
Among the total 1116 patients, 44 patients suffered from SE (3.9%, 30 males, 65±19 years old). Among them,
NCSE alone in 22 patients (50%), GCSE alone in 7 patients (16%), Coexistence of GCSE and NCSE during
hospitalization in 15 patients (34%). mNCSE patients (n=4) manifested postictal organ dysfuctions in 4 patients,
post-hyperventilatory apnea in 2 patients, central alveolar hypoventilation in 1 patient. Underlying conditions of
mNCSE were encephalitis in 2 patients, meningoencephalitis in 1 patient, sepsis and cerebral infarction in 1
patient, and mortality reached 50%. In NCSE other than mNCSE (n=33), recurrent NCSE was observed in 3
patients, protracted NCSE 3 patients, comatose NCSE 4 patients, NCSE with postictal organ dysfuctions 9
patients.
Conclusions
NCSE is more frequently observed than GCSE and they often coexist. mNCSE is a fatal condition and is often
associated with inflammation of the central nervous system and postictal organ dysfuctions. Also, there exist those
patients with critical NCSE other than mNCSE.
Financial Support: None
Neurocrit Care
107
MYXEDEMA COMA ASSOCIATED WITH NON-CONVULSIVE STATUS EPILEPTICUS
Awss Zidan1, Ahmed Bedair2, Ilya Bragin1, Julius Gene Latorre1
1
Upstate Medical University Hospital-Department of Neurology, Syracuse, NY, USA, 2Faculty of Medicine-Ain
Shams University, Cairo, Egypt
Introduction
Myxedema coma is a rare presentation of severe hypothyroidism that features altered mental status and
hypothermia. Although the association between myxedema coma and abnormal electroencephalogram (EEG)
findings has been established since the mid twentieth century, seizures have been rarely reported as a
complication of this deadly disease. Here we report a case of myxedema coma that presented with a seizure and
later progressed to non-convulsive status epilepticus (NCSE).
Methods
Case report.
Results
An 86-year-old female with no past history of seizure disorder presented with lethargy and generalized weakness.
Physical exam was significant for hypotension, bradycardia, hypothermia of 33°C, hypoventilation and skin
puffiness. Initial evaluation revealed hypoglycemia and urinary tract infection. Thyroid Stimulating Hormone (TSH)
was elevated to 350 uIU/ml. Patient was intubated and aggressively managed in critical care unit with intravenous
(IV) levothyroxine, hydrocortisone and antibiotics. The following day, eyelid twitching, followed by clonic
convulsions of the extremities occurred and was successfully aborted with lorazepam. Levetiracetam was initiated.
EEG showed semirhythmic generalized slowing with embedded sharp waves, most prominent in bilateral posterior
head regions, consistent with NCSE. These electrographical seizures were successfully terminated using a
lorazepam challenge test with re-emergence of voluntary withdrawal to painful stimulation. Despite aggressive
treatment with IV levothyroxine and antiepileptis under continuous video-EEG monitoring and achieving full control
of her NCSE, she developed multi-organ failure which eventually led to her death.
Conclusions
NCSE following myxedema coma is a rare occurrence. Although the exact mechanism is not clear, few patients
were described in the literature to have late-onset seizures that were stopped permanently after replacement of
thyroid hormones. To our knowledge, this is the third case reported regarding the association between status
epilepticus and myxedema coma. Despite major advances in monitoring and treatment, mortality remains high.
Financial Support: None
SEIZURES
ePoster 95
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108
Neurocrit Care
SEPTEMBER 12
ePoster Presentations
Friday, September 12
Session II
5:15 – 6:45 pm
Kiosks 1 - 5 located in 5th Ave
Kiosks 6 - 7 located in Grand Crescent
Subarachnoid hemorrhage – Kiosk 1
#
Time
Title
98
5:15
99
5:23
InflammatoryResponsetoSubarachnoidHemorrhage:DoesthePresenceof
anAneurysmMatter?
EarlyElevationofPlasmaSolubleFmsͲlikeTyrosineKinaseͲ1isAssociated
withPoorFunctionalOutcomeafterSubarachnoidHemorrhage
Hematologicalmarkerscanhelppredictclinicalvasospasminpatientswith
aneurysmalsubarachnoidhemorrhage
MilrinonetoImproveOutcomeincerebralvasospasmafterSAH.From
april2012toapril2013NeuroͲICUCajadelSeguroSocial.Panamá
ElectrocardiographicChangesAreAssociatedwithCardiacInjury,Morbidity,
andMortalityFollowingSubarachnoidHemorrhage
Markersofnutritionalstatusatadmissiondidnotpredictfunctional
outcomesatdischargeinaneurysmalsubarachnoidhemorrhage
LevetiracetamPharmacokineticsInSubarachnoidHemorrhagePatientsWith
AugmentedRenalClearance:AMonteCarloSimulation
IntravenousAcetaminophenforAcutePainControlinNeurocriticalCare
SubarachnoidHemorrhagePatients
InfectionsafterSubarachnoidHemorrhage:ImportanceofTimingandImpact
onOutcomes
HumanAlbumin(HA)usageinsubarachnoidhemorrhage(SAH)patientsatUS
AcademicMedicalCenters:analysisoftheUniversityHealthSystem
Consortium(UHC)database
HowPoorͲGradeSubarachnoidHemorrhagePatientsDie?
100 5:31
101 5:39
102 5:47
103 5:55
104 6:03
105 6:11
106 6:19
107 6:27
108 6:35
109 6:43
MeasuredandCalculatedRestingEnergyExpenditureinNeurocriticalCare
Patients
Presenting
Author
T.Almaghrabi
S.Chou
I.DaSilva
A.DeLeon
K.Duello
H.Grewal
C.May
K.Pearson
S.Samuel
J.Suarez
A.L.deOliveira
Manoel
A.Vizzini
Medical Issues in NeuroICU - Kiosk 2
#
Time
110 5:15
111 5:23
112 5:31
113 5:39
114 5:47
115 5:55
Title
DuralSinusThrombosis:AcomplicationofMTHFRdeficiencycombinedwith
oralcontraceptivepills
CriticalCareCourseofPatientswithAcuteBasilarArteryOcclusion
IncidenceandDiseaseSeverityareDifferentforBrainInjuredPatientswith
TracheostomyReadmittedtotheICU
KidneyͲBrainLinkinTraumaticBrainInjuryPatients?
CutoffValueforCerebrospinalFluidLactatetoTreatPresumedInfectionin
PatientsWithVentriculostomies
IntraventricularNicardipineforReversibleVasospasmRelatedtoCryptococcal
Meningovasculitis
Presenting
Author
H.Brooks
J.Chalela
M.Datta
C.Dias
E.Dunn
J.Elefritz
Neurocrit Care
117 6:11
118 6:19
119 6:27
120 6:35
121 6:43
Epiduralabscessresultinginstrokesandmyelopathyinthesettingofinvasive
pneumococcaldisease
ExtubationFailureinNeurocriticalCarePatients:ARetrospectiveStudy
EffectofProbioticsontheIncidenceofHealthcareͲAssociatedInfectionsin
MechanicallyVentilatedNeurointensiveCarePatients
ComplicationRatesof3%HypertonicSalineInfusionthroughPeripheral
IntravenousAccess.
GroupBStreptococcus;ARareCauseofMeningitisinNonpregnantAdults:
CaseReport
ExtracorporealTherapyfortheManagementofPhenytoinToxicity
D.Halleran
D.E.Kahn
J.Kenna
C.Perez
R.Sweis
M.Vo
Head and Spine Trauma – Kiosk 3
#
Time
122 5:15
123 5:23
124 5:31
125 5:39
126 5:47
127 5:55
128 6:03
129 6:11
130 6:19
131 6:27
132 6:35
133 6:43
Title
RiskFactorsforDelayedIntraparenchymalHematomaEnlargementafter
ModerateandSevereTraumaticBrainInjuryusingMultivariableRegression
Modeling
ShouldPatientswithFalcineorTentorialSubduralHematomasBeTransferred
toaNeurocriticalCareUnit?
IsolatedSevereTraumaticBrainInjuryIsNotanIndependentRiskFactorFor
TheDevelopmentofCoagulopathy
NovelMethodUsingCerebralAngioplastyandMilrinoneInManagementOf
ClinicalCerebralVasospasmAfterSevereTraumaticBrainInjury
NonͲNeurologicalComplicationsInTraumaticNeurosurgicalPatientsInNeuro
ICU:AProspectiveObservationalStudy
PointͲofͲcaretestingintheacutemanagementofmildtraumaticbraininjury:
Identifyingthecoagulopathicpatient
Predictorsofradiographicprogressionofintracranialhemorrhageinmild
traumaticbraininjury
PrognosticValueofQuantitativeWholeBrainDiffusionWeightedMRIin
TraumaticBrainInjury
LackofRace/EthnicityDifferencesinSevereTraumaticBrainInjuryMortality
NotSuchaLongShot:Mortality,DischargeFunctionandOrganDonationin
PenetrainingBrainInjury
IntrathecalinhibitionofTNFreducesinflammationͲmediatedsecondaryinjury
inaratmodelofcervicalspinalcordinjury
RiskFactorsforContusionExpansioninAcuteTraumaticBrainInjury
Presenting
Author
R.Allison
R.Sweis
A.L.deOliveira
Manoel
L.Bermejo
K.Goyal
Y.Gozal
Y.Gozal
K.Hirsch
SͲMPark
T.Paterson
N.Singhal
L.Zimmermann
Head and Spine Trauma (overflow) – Kiosk 4
#
Time
136 5:31
141 6:11
143 6:27
144 6:35
145 6:43
Title
WeightͲbaseddoseͲresponsecurveofHTSversusmannitolinthe
managementofelevatedICP
VariabilityofBrainDeathDeterminationGuidelinesinOhioTraumaCenters
WillingnesstoFavorAggressiveCareandLivewithDisabilityfollowingSevere
TraumaticBrainInjury:ASurveyofHealthyYoungAdultsinHawaii
SleepfeaturesoncontinuousEEGpredictneurologicalrecoveryfromsevere
traumaticbraininjury
TraumaticBrainInjuryShiftsBrainDrugTransporterLevels:ImplicationsFor
DrugTherapies
Presenting
Author
L.Koffman
F.Muakkassa
K.Nakagawa
D.Sandsmark
F.Willyerd
SEPTEMBER 12
116 6:03
109
110
Neurocrit Care
SEPTEMBER 12
Ischemic Stroke – Kiosk 5
#
Time
146 5:15
147 5:23
148 5:31
149 5:39
150 5:47
151 5:55
152 6:03
153 6:11
154 6:19
155 6:27
156 6:35
157 6:43
Title
IntravenousrtͲPAplusEptifibatideversusIntravenousrtPAAloneinSevere
IschemicStrokes:APostHocAnalysis
IntravenousThrombolysisforCerebralVenousThrombosis:Reportof2Cases
CurrentPracticeSurveyRegardingtheUtilizationofSafetyScanspostͲ
thrombolysis(tPA)inAcuteIschemicStroke
DoesStatininfluenceinpatienthospitalmortalityinstrokepopulation?
DualAntiplateletTherapyisAssociatedwithCoagulopathyDetectableby
ThrombelastographyinAcuteStroke
DelayedBasilarArteryOcclusionDiagnosis:FiveCasesandtheLessonsWe
HaveLearned
FactorsInfluencingTracheostomyinIschemicStrokePatientsoftheNSICU
CocaineUseisAssociatedwithMoreRapidClotFormationandWeakerClot
StrengthinAcuteStroke
IVClevidipine(CleviprexR)rapidlycontrolsbloodpressure(BP)inacute
ischemicstroke(AIS).
EvaluationofIntravenousRecombinantTissuePlasminogenActivatorDosing
CharacteristicsandPatientOutcomesatanAcademicMedicalCenter
ImprovingDoortoNeedleTimesandSafetyinCVAPatients:TheNCRNRole
CollateralBloodFlowinLargeVesselEmbolism:aPredictorofCoreand
FinalInfarctVolumes,CTPerfusionAbnormalities,andPatientOutcome.
Presenting
Author
O.Adeoye
F.AlͲAjlan
K.Alsherbini
S.Izzy
M.McDonald
N.Organek
J.Patel
T.Almaghrabi
K.Polderman
J.Rocker
R.Stillian
J.Whitlock
Ischemic Stroke (overflow) – Kiosk 4
#
Time
134 5:15
137 5:39
Title
AssociationofrtͲPAandAcuteMyocardialInfarctionwithSurvivalofStroke
PatientsDuringaDecadeinUnitedStates
APopulationͲBasedStudyofIncidence,Associations,andOutcomeof
MechanicalVentilationinLifeͲThreateningStroke
Presenting
Author
K.Carr
S.Lahiri
ICU Organization and Technology – Kiosk 6
#
Time
158 5:15
159 5:23
160 5:31
161 5:39
162 5:47
163 5:55
164 6:03
165 6:11
Title
HighͲFidelitySimulationVersusTraditionalDidacticTechniquesforTeaching
NeurologicalEmergenciestoNeurologyResidents:AFeasibilityStudy.
ImprovingBedsideRNPracticeandMorale:TheImplementationoftheUnit
BasedPracticeCouncil
EvaluatingtheQualityofRNReportaftertheInitiationofaNeuroscience
SpecificHandoff
ImprovingtheQualityofPrimaryPalliativeCareDeliveryintheNeuroscience
IntensiveCareUnit
Ridingthewave:APilotStudyofNeurocriticalCareNursePractitioner
simulationtrainingforcentrallineplacement
OptimizationofIdealNSICUPatientͲtoͲNursingStaffRatiosThroughUtilization
ofPortableCT
HowtoUseaNeurocriticalCareDashboardtoDriveOperationalEfficiencies
andImprovePatientCare
NeurocriticalCareServiceImpactonHemorrhagicStrokeOutcomes
Presenting
Author
S.Agarwal
R.Stillian
N.Fitzwater
K.Garner
T.Lawson
T.Lee
A.Lefebvre
A.Lefebvre
Neurocrit Care
167 6:27
168 6:35
169 6:43
MandatoryIntensivistConsultationsDecreaseICULengthofStayandAllowfor
anIncreaseinAdmissionstoaNeurocriticalCareUnit
FrequencyandResponseTimestoClinicalandDeviceAlarmsinaNeurological
IntensiveCareUnit
Evaluationofanovelbraintissueprobeforcombinedintracranialpressure,
braintemperature,andcerebralbloodflowmonitoring:aprospective,
multicenterstudy
SafetyofPeripheralPhenylephrineAdministrationIntheNeurocriticalCare
Unit
M.Rodricks
J.M.Schmidt
M.Seule
B.Wolfe
ICU Organization and Technology (overflow) – Kiosk 4
#
Time
135 5:23
138 5:47
139 5:55
140 6:03
142 6:19
Title
Theincidenceanddeterminantsofbraintissuehypoxiaincardiacarrest
survivorswithsevereneurologicalinjury
TheDigitalIntern:Evaluationofcomputercontrolledalgorithmsinthe
neurocriticalcareunit
TheuseofanticoagulationandantiplateletagentsbeforeremovalofEVDsͲͲ
howsafeisit?
UnderstandingDischargeDelaysintheNeuroscienceIntensiveCareUnit
WebͲbasedAssessmentofOutcomesAfterIntracranialHemorrhage
Presenting
Author
J.Elmer
J.Medow
C.Miller
N.Morris
A.Naidech
Intracerebral hemorrhage – Kiosk 7
#
Time
170 5:15
171 5:23
172 5:31
173 5:39
174 5:47
175 5:55
176 6:03
177 6:11
178 6:19
179 6:27
180 6:35
Title
SimulationofBestͲConsentandFailedͲConsentElementsfromCLEARͲIII:A
Randomized,PlaceboControlledTrial
TheExcessCostofInterͲIslandTransferofPatientswithSpontaneous
IntracerebralHemorrhage
Theassociationbetweentransfusionandoutcomesinintracerebralhemorrhage
patientswithandwithoutcoronaryarterydisease:aretrospectiveanalysis
Serumalbuminlevelsinintracranialhemorrhages:Correlationwithoutcome
ThrombosisofIntraventricularCatheterPlacedAfterIntraventricular
Hemorrhage:IntraͲcatheterrtͲpAThrombolysis
SignificanceofHemodynamicandHeartratevariabilityinacutephaseof
SpontaneousIntraͲcerebralhemorrhage:ASingleCenterStudy
UtilityOfCTAngiographyInManagementOfIntracerebralHemorrhage
Presenting
Author
W.Freeman
K.Nakagawa
A.Khawaja
K.Limaye
C.Mehta
M.Mendoza
S.
Rajagopalan
Renalreplacementtherapymodeandtiminginpatientswithacutespontaneous C.SanLuis
intracerebralhemorrhageintheneurocriticalcareunit
YoungerAgeamongNativeHawaiiansandotherPacificIslandersImpactsthe
K.Shaw
RacialDifferencesintheProcessofWithdrawalofLifeSupportafter
IntracerebralHemorrhage
TroponinElevationinSpontaneousIntracranialHemorrhage
P.Tummala
RateofPeriͲHematomalEdemaExpansionPredictsMortalityafterIntracerebral S.Urday
Hemorrhage
SEPTEMBER 12
166 6:19
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SUBARACHNOID HEMORRHAGE
112
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ePoster 98
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INFLAMMATORY RESPONSE TO SUBARACHNOID HEMORRHAGE: DOES THE PRESENCE OF AN
ANEURYSM MATTER?
Tareq S Almaghrabi1, Kaushik N Parsha2, Nasim Rezanejad1, Georgene W Hergenroeder1, Ranier Reyes1, Dong
kim1, Tiffany R Chang1,2, Nancy J Edwards 1,2, Kiwon Lee1,2, Sean I Savitz2, H Alex Choi1,2
1
University of Texas Medical School at Houston/ Neurosurgery, Houston, TX, USA, 2University of Texas Medical
School at Houston/ Neurology, Houston, TX, USA
Introduction
Subarachnoid hemorrhage (SAH) is associated with an intense inflammatory reaction demonstrated by increase in
inflammatory markers in serum, CSF and interstitial fluid. The cerebral inflammatory response is associated with
delayed cerebral ischemia and worse outcomes. We analyzed whether levels of plasma inflammatory cytokines,
differ in patients with aneurysmal SAH (aSAH) compared to SAH patients without an identified cause for SAH on
angiography (nSAH).
Methods
We prospectively enrolled patients presenting with SAH to a single tertiary academic medical center between 2009
and 2013. Demographic and clinical information was gathered prospectively. Venous blood was drawn within 24
and 48 hours of presentation. A panel of cytokines was measured using a multiplex bead-based suspension
immunoassay. Delayed cerebral ischemia was defined as clinical symptoms from vasospasm or infarction on
imaging from vasospasm. Poor clinical outcome was defined as a modified ranking of >3 at discharge.
Results
A total of 126 patients were included, 101 with aSAH and 25 nSAH. Between groups there was no difference in
baseline characteristics of age, gender and proportion of Fisher Grade 3 (78% v 89%). There was a trend towards
worse Hunt-Hess grades in aSAH (poor grades 8% v 25%, p=0.1). There was no difference in poor clinical
outcomes between groups. Incidence of DCI was significantly higher in aSAH (4% versus 24%, p=0.02). The nSAH
group had significantly higher MIP-1alpha (13.2 vs 5.01 pg/ml, P< 0.01) and TNF alpha (22.5 vs 16.8 pg/ml,
p=0.01) levels compared to aSAH patients.
Conclusions
nSAH was associated with a more intense peripheral cytokine reaction compared to aSAH. Despite previous
studies that suggest inflammation after SAH is associated with DCI and worse outcomes our findings suggest a
more complicated interaction. Further studies to corroborate these findings are needed.
Financial Support: None
113
ePoster 99
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EARLY ELEVATION OF PLASMA SOLUBLE FMS-LIKE TYROSINE KINASE-1 IS ASSOCIATED WITH POOR
FUNCTIONAL OUTCOME AFTER SUBARACHNOID HEMORRHAGE
Sherry H-Y Chou1, 2, Steven K Feske1, 2, Sarah Clark1, Rose Du1, 2, Galen V Henderson1, 2, Farzaneh A Sorond1, 2,
Eng H Lo3, 2, MingMing Ning3, 2
1
Brigham and Women's Hospital, Boston, MA, USA, 2Harvard Medical School, Boston, MA, USA, 3Massachusetts
General Hospital, Boston, MA, USA
Introduction
Vasospasm and brain injury following subarachnoid hemorrhage (SAH) are associated with tissue hypoxia and
vascular endothelial growth factor (VEGF) release. Soluble Fms-like tyrosine kinase-1 (sFlt-1) is an endogenous
VEGF inhibitor released in response to hypoxia and nitric oxide deficiency. We hypothesize sFlt-1 elevation may be
associated with vasospasm and poor SAH outcome in human.
Methods
We prospectively enrolled consecutive SAH subjects, banked serial blood samples, and measured their outcome at
3 month intervals using modified Rankin scores (mRS). Poor functional outcome was defined as mRS>2.
Angiographic vasospasm was defined as >50% caliber reduction in any cerebral artery on post-SAH day 7
angiogram. In 63 SAH subjects, we compared plasma sFlt-1 by ELISA on post-SAH days 3 and 5 by vasospasm
and by outcome status. We used Wilcoxon rank sum or Student's t-test depending on data distribution. Bonferroni
correction was applied for multiple comparisons. Logistic regression was used to adjust for confounders.
Results
Twenty-seven subjects (43%) had poor 3-month outcome and 31 (49%) developed vasospasm. Elevated sFlt-1
level on post-SAH day 3 was associated with poor 3-month outcome (p=0.02) while post-SAH day 5 sFlt-1 level
showed no association with outcome. SFlt-1 levels were not associated with Hunt and Hess (HH) or Fisher grades
or with vasospasm. SFlt-1 was inversely correlated to VEGF (p=0.04, r=0.26). Post-SAH day 3 sFlt-1 level was
independently associated with poor SAH outcome after adjustment for HH grade, age, and VEGF level (p=0.03).
VEGF was not associated with vasospasm or SAH outcome.
Conclusions
Early elevation of plasma sFlt-1 on post-SAH day 3 is independently associated with poor 3-month SAH outcome
after adjustment for clinical predictors of SAH outcome and for VEGF. Inverse correlation suggests possible
negative feedback control between sFlt-1 and VEGF in SAH. Replication in a larger cohort is necessary to validate
sFlt-1 as a potential biomarker for SAH outcome.
Financial Support: This work is supported by The Harvard Clinical and Translational Science Center, the
American Heart Association (10CRP2610341, Chou) and the National Institute of Health - NINDS (K23NS073806 Chou, R21NS52498 - Ning, R01NS48422 - Ning, R37NS37074 - Lo, P01NS55104 - Lo).
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HEMATOLOGICAL MARKERS CAN HELP PREDICT CLINICAL VASOSPASM IN PATIENTS WITH
ANEURYSMAL SUBARACHNOID HEMORRHAGE
Ivan Da Silva1, J. Javier Provencio2, Joao Gomes2, Gabriel De Freitas3
1
Hospital Copa D´Or, Rio de Janeiro, Brazil, 2Cleveland Clinic Foundation, Cleveland, OH, USA, 3Instituto D´Or de
Ensino e Pesquisa, Rio de Janeiro, Brazil
Introduction
Ischemic lesions secondary to vasospasm in patients with aneurysmal subarachnoid hemorrhage are known
predictors of worse outcome. Currently, there is no clinical method or ancillary test that can reliably predict which
subset of patients will develop clinical vasospasm. The aim of our study was to find metabolic derangements that
could help identify patients at risk
Methods
We retrospectively studied 55 patients admitted to a large academic center with aneurysmal subarachnoid
hemorrhage. Data from transcranial doppler ultrasound, metabolic and clinical factors, as well as demographic and
radiographic information were collected. We used statistical tools (Pearson´s chi-square and Mann Whitney U
statistical tests) to analyze which variables were directly correlated with the development of clinical vasospasm.
Results
Of 55 patients, 14 developed clinical vasospasm. Anemia (hemoglobin< 10mg/dl) and leukocytosis (total white
blood cell count>10000 cells/mm3) on the third day after bleeding were statistically correlated with the outcome (
p< 0.0329, CI 1.12-15.16, OR 4.1250 for anemia and p< 0.0463, CI 1.03-26.13, OR 5.1818 for leukocytosis). A
multiple logistic regression model was performed and the findings were still statiscally significant after adjustment
for age, sex and modified Fisher scale. When used as a diagnostic tool on the third day after the intracranial
hemorrhage, the occurrence of both anemia and leukocytosis would have a sensitivity of 42%, specificity of 87%
and a negative predictive value of 81%, with same findings replicated in patients with mean flow velocities of the
middle cerebral arteries lower than 120cm/s on transcranial doppler assessment.
Conclusions
The presence of leukocytosis and anemia during the third day after subarachnoid hemorrhage is statistically
correlated with the occurrence of clinical vasospasm. At the same time, the absence of such findings is also a
powerful predictor of patients who are at lower risk of developing clinical vasospasm.
Financial Support: None
115
ePoster 101
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MILRINONE TO IMPROVE OUTCOME IN CEREBRAL VASOSPASM AFTER SAH. FROM APRIL 2012 TO
APRIL 2013 NEURO-ICU CAJA DEL SEGURO SOCIAL. PANAMá
Alvino De Leon MD1, Guadalupe Castillo Abrego MD1, Kees Polderman MD PhD2, Guillermo Castillo Abrego MD1,
Fernando Alfaro MD 1
1
Caja del Seguro Social Hospital / Neuro ICU, Panama, Panama, 2Neurocritical Care Service/ Critical Care
Department, Pittsburgh, PA, USA
Introduction
Subarachnoid hemorrhage (SAH) is one of the top admitting diagnoses in the Neuro-ICUs. Delayed cerebral
ischemia (DCI) associated to cerebral vasospasm occurs in 30% of the patients with SAH. With optimal therapy
the mortality remain high. Previous studies have suggested possible efficacy of milrinone in the treatment for
cerebral vasospasm. In the current study we outline the safety, efficacy and complications with the use of milrinone
in our SAH population.
Methods
Study sample included patients with SAH and with a secure aneurysms (37 endovascular, 3 clipping) were enroll.
All patients received prophylactic against vasospams (nimodipin). Workup included head CT and lab assessment
to ruled out hypoxia, electrolyte abnormalities or other potential triggers of DCI. Vasospasms was confirmed by
DSA in all the patients. Milrinone infusion (0.75 mcg/kg/min) was initiated if predefined parameters were met.
Dosage was increased until 1.25 mcg/kg/min or neurological sign and symptoms resolved.
Vasopressor(norepinephrine) were used if need. If vasospams did not resolve emergency angioplasty was perform.
Milrinone infusion was kept 48 hours after the basal neurological status was achieved and decreased
0.25mcg/kg/min every 24 hours.
Results
40 patients were enrolled (17 males / 23 females; ages 52 to 70, mean 61) with 24 WFNS III, 10 WFNS IV, 6
WFNS V; all had a modified Fisher scale of 3. No patient experienced rebleeding. The mean time for presenting
CVS was 4.9 days. The mean duration of CVS was 8 days. The need for vasopressor was 20% (N=8). 28 patients
return to the basal neurological status within the first 36 hours, all others also returned to baseline in the next 36
hours. Resolution of CVS was confirmed by DSA in all patients. Only one patient need a emergency mechanical
angioplasty. At 12 months follow up 4 patients had died from complications not related to DCI (mostly infectious
complications). Good outcome was noted in 92.5% with mRankin score 3.
Conclusions
Milrinone is a safe and effective agent to control vasospasms in patients with SAH. Its vosodilatator and positive
inotropic effects may contribute to the beneficial properties noted in our study
Financial Support: None
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Neurocrit Care
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ELECTROCARDIOGRAPHIC CHANGES ARE ASSOCIATED WITH CARDIAC INJURY, MORBIDITY, AND
MORTALITY FOLLOWING SUBARACHNOID HEMORRHAGE
Katherine M. Duello, Jay P. Nagel, Olufunso W. Odunukan, William D. Freeman, Joseph L. Blackshear
Mayo Clinic Florida, Jacksonville, FL, USA
Introduction
Electrocardiographic (ECG) and cardiac enzymatic changes may occur following subarachnoid hemorrhage (SAH).
Enzymatic changes are associated with a poor prognosis, but their utility as predictors of poor outcome may be
limited by their lower prevalence. We sought to determine if the combination of corrected QT interval (QTc) and
ECG changes could predict biomarker elevation, Glasgow Coma Scale (GCS) and mortality.
Methods
We reviewed the records of all non-traumatic SAH patients from March 2011 to December 2012 including
electrocardiographic changes (ST elevation, T wave inversions or ST depression, anterior or anteroseptal infarcts,
any ST or T wave changes) and QTc intervals. Enzymatic changes were dichotomized as troponin T 0.10 ng/mL
vs < 0.10 ng/mL, GCS as > 8 vs 8, and mortality as either alive or dead. QTc interval was prolonged if > 500
milliseconds. Statistical analysis was performed by Fisher's exact test.
Results
Electrocardiographic changes were seen in 100 / 159 (63%), and consisted of 10 ST elevations, 20 T wave
inversions or ST depressions, 22 anterior or anteroseptal infarcts, and 86 ST or T wave changes. QTc prolongation
was found in 64/159 (40%). Troponin T elevations were present in 40/159 (25%). In patients with both QTc
prolongation and EKG abnormalities troponin was elevated in 24/49 (49%), compared to 3/47 (6%) with neither
EKG abnormality or QTc prolongation, and 22-25% with either EKG abnormality or QTc prolongation. The
combination of EKG abnormality and prolonged QTc was strongly associated with troponin elevation (Odds ratio
14.08, 95% CI 3.84-14.50, p< 0.0001), mortality (Odds ratio 8.13, 95% CI 2.94-22.46, P < 0.0001) and GCS 8
(Odds ratio 5.09, 95% CI 2.09-12.40, p< 0.0005).
Conclusions
ECG changes and QT prolongation are more prevalent findings in SAH than cardiac enzymatic changes. When
considered jointly, they may predict cardiac injury, lower GCS and increased mortality.
Financial Support: None
117
ePoster 103
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MARKERS OF NUTRITIONAL STATUS AT ADMISSION DID NOT PREDICT FUNCTIONAL OUTCOMES AT
DISCHARGE IN ANEURYSMAL SUBARACHNOID HEMORRHAGE
Harpreet S. Grewal1, Neha S. Dangayach2, Jens Witsch2, Emma Meyer2, Christina M. Falo2, Sachin Agarwal2,
Michael J. Schmidt2, Sander Connolly2, Stephan Mayer3, Jan Claassen2
1
Metrohealth Medical Campus of Case Western Reserve University/Internal Medicine, Cleveland, OH, USA,
2
Columbia University Medical Center/Neurology, New York, NY, USA, 3Columbia University Medical
Center/Neurology, New York, NY, USA, 4Columbia University Medical Center/Neurology, New York, NY, USA,
5
Columbia University Medical Center/Neurology, New York, NY, USA, 6Columbia University Medical
Center/Neurology, New York, NY, USA, 7Columbia University Medical Center/Neurology, New York, NY, USA,
8
Columbia University Medical Center/Neurosurgery, New York, NY, USA, 9Icahn School of Medicine at Mount
Sinai/Neurology, New York, NY, USA, 10Columbia University Medical Center/Neurology, New York, NY, USA
Introduction
Poor pre-morbid nutritional status has been associated with worse outcomes in critically ill patients. There are few
markers of pre-morbid nutritional status which are easily available in hospitalized patients like height, weight, bodymass-index (BMI) and serum albumin. In this study we hypothesized that surrogate markers of nutritional status;
albumin at the time of admission and BMI will be associated with mortality and functional outcomes at the time of
discharge.
Methods
Adult patients >=18 with aneurysmal subarachnoid hemorrhage were enrolled in a single center, prospective,
observational cohort database between July 1996 to April 2014. Clinical, radiolographic and outcomes data were
collected prospectively. Admission albumin and BMI were assessed for the cohort. Univariate and multivariate
logistic regression analysis were performed and controlled for known markers of functional outcomes in patients in
SAH. Outcome measures were mortality and a dichmotomized MRS 1,2,3 versus 4,5.
Results
We conducted a binary logistic regression analysis to examine the impacts of surrogate markers of nutritional
status; admission albumin and BMI on functional outcomes in 1617 patients. Predictors included age, sex, severity
of SAH, presence of vasospasm, hydrocephalus, re-bleed, albumin and BMI. In the multivariate model after
controlling for known predictors of functional outcomes in patients with SAH, albumin and BMI were not found to be
significantly associated with functional outcomes (BMI OR 1.02, CI 0.99-1.05; albumin OR 1.00, CI 0.99-1.02).
Conclusions
In spite of being important predictors of outcomes in critically ill patients; we did not find BMI and admission
albumin to be predictive of functional outcomes and mortality in patients with SAH.
Financial Support: None
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ePoster 104
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LEVETIRACETAM PHARMACOKINETICS IN SUBARACHNOID HEMORRHAGE PATIENTS WITH
AUGMENTED RENAL CLEARANCE: A MONTE CARLO SIMULATION
Casey C May, Shaily Arora, Sara E Parli, Justin F Fraser, Melissa L Thompson Bastin, Aaron M Cook
University Of Kentucky HealthCare, Lexington, KY, USA
Introduction
Patients with subarachnoid hemorrhage (SAH) typically exhibit hyperdynamic cardiovascular hemodynamics, which
may lead to increased medication clearance. The aim of this study was to evaluate the actual creatinine clearance
(CrClA) in an aneurysmal SAH (SAH) population and evaluate how this may impact renally cleared medications.
Methods
This was a prospective, single-center study in a neurocritical care ICU at a university hospital. At total of 20
patients were consented and provided a 24-hour urine sample to measure the CrClA. If patients experienced
cerebral vasospasm (CV), a 24-hour urine collection was repeated during vasospasm treatment. Serum
concentration-time profiles were simulated for multiple IV doses of levetiracetam using Monte Carlo Simulation
(MCS) to assess the probability of target attainment (PTA) for attaining levetiracetam trough concentrations of
6mg/L based on the CrClA values obtained in this population.
Results
Among the 20 patients enrolled, the mean baseline CrClA was 689.0 ± 337.8 ml/min/1.73m2 and this differed
significantly from the baseline estimated creatinine clearance (CrClE) 144.9 ± 42.8 ml/min/1.73m2 (p< 0.001). Four
patients developed CV, but their mean CV CrClA was no different than baseline CrClA (814.9 ± 271.4
ml/min/1.73m2, p=0.37). MCS suggested that levetiracetam dosing poorly achieved target attainment unless thrice
daily dosing was utilized.
Conclusions
Augmented renal clearance appears to be present in patients with recent SAH. The degree of ARC in SAH patients
may impact the pharmacokinetics of commonly used agents. More frequent therapeutic drug monitoring for such
agents like levetiracetam may be necessary in this population.
Financial Support: None
119
ePoster 105
___________________________________________________________________________________
INTRAVENOUS ACETAMINOPHEN FOR ACUTE PAIN CONTROL IN NEUROCRITICAL CARE
SUBARACHNOID HEMORRHAGE PATIENTS
Kathleen Pearson1, Ahmad Bayrlee1, Stacy Voils2, Perry Taylor1, Christina Szabo1, Scott Simon1, Gretchen M.
Brophy1
1
Virginia Commonwealth University, Medical College of Virginia, Richmond, VA, USA, 2University of Florida College
of Pharmacy, Gainesville, FL, USA
Introduction
The use of intravenous (IV) acetaminophen (APAP) may reduce opioid consumption, minimize adverse events,
improve pain relief and satisfaction, facilitate earlier recovery, and reduce costs of hospitalization. Currently, no
data exist evaluating the effects of IV APAP on pain control in neurocritical care patients. This study evaluates
differences in pain scores and the need for rescue medications in patients receiving IV APAP as compared to other
analgesics for acute pain in neurocritical care subarachnoid hemorrhage (SAH) patients.
Methods
This retrospective study evaluated 157 SAH patients admitted to the Neuroscience ICU between May 2012-2013
who received analgesics < 12hrs after neurosurgical intervention. The mean pain intensity differences (PID) within
6hrs of IV APAP vs. other analgesics were compared. Additionally, the need for rescue medications < 6hrs after
the initial analgesic was compared. Data were analyzed using Chi Square, Fisher's Exact or Wilcoxon tests.
Results
Mean pain scores for the IV APAP group (n=15) pre-dose, 0-3hrs post dose, and 3-6hrs post-dose were 2.5, 1.3,
and 0.9, respectively. The mean PID for patients receiving IV APAP was 1.6 compared to 0.9 for oral APAP (n=8);
1.8 for fioricet (n=63); 0 for oral opioids (n=3); 2.9 for IV opioid (n=60); and 1.5 for others (n=8) (p=0.2). Rescue
medications were needed in 50% of IV APAP patients as compared to 50% receiving oral APAP, 70% fioricet,
100% oral opioids, 70% IV opioids and 100% other analgesics (p=0.2).
Conclusions
The use of IV APAP for acute pain in neurocritical care SAH patients was shown to decrease pain scores over a
6hr period following initial dosing, with only 50% of patients receiving rescue medications. Although beneficial
trends were observed for IV APAP, outcomes were statistically comparable to other agents including oral APAP,
opioid analgesics and fioricet. Larger studies need to be conducted to determine optimal pain management
therapies.
Financial Support: Brophy: Speakers bureau Cadence Pharma (no activity for > 12 months)
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INFECTIONS AFTER SUBARACHNOID HEMORRHAGE: IMPORTANCE OF TIMING AND IMPACT ON
OUTCOMES
Sophie Samuel1, Nasim Rezanejad2, Ranier Reyes2, Tiffany R Chang2, Nancy J Edwards2, Kiwon Lee2, Teresa A
Allison1, Huimahn A Choi2
1
Department of Pharmacy. Memorial Hermann - Texas Medical Center, Houston, TX, USA, 2Department of
Neurosurgery and Neurology. The University of Texas Medical School at Houston, Houston, TX, USA
Introduction
The purpose of this study was to examine the incidence of early vs late nosocomial infections after subarachnoid
hemorrhage (SAH) and to explore associations with delayed cerebral ischemia (DCI) and clinical outcome.
Methods
This is a retrospective cohort study of SAH patients admitted to a tertiary academic medical center from January,
2012 - June, 2013. Definition of ventriculitis/meningitis, pneumonia, blood stream infections, urinary tract infections
and Clostridium difficile were adapted from IDSA practice guidelines. Nosocomial infections were categorized into
two groups early (before 7 days) and late (after 7 days). DCI was defined as a clinical change due to vasospasm or
an infarction on brain image secondary to vasospasm. Poor outcome was defined as a modified rankin scale of >3.
Results
A total of 119 patients were included in our analysis. 40(34%) developed a nosocomial infection. 16 (13%) were
early infections and 25 (21%) were late infections. UTI 20(17%) and pneumonia 13(11%) were the most common
infectious complications. There were no identified significant risk factors for the development of early infection.
Presence of early infection was not associated with an increase rate of DCI or an increase rate of poor outcome.
Late infections were associated with presence of IVH (48 % vs 52 %; p=0.04), respiratory failure (72 % vs 26 %;
p=< 0.01) and DCI (48 % vs 14 %; p=< 0.01). The occurrence of late infections was significantly associated with
longer hospital length of stay and poor outcomes at discharge.
Conclusions
Pneumonia and UTI were common infectious complications. Early infections were not associated with DCI and did
not significantly impact clinical outcomes at discharge. Clinical and radiologic severity on presentation was risk
factors for occurrence of late infections. Late infections are associated with longer length of stay and worse
outcomes at discharge.
Financial Support: None
121
ePoster 107
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HUMAN ALBUMIN (HA) USAGE IN SUBARACHNOID HEMORRHAGE (SAH) PATIENTS AT US ACADEMIC
MEDICAL CENTERS: ANALYSIS OF THE UNIVERSITY HEALTHSYSTEM CONSORTIUM (UHC) DATABASE
Jose I Suarez1, Renee H Martin2, Eusebia Calvillo1, Samuel F Hohmann3, Eric M Bershad1, Chethan P V Rao1,
Alexandros Georgiadis1
1
Baylor College of Medicine, Houston, TX, USA, 2Medical University of South Carolina, Charleston, SC, USA,
3
University HealthSystem Consortium, Chicago, IL, USA
Introduction
SAH patients have been traditionally treated with significant amounts of intravenous (IV) fluids. HA and crystalloids
have been the preferred IV therapy. HA is expensive and its use has been questioned in general ICU populations.
Usage of HA in SAH patients in the US is currently unknown. We set out to determine trends in HA usage and
associated outcomes.
Methods
We studied all adult SAH patients entered into the UHC database from 2009-2013. We collected basic
demographics, underlying co-morbidities, severity of illness, type of hospital admission (medical vs surgical), inhospital complications, length of stay (LOS), 30-day re-admission rates, hospital costs, and discharge disposition.
We used the Mantel-Haenszel X2 test to determine the statistical significance of temporal changes in observed
outcome and patient characteristics. We evaluated changes in rates of ALB usage by fitting a mixed-effects model
with a Poisson link function and state-specific random intercepts, adjusting for age, sex, and race.
Results
We studied 30,464 adult SAH patients: 6,583 (21.6%) received HA and 23,881 (78.4%) did not. Most patients were
White (61%) and female (67%). HA use has remained low and unchanged in medical patients but has decreased in
surgical cases, especially in higher-volume centers (41% to 24% in centers with > 60 patients per year). Hospital
LOS and charges were significantly higher in HA patients (median 21.7 d and $103,864) than in non-HA group
(median 12.2 d and $54,638). Home discharges were higher in the non-HA group (50.1% vs 35.3%) and 30-day readmission rates were higher in the HA group (18.6% vs 12.9%).
Conclusions
HA use in SAH patients is associated with higher severity of illness, hospital LOS, and costs. HA use has been
declining in surgical SAH patients. The latter may be due to a decline in hypervolemic therapy in recent years.
Financial Support: None
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HOW POOR-GRADE SUBARACHNOID HEMORRHAGE PATIENTS DIE?
Airton Leonardo de Oliveira Manoel1,2, David Turkel-Parrella1,2, Ekaterina Kouzmina1, Alberto Goffi2,3, Tom
Marotta1,2, Menno Germans1,2
1
St. Michael's Hospital/Neuroscience Research Program, Toronto, ON, Canada, 2University of Toronto, Toronto,
ON, Canada, 3Toronto Western Hospital, Toronto, ON, Canada
Introduction
Aneurysmal subarachnoid hemorrhage (SAH) is associated with a high mortality rate, especially among patients
who present with World Federation of Neurological Surgeons (WFNS) grades 4 and 5. The aim of study was to
addresses the causes of mortality in the patients who are admitted as WFNS grade 4 and 5.
Methods
A consecutive cohort of poor-grade SAH patients (WFNS 4 and 5), admitted to a high-volume SAH center between
January 2009 and June 2013, was retrospectively assessed. The primary outcome was in-hospital mortality and its
causes.
Results
The study population consisted of 179 poor-grade SAH patients (mean age 56 ±12; 68% female) of which 77 (43%)
and 102 patients (57%) were WFNS 4 and 5, respectively. In total, 58 (18%) patients died, of which 46 (79%) were
WFNS 5. Thirty-three (57%) patients died before, and 25 (43%) died after aneurysm obliteration. The rate of deaths
after aneurysm obliteration were similar (WFNS 4: 10%; WFNS 5: 17%; p=0.33) but significant more WFNS 5
patients died before aneurysm treatment, when compared with WFNS 4 patients (5% and 28%, respectively (p<
0.01)). Five main causes of death were identified (n, %): withdrawal of life support [(WOLS) 33, 57%], death by
neurological criteria (16, 28%), cardiac death (3, 5%), rebleed (3, 5%), and refractory intracranial pressure (3, 5%).
WOLS and death by neurological criteria alone accounted for 85% of all deaths. The median (±SD) time between
hospital admission and death owing to WOLS before and after aneurysm treatment was 2 ±7 and 10 ±58 days,
respectively.
Conclusions
The mortality among poor-grade SAH patients in our population was 18%, with the highest risk in WFNS 5 patients
without aneurysm obliteration. Withdrawal of life support and death by neurological criteria account for the majority
of deaths in this population.
Financial Support: None
123
ePoster 109
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MEASURED AND CALCULATED RESTING ENERGY EXPENDITURE IN NEUROCRITICAL CARE PATIENTS
Angela N Vizzini1, William D Freeman2
1
Mayo Clinic Florida, Department of Nutrition, Jacksonville, FL, USA, 2Mayo Clinic Florida, Departments of
Neurology, Neurosurgery, Critical Care, Jacksonville, FL, USA
Introduction
Resting energy expenditure (REE), the caloric requirements needed to maintain vital organ function, is altered with
illness, stress, or trauma to the body. Multiple research studies indicate that stroke patients have hypermetabolism
up to 140% as a result of increased levels of cytokines and counterregulatory hormones. Provision of adequate
calories to meet metabolic demand is crucial in recovery for critically ill stroke patients. Indirect calorimetry is the
most accurate method to measure energy expenditure; however cost and lack of access inhibit its use at many
facilities. In the absence of indirect calorimetry clinicians rely on the Penn State Equation 2003b to calculate
requirements. The aim of this study was to compare measured results of indirect calorimetry to estimated energy
requirements calculated by the PSU 2003b equation in critically ill stroke patients.
Methods
Ten critically ill, mechanically ventilated patients (mean age 56.5 years, mean BMI 28.2) with diagnosis of
subarachnoid hemorrhage (SAH) or ischemic stroke were retrospectively included in this study. Indirect calorimetry
was conducted while patients were intubated and results were compared with resting metabolic rate calculated with
PSU 2003b.
Results
Eight patients were receiving sedatives at the time of indirect calorimetry with one patient receiving calories from
Propofol (218 calories in 24 hours). Enteral nutrition was infusing for eight patients. The enteral regimen was
decreased to account for propofol calories. Regression analysis showed poor correlation (r2= 0.36) between REE
measured by indirect calorimetry and REE calculated with PSU 2003b.
Conclusions
Indirect calorimetry remains the gold standard method to determine REE in hospitalized patients. The PSU 2003b
equation underestimates energy requirements in 60% of critically ill stroke patients. Inadequate nutrient delivery in
critical illness may delay recovery. Because indirect calorimetry is not available at all facilities, further research
studies should address a corrective cofactor for predictive equations used for neurocritically ill patients.
Financial Support: None
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DURAL SINUS THROMBOSIS: A COMPLICATION OF MTHFR DEFICIENCY COMBINED WITH ORAL
CONTRACEPTIVE PILLS
Holly Brooks, ACNP1, Adam King, MD2, Avinash Kumar, MD, FCCM, FCC3
1
Vanderbilt University Medical Center / Department of Anesthesia, Nashville, TN, USA, 2Vanderbilt University
Medical Center / Department of Anesthesia, Nashville, TN, USA, 3Vanderbilt University Medical Center /
Department of Anesthesia, Nashville, TN,
Introduction
Cerebral venous thrombosis is a rare disorder with an annual incidence estimated to be 3 to 4 cases per million
with an increased incidence in pregnant women. We report a challenging case of dural venous sinus thrombosis in
a female with known MTHFR deficiency recently started on oral contraceptive pills.
Results
Case: A 49 yo female with known MTHFR deficiency presented to an outside hospital with complaints of a
headache that had been continuous for the last two weeks. Of note, she had recently been started on oral
contraceptive pills for dysfunctional uterine bleeding. Radiographic imaging revealed a dural venous thrombosis
with near complete thrombosis of the right transverse sinus extending into the internal jugular with partial
thrombosis of the left transverse sinus. Upon transfer to Vanderbilt, the patient was started on a Heparin drip with a
PTT goal of 60-80. Exam was non-focal except for refractory headache. Due to continued clot burden,
endovascular thrombectomy was performed. After anticoagulation and intervention, the patient only had continued
thrombosis of the anterior portion of the transverse sinus. After intervention, the headache improved and the
patient was discharged home on Coumadin therapy with folic acid supplementation.
Conclusions
Venous sinus thrombosis remains a relatively rare cause of intracerebral hemorrhage. The incidence is increased
during pregnancy and woman are three times as likely as men to manifest with this clinical syndrome. Risk factors
for development include hypercoagulable state, pregnancy, contraceptive use or age less than 40. The majority of
patients who are diagnosed have at least one risk factor. MTHFR is the rate limiting enzyme in methionine
synthesis. A deficiency in this enzyme may lead to neural tube defects, dementia, colon cancer and occlusive
vascular disease.
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CRITICAL CARE COURSE OF PATIENTS WITH ACUTE BASILAR ARTERY OCCLUSION
Julio A. Chalela1, Khaled Asi2, Joao Gomes3
1
Medical University of South Carolina, Charleston, SC, 2Cleveland Clinic, Cleveland, OH, 3Cleveland Clinic,
Cleveland, OH,
Introduction
We sought to characterize the critical care course of patients with acute basilar artery occlusion (BAO) to determine
if advances in imaging, thrombolysis and critical care have impacted morbidity.
Methods
Retrospective study performed at two large academic centers. BAO patients admitted during a 3 year period where
identified and the following variables were abstracted: demographics, time to presentation, NIHSS, BAO occlusion
site, use of thrombolysis, infarct location on CT/MRI, and ICU complications (pneumonia, sepsis, extubation failure,
myocardial infarction, acute renal failure, acute lung injury, need for gastrostomy, intracranial hemorrhage,
withdrawal of care). Fishers exact test was used for categorical variables and proportion of the means test (t test)
for continuous.
Results
The sample comprised 59 patients with a median age of 63 (range 35-88) and median NIHSS of 19 (0-37). Men
comprised 36/59(61%) of the sample. The median time to presentation was 8 hours (range 1-72). BAO was
proximal in 12%, mid in 15%, distal in 39%, multi-focal in 19%, and complete in 15%. 24%of patients did not
receive recanalization therapy, while 76% received IV tPA, endovascular therapy, or combination. ICU
complications occurred in 61% with the most common being extubation failure in 44%, followed by ICU stay > 7
days in 34%, need for PEG in 29 %, pneumonia in 22%, and sepsis in 20%. Palliative care was instituted in 32%.
The leading death cause was withdrawal of care. The most important predictors of complications (any) were
NIHSS, intubation on admission, and pontine involvement (p 0.007, 0.01 and 0.03 respectively). The most
important predictor of palliative care was age (p 0.02). ICU complications, gastrostomy placement, and extubation
failure increased length of stay (P< 0.05 for all).In logistic regression analysis NIHSS was the only predictor of
complications.
Conclusions
Despite recent therapeutic advances, BAO patients continue to have complicated ICU stay. NIHSS predicts ICU
complications and age predicts palliative care institution.
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INCIDENCE AND DISEASE SEVERITY ARE DIFFERENT FOR BRAIN INJURED PATIENTS WITH
TRACHEOSTOMY READMITTED TO THE ICU
Mohit Datta, Vinciya Pandian, Marek Mirski, Paul Nyquist
Johns Hopkins University, Baltimore, MD, USA
Introduction
Neurocritical care patients with primary brain injury and tracheostomy transferred to floor beds are often readmitted
and become ventilator dependent. The differences in the incidence of readmission between brain injured and
general medical/surgical patients is unknown. Our goal was to identify incidence and patterns of respiratory failure
that were directly related to primary brain injury.
Methods
Retrospective chart review was conducted on all patients who received a tracheostomy between 2007 and 2013 at
a large teaching hospital. Chest x-rays (CXR) were reviewed by independent reviewers. Severity of illness was
measured using Sequential Organ Failure Assessment tool (SOFA). Frequencies, percentages, means, and
standard deviations were computed. We compared the incidence and reasons for readmission between patients
with and without primary brain injury.
Results
Total 1644 ICU patients with tracheostomy (2007-2013). Mean age was 57 years and 61% were men. 58% were
Caucasians and 35 % African Americans. 164 (10%) were readmitted to an intensive care unit. Patients with
primary brain injury were readmitted with a higher incidence than those from the general medical/surgical patients;
47 of 355 (13.2%) vs.117 of 1289 (9.1%) (p=0.020) even though they had a lower average SOFA score (mean=
4.98 vs. 6) (p=0.039) with fewer medical comorbidities. Of these 47 patients, 29 were readmitted for pulmonary
complications including atelectasis, pleural effusions, and pulmonary edema.
Conclusions
Brain injured patients with tracheostomy were readmitted to ICU with greater frequency than general
surgical/medical patients even though they had a lower severity of illness scores and fewer comorbidities. They
also had a variety of pulmonary complications on CXR that include pulmonary edema, pleural effusion, and
atelectasis.
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KIDNEY-BRAIN LINK IN TRAUMATIC BRAIN INJURY PATIENTS?
Celeste Dias1, A. Rita Gaio2, Elisabete Monteiro1, Silvina Barbosa1, Antonio Cerejo3, Joseph Donnelly4, Oscar
Felgeiras2, Peter Smielewski4, Jose-Artur Paiva1, Marek Czosnyka4
1
Intensive Care Department, Neurocritical Care Unit, Hospital Sao Joao, Porto, Portugal, 2Centre of Mathematics of
the University of Porto, Department of Mathematics, Faculty of Sciences, University of Porto, Porto, Portugal,
3
Neurosurgery Department, Hospital Sao Joao, Porto, Portugal, 4Division of Neurosurgery, Department of Clinical
NeurosciencesAddenbrooke's Hospital, Cambridge, United Kingdom
Introduction
Kidney hyperfiltration with augmented renal clearance is frequently observed in patients with traumatic brain injury
(TBI). The aim of this study is to report preliminary findings about the relationship between brain autoregulation
impairment, estimated kidney glomerular filtration rate and outcome in critically ill patients after TBI.
Methods
Data collected from a cohort of 18 consecutive patients with severe TBI managed with intracranial pressure (ICP)
monitoring in a Neurocritical Care Unit were retrospectively analyzed. Early morning blood tests were performed for
routine chemistry assessments and we analyzed creatinine and estimated creatinine clearance (CrCl), osmolarity
and sodium. Daily norepinephrine dose, protein intake, and water balance were documented. Time average of
brain monitoring data (ICP, cerebral perfusion pressure and cerebrovascular reactivity pressure index - PRx) were
calculated for 6h before blood tests. Patient outcome was evaluated using Glasgow Outcome Scale at 6 month.
Multiple linear regression models to study the effects of the above variables on PRx throughout time were used.
Results
A total of 194 complete daily observations from 18 adult consecutive multiple trauma patients with severeTBI were
analyzed. At hospital admission the median post-resuscitation Glasgow Coma Score was 6 (range 3-12), mean
SAPSII score was 44.7 with predicted mortality of 36%. Hospital mortality rate was 27% and median GOS at 6
month after discharge was 3. CrCl was found to have a negative correlation with PRx (R = - 0.82), with statistically
significant crude (p< 0.001) and adjusted (p=0.001) effects. There was a mean decrease of 0.01 in estimated PRx
for each increase of 10 ml/min in CrCl. Amongst possible confounders only norepinephrine was shown to have a
significant effect. Mean PRx value for GOS< 3 was greater than mean PRx for GOS3 (p=0.0225).
Conclusions
Better cerebral autoregulation evaluated with cerebrovascular pressure reactivity index (PRx) is significantly
correlated with augmented renal clearance in TBI patients and associates with better outcome.
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CUTOFF VALUE FOR CEREBROSPINAL FLUID LACTATE TO TREAT PRESUMED INFECTION IN PATIENTS
WITH VENTRICULOSTOMIES
Emily J Dunn, Bichun Ouyang, Sayona John, Richard Temes, Rajeev Garg, Katharina Busl, Torrey Boland,
Sebastian Pollandt, George Lopez, Kamaljit Singh, Thomas Bleck
Rush University Medical Center, Chicago, IL, USA
Introduction
We attempted to determine the CSF lactate concentrations most likely to correspond to a culture-positive CSF
infection, with the aim of making more judicious antibiotic decisions for patients with ventriculostomies.
Methods
With IRB approval, we reviewed all CSF lactate concentrations for all patients admitted to an academic medical
center from 2008 to 2013. There were 1052 patients with 2998 CSF lactate values. Of these, 51 patients had a
corresponding positive CSF bacterial culture. We constructed a receiver operating characteristic curve to determine
the CSF lactate concentration that most accurately corresponded to a positive CSF culture.
Results
The area under the receiver operating characteristic curve was 0.72. Using a CSF lactate level cutoff of 4.0 the
sensitivity and specificity were 60.8% and 76.4% respectively. Increasing the cutoff to 5.0 gave a sensitivity of
56.9% and a specificity of 86.1%.
Conclusions
This is the first single center study with over 1000 patients to determine an appropriate CSF lactate concentration
cutoff value for treating presumed CSF infection in patients with ventriculostomies. Many centers use a cutoff of 4.0
mmol/L. According to this data, using a cutoff of 5.0 mmol/L could result in more appropriate empiric antibiotic use
pending culture results. This could reduce adverse antibiotic effects for patients, prevent increasing microbial
antibiotic resistance, and conserve healthcare resources.
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INTRAVENTRICULAR NICARDIPINE FOR REVERSIBLE VASOSPASM RELATED TO CRYPTOCOCCAL
MENINGOVASCULITIS
Jessica Elefritz, Shaheryar Hafeez, Sarah Adriance, Christy Cornwell, Asma Zakaria
The Ohio State University Wexner Medical Center, Columbus, OH, USA
Introduction
Basilar meningovasculitis causing diffuse vasospasm is an under recognized complication of CNS cryptococcal
infection. We report the first case of intraventricular (IVT) nicardipine used to alleviate reversible vasospasm
associated with fungal meningitis.
Methods
Case report
Results
A 28-year-old immunocompetent male diagnosed with Cryptococcal meningitis treated with one month of
amphotericin B, flucytosine, and serial lumbar punctures, presented with lethargy and persistent dysmetria and
dysarthria. CSF examination showed clearance of the Cryptococcus fungus but ICP remained high; therefore, an
external lumbar drain was placed. After an initial two-day improvement, the patient became lethargic and had
alternating episodes of hemiplegia, which progressed to a comatose state and bilateral extensor posturing.
Continuous EEG showed diffuse slowing and no seizure activity. An extraventricular drain (EVD) was placed for
ICP monitoring, however, pressures remained consistently 20 mmHg. Repeat MRI showed scattered bilateral
cerebral ischemia and leptomeningeal enhancement. Diffuse vascular spasm was suspected on computed
tomography angiography (CTA). This finding prompted an unsuccessful attempt at angiographic spasmolysis of the
bilateral ICAs using intra-arterial verapamil. Initial TCD showed severe right (186 cm/s) and left (220 cm/s) middle
cerebral artery (MCA) vasospasm. High-dose methylprednisolone and IVT nicardipine 4mg/2mL every 8 hours
were initiated. One hour following IVT nicardipine administration, the MCA velocities improved on the right (110
cm/s) and left (104cm/s). Over the next several days, the patient was extubated, communicative, and tolerating a
regular diet. A total of 12 doses of nicardipine were administered. A follow up CTA showed no signs of vasospasm.
The patient was discharged to a rehabilitation facility on oral antifungals and nimodipine.
Conclusions
The treatment of elevated ICP associated with Cryptococcal meningitis consists of serial LPs, IV steroids, and CSF
diversion. However, no literature exists on the association of cerebral vasospasm in Cryptococcal
meningovasculitis or its treatment with intraventricular nicardipine.
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EPIDURAL ABSCESS RESULTING IN STROKES AND MYELOPATHY IN THE SETTING OF INVASIVE
PNEUMOCOCCAL DISEASE
Devin R Halleran1, Awss Zidan2, Ruham Alshiekh-Nasany3
1
Upstate Medical University College of Medicine, Syracuse, NY, USA, 2Upstate Medical University Hospital Department of Neurology, Syracuse, NY, USA, 3University of Aleppo, Aleppo, Syria
Introduction
Invasive pneumococcal disease is a rare entity in the post-antibiotics era. The extension of the infection to the
meninges and adjacent paraspinal spaces has never been described in immunocompetent adults. Here we report a
case of pneumococcal meningitis that was complicated by multiple abscesses resulting in both ischemic and
compressive phenomena. Detailed neurological examination and neuroimaging studies allowed for rapid
recognition and treatment.
Methods
Case report.
Results
A 62-year-old psychiatric-facility-resident female presented with new-onset fever and altered mental status. Initial
physical exam was significant for hyperthermia of 101°F, mild tachycardia and tachypnea, bilateral withdrawal to
painful stimulation, and reactive pupils. She soon became stuporous and endolaryngeal tube was inserted for
airway protection. Initial work-up revealed leukocytosis of 22,000/ul with a neutrophilic predominance. Lumbar
puncture was consistent with bacterial infection. Blood and CSF cultures revealed Streptococcus pneumoniae.
Broad-spectrum antibiotics were initiated and laboratory improvement was noted. Repeat physical examination
upon extubation two days later revealed left-sided 3rd nerve palsy and hemiplegia. MRI brain revealed small
scattered foci of restricted diffusion consistent with infarcts, but did not explain the left-sided findings. CT
angiogram showed complete occlusion of the vertebral artery from an adjacent compressive hypodense collection.
MRI spine showed osteomyelitis/diskitis in multiple vertebrae and diffuse prevertebral and epidural enhancing fluid
collections representing abscesses causing cervical cord compression. Urgent surgical decompression was
performed. She is currently stable and has demonstrated mild improvement in her neurologic status.
Conclusions
Pyogenic epidural and prevertebral abscesses are a rare complication of invasive pneumococcal infection. Epidural
infection can injure the nervous system either directly by mechanical compression or indirectly by vascular
occlusion. We present a case of severe pneumococcal infection which resulted in multiple abscesses, compressive
myelopathy, and ischemic strokes from an occluded vertebral artery. Prompt identification and treatment may help
avoid permanent neurological damage and improve outcomes.
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EXTUBATION FAILURE IN NEUROCRITICAL CARE PATIENTS: A RETROSPECTIVE STUDY
D. Ethan Kahn DO, Kathryn E Fulda, John Getchell RN, Gerald Fulda MD
Christiana Care Health System, Newark, DE, USA
Introduction
Between 5-20% of extubation attempts result in reintubation. Protocol driven spontaneous breathing trials (SBT)
are utilized to improve rates of successful extubation. Although proven to accurately predict success in the medical
population, data is limited regarding efficacy in neurocritical care patients. In this study, we sought to identify
parameters common to critical care neurology patients with adequate SBT who failed extubation within 48 hours.
We hypothesized that a low Glasgow Coma Scale score (GCS< 8), weak cough/gag, and moderate-to-copious
secretions would be common in this population.
Methods
This was a retrospective chart review. Subjects consisted of neurocritical care patients with acceptable SBT
parameters based on institution protocol who failed extubation and were reintubated within 48 hours. Baseline
parameters included age, rapid-shallow-breathing-index (RSBI ), and admitting GCS. At the time of extubation,
GCS, strength of cough/gag, secretion grades, and ability to follow commands was recorded.
Results
Fifty-five cases among 48 patients met inclusion criteria, of whom 7 were reintubated twice. Fifty-four cases met
SBT parameters for extubation. Mean RSBI=42 (interquartile range 24-54), mean age=63 years (range 18-89).
Thirty-two patients (58.2%) had a low admitting GCS. At the time of extubation, 3/55 patients (5.5%) had a low
GCS. Secretions were absent (N=3, 5.5%), scant/small (N=35, 63.6%), moderate (N=11, 20%) and large/thick
(N=6, 10.9%). Of the 36/55 patients in whom data was available, 8/36 (22%) exhibited a weak cough/gag. Thirteen
of 55 (24%) patients were not following commands at the time of extubation. Thus, of the four parameters
assessed at the time of extubation, most patients exhibited a high GCS, scant/small secretions, and strong
cough/gag, and could follow commands.
Conclusions
Low GCS, weak cough/gag, moderate-to-copious secretions, and inability to follow commands were not common in
our cohort. This suggests that other mechanisms unique to neurocritical care patients may be responsible for
extubation failure despite an adequate SBT.
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EFFECT OF PROBIOTICS ON THE INCIDENCE OF HEALTHCARE-ASSOCIATED INFECTIONS IN
MECHANICALLY VENTILATED NEUROINTENSIVE CARE PATIENTS
John Kenna1, Leana Mahmoud2, N. Stevenson Potter3, Corey R. Fehnel3, Bradford B. Thompson3, Linda C.
Wendell3
1
Rhode Island Hospital/University of Rhode Island, College of Nursing, Providence, RI, USA, 2Rhode Island
Hospital, Department of Pharmacy, Providence, RI, USA, 3Rhode Island Hospital, Departments of Neurology and
Neurosurgery, Providence, RI, USA
Introduction
Hospital-associated infections (HAIs) are seen in 17% of critically-ill patients. Probiotics might aid in reducing the
incidence of HAIs, especially ventilator-associated pneumonia and Clostridium difficile associated disease
(CDAD) in intensive care unit (ICU) patients, but the data is limited. To our knowledge, the effect of probiotics on
HAIs has not been studied in the neurocritically-ill population. We hypothesized that the implementation of
probiotics in mechanically ventilated patients in the NeuroICU would decrease the incidence of HAIs in our patient
population.
Methods
A retrospective review of mechanically ventilated patients admitted to the NeuroICU from July 1, 2011 to December
31, 2011 and July 1, 2012 to December 31, 2012. In the first group, probiotics were not used. In the second group,
Lactobacillus twice daily was added as part of a quality improvement initiative.
Results
None of the patients in the first group were on probiotics, and 98% of patients in the second group were on
probiotics for a median of 10 days (IQR 4-20). Median age between the non-probiotic and probiotic groups was
similar [59 years (46-74) vs. 62 years (54-74), respectively]. There was no decrease in the incidence of HAIs in the
probiotic group vs. the non-probiotic group [total HAIs 13 vs. 7, p=0.32, VAP 2 vs. 2, p=1, CDAD 2 vs. 0, p=0.23,
catheter-associated bloodstream infections (CA-BSI) 3 vs. 0, p=0.11, catheter-associated urinary tract infections
(CA-UTI) 4 vs. 5, p=1]. No patients developed Lactobacillus bacteremia. There was also no significant difference in
ventilator days, length of ICU or hospital stays, in-hospital mortality or discharge status.
Conclusions
While probiotics can be safely administered in neurocritically-ill patients, the implementation of probiotics did not
significantly decrease the incidence of HAIs in our study population.
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COMPLICATION RATES OF 3% HYPERTONIC SALINE INFUSION THROUGH PERIPHERAL INTRAVENOUS
ACCESS
Claudia A Perez1,2, Pamela Coffie2, Cory D Kasier2, Jojo P Koshy2, Stephen A Figueroa1,2,3
1
UT Southwestern Medical Center/Neurology & Neurotherapeutics, Dallas, TX, USA, 2Parkland Health & Hospital
System, Dallas, TX, USA, 3UT Southwestern Medical Center/Neurosurgery, Dallas, TX, USA
Introduction
Hyperosmolar therapy with hypertonic saline (HTS) is a cornerstone in the management of intracranial
hypertension due to cerebral edema. Guidelines for initiation, dosing and safety for administration are lacking.
Theoretical safety concerns remain for infiltration, thrombophlebitis, tissue ischemia and venous thrombosis
associated with continuous 3%HTS administered via peripheral IV (pIV). It is common practice at many institutions
to allow only central venous catheter infusion of 3% HTS, with little published safety data in relation to peripheral
administration.
Methods
We prospectively monitored patients admitted to Parkland Hospital Surgical ICU who received peripheral 3%HTS,
as part of a quality improvement project. Our hospital policy was changed to allow the administration of 3%HTS in
approved areas via 16-20 gauge pIVs up to a max infusion rate of 50mL/hour in patients without central venous
access. We documented gauge, location, maximum infusion rate and total hours of administration. Patients were
assessed for infiltration, erythema, swelling, phlebitis, hemolysis, thrombosis and line infection.
Results
From October 2013 - May 2014, 28 subjects across 34 peripheral lines were monitored. The rate of complications
was 11.7% (n=4) per lines assessed in 3 patients. The documented complications included infiltration (n=1),
erythema (n=1) and swelling (n=1). There was one incidence of right brachial vein thrombosis in one patient who
received 3% HTS via pIV for one hour. Overall subjects received 3% HTS for a duration between (1-252 hours)
with infusion rates of (30-50 mL/hour).
Conclusions
There is low risk of minor, non-limb or life threatening complications from pIV administration of prolonged 3% HTS
infusion therapy. It is generally accepted that central venous infusion may reduce risk of these minor complications
but may increase risk of more serious associated complications; blood stream infection, pneumothorax and arterial
injury. The concern regarding the safety risks of pIV administration of 3% HTS may be overstated and unfounded.
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GROUP B STREPTOCOCCUS - A RARE CAUSE OF MENINGITIS IN NONPREGNANT ADULTS: CASE
REPORT
Rochelle Sweis, Tom Bleck
Department of Neurological Sciences, Section of Neurocritical Care, Rush University Medical Center, Chicago, IL,
USA
Introduction
Streptococcus agalactiae or group B streptococcus (GBS) is recognized as a major cause of neonatal meningitis
and sepsis which often follow maternally derived infection during pregnancy. In recent years, the GBS disease
spectrum has emerged amongst adults with a reported annual incidence of 2.4 to 4.4 cases per 100,000
population. GBS meningitis in adults is a rare entity which can occur without any predisposing factor or secondary
to bacteremia acquired either in the community or noscomially.
Methods
Case Report
Results
We report a case of a 60-year-old male with past medical history of diabetes mellitus, coronary disease and prior
myocardial infarction, poor dentition, hypertension, chronic stasis dermatitis, and previous left lower extremity
cellulitis admitted with one day onset of disorientation and agitation. CT brain with contrast showed small ring
enhancing lesion within left occipital lobe with surrounding vasogenic edema and mass effect concerning for
abscess versus less likely neoplastic process. MR Stealth revealed 2.2 x 2 x 2.3 cm ring enhancing lesion in left
occipital lobe with marked central restricted diffusion and surrounding vasogenic edema. He underwent left
occipital craniotomy and evacuation of brain abscess. While no heart murmurs or peripheral stigmata of infective
endocarditis were appreciated, four of four blood cultures were positive for GBS. Cultures from the brain abscess
also cultured GBS. Transthoracic echocardiogram was negative for valvular dysfunction and vegetations.
Transesophageal echocardiogram could not be completed. He was treated with a six week course of Ceftriaxone
for GBS occipital abscess and presumptive endocarditis despite a negative TTE. Poor dentition with bacteremia
was the suspected source of infection resulting in secondary hematogenous seeding of the brain.
Conclusions
GBS is an infrequent cause of meningitis in adults but carries a high case-fatality rate and should not be
considered an exclusive peripartum infectious process.
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EXTRACORPOREAL THERAPY FOR THE MANAGEMENT OF PHENYTOIN TOXICITY
Mai Vo1, Jingjing Zhang2, Samer Melhem1, Kees H Polderman1, Lori A Shutter1
1
University of Pittsburgh Medical Center Department of Critical Care Medicine, Pittsburgh, PA, USA, 2University of
Pittsburgh Medical Center Department of Nephrology, Pittsburgh, PA, USA
Introduction
Phenytoin toxicity is typically treated with supportive care. Dialysis has been used for patients with life threatening
clinical symptoms, but its role remains controversial. We report the efficacy of high-flux hemodialysis and
continuous veno-venous hemodiafiltration (CVVHDF), and the successful management of two patients with
phenytoin toxicity, one who survived despite phenytoin levels that exceeded the maximum levels previously
reported for a survivor.
Methods
Patient A was a 23-year-old woman with a history of seizures on phenobarbital who presented to an outside
hospital with status epilepticus. She was given high-dose fosphenytoin, then transferred to our facility where initial
total phenytoin level was 139.0ug/mL (adjusted level for albumin 193.1ug/mL, normal therapeutic level 1020ug/mL). After one week of supportive care, total phenytoin levels plateaued between 65-80ug/mL; and, because
of prolonged coma, she underwent two sessions of high-flux hemodialysis. Patient B presented after bradycardic
arrest with a total phenytoin level of 59.1ug/mL (adjusted 84.4ug/mL) and was immediately treated with 22-hours
on CVVHDF due to hypotension.
Results
Patient A's total serum phenytoin concentration level decreased from 64.6ug/mL to 38.4ug/mL after the first high
flux dialysis session and her motor exam improved from decorticate posturing to spontaneous, non-purposeful
movements. After a second dialysis session, phenytoin levels fell from 31.7ug/mL to 17.0ug/mL with increase
wakefulness. On one year follow-up, she had persistent ataxia and tremor but otherwise had minimal neurological
deficits. Patient B had a similar rapid reduction in phenytoin levels with CVVHDF (59.1ug/mL prior to CVVHDF,
35.4ug/mL after 12hr, 21.1ug/mL after 22hr); and, the patient rapidly returned to her baseline functional status.
Conclusions
High-flux dialysis and CVVHDF significantly enhances clearance of phenytoin despite high protein binding. These
types of extracorporeal removal techniques should be considered as therapy earlier in cases of phenytoin toxicity
with significant neurological compromise.
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HEAD AND SPINE TRAUMA
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RISK FACTORS FOR DELAYED INTRAPARENCHYMAL HEMATOMA ENLARGEMENT AFTER MODERATE
AND SEVERE TRAUMATIC BRAIN INJURY USING MULTIVARIABLE REGRESSION MODELING
Randall Z Allison1, Kazuma Nakagawa1,2, Michael S Hayashi1,2, Daniel J Donovan1, Matthew A Koenig1,2
1
The University of Hawaii John A. Burns School of Medicine, Honolulu, HI, USA, 2The Queen's Medical Center,
Honolulu, HI, USA
Introduction
After traumatic brain injury (TBI), delayed enlargement of intraparenchymal hematomas (IPH) has been reported in
up to 40% of patients but predictive models for IPH enlargement have not been developed.
Methods
The trauma database from the only American College of Surgeons verified trauma center in Hawaii was queried to
identify consecutive patients admitted for non-penetrating moderate and severe TBI from 2008-2013. Retrospective
chart review was undertaken to collect additional variables. IPH volume was estimated using the ABC/2 method.
The primary outcome was IPH enlargement by 10 mL on serial imaging. Chi-square and ANOVA were used to
identify factors associated with IPH enlargement (p< 0.1) which were then included in a multivariable logistic
regression model.
Results
419 patients were screened, of whom 286 had repeat imaging and were included in the analyses. Mean age was
47.6±26.7 years, 70.6% were male, 38.8% were Asian, 29.7% were Native Hawaiian or Pacific Islander, and 25.2%
were white. Mechanism of injury was fall in 48.3%, motor vehicle crash in 25.2%, and assault in 15.0%. In-hospital
mortality was 20.6%. Sixty-one patients (21.3%) had delayed IPH enlargement, which was symptomatic in 52% of
cases. On univariable analyses, IPH enlargement was associated with older age, higher initial systolic blood
pressure, anti-platelet medications, anticoagulants, subarachnoid hemorrhage (SAH), subdural hematoma (SDH),
skull fracture, frontal contusion, and shorter interval from injury to initial CT. Packed red blood cells (pRBC)
transfusion was protective. In a stepwise logistic regression model, SAH (OR 6.33), SDH (OR 3.46), skull fracture
(OR 2.67), and pRBC transfusion (OR 0.31) were independently associated with IPH enlargement (p< 0.05).
Conclusions
We identified risk factors for delayed IPH enlargement after moderate and severe non-penetrating TBI. These
factors could be used to identify patients at high risk for IPH enlargement who require closer clinical and
radiographic monitoring and may benefit from investigational treatments.
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SHOULD PATIENTS WITH FALCINE OR TENTORIAL SUBDURAL HEMATOMAS BE TRANSFERRED TO A
NEUROCRITICAL CARE UNIT?
Rochelle T Sweis1, Bichun Ouyang2, George Lopez1, Richard E Temes1, Sebastian Pollandt1, Katharina M Busl1
1
Department of Neurological Sciences, Section of Neurocritical Care, Rush University Medical Center, Chicago, IL,
USA, 2Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA
Introduction
Patients with subdural hematomas (SDH) are frequently transferred to tertiary care centers with dedicated
neurocritical care units for management. SDH commonly occur over the convexity of the brain, often secondary to
trauma. While many prognostic factors, treatment strategies, and outcomes for convexity SDH have been reported,
little is known about outcomes of tentorial and falcine SDH. This study describes features and outcomes of isolated
tentorial and falcine SDH.
Methods
Adult patients admitted to Rush University Medical Center (RUMC) between January 2009 and March 2012 with
isolated acute SDH were reviewed for clinical and radiographic findings, comorbidities, treatment, length of
ICU/hospital stay (LOS), and outcome. Univariate analyses were performed to assess characteristics of patients
with isolated falcine/tentorial SDH and outcomes (favorable [discharge to home/acute rehabilitation], versus
unfavorable [death/hospice/skilled nursing facility/long term care]).
Results
Of 210 patients with SDH, mean age was 69.5 years (SD 16.2); 117 (56%) were male; 30 (14%) required
intubation, 98 (47%) underwent surgical SDH evacuation. Twenty-seven patients had isolated falcine or tentorial
SDH, with known traumatic etiology in 23, and 3 in the setting of coagulopathy. None of the falcine/tentorial SDH
patients required surgery or intubation. Compared with convexity SDH, patients with falcine/tentorial SDH were
younger (59.7 vs. 70.9 yrs, p = 0.01), had higher admission GCS scores at the referring hospital (p = 0.01) and
RUMC (p = 0.004), and shorter median ICU-LOS (1 vs. 3, p < 0.0001). All patients (100%) with falcine/tentorial
SDH had favorable outcome versus 68% with convexity SDH (p = 0.0005).
Conclusions
Isolated tentorial or falcine SDH represent a benign entity among patients with acute SDH, with no need for
surgical intervention, short LOS, and favorable outcome. Our data indicate that for patients with isolated
falcine/tentorial SDH, in the absence of other factors requiring higher level of care, transfer to a neurocritical care
center may not be indicated.
Financial Support: None
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ISOLATED SEVERE TRAUMATIC BRAIN INJURY IS NOT AN INDEPENDENT RISK FACTOR FOR THE
DEVELOPMENT OF COAGULOPATHY
Airton Leonardo de Oliveira Manoel1,2, Antonio Capone Neto4, Alberto Goffi2,3, Sandro Rizoli2,5
1
St. Michael's Hospital/Neuroscience Research Program, Toronto, ON, Canada, 2University of Toronto, Toronto,
ON, Canada, 3Toronto Western Hospital, Toronto, ON, Canada, 4Hospital Israelita Albert Einstein, São Paulo,
Brazil, 5St. Michael's Hospital/Director of Trauma - Division of General Surgery, Toronto, ON, Canada
Introduction
The presence of coagulopathy is common after severe trauma and has been associated with increased mortality.
The aim of this study was to identify whether isolated severe traumatic brain injury (TBI) is an independent risk
factor for coagulopathy.
Methods
Adult patients admitted to a Level I Trauma Center within 6 hours of injury underwent comprehensive coagulation
assessment by means of classic tests, thromboelastography (TEG) and advanced laboratorial analysis,
including the measurement of coagulation factors (CF) and biomarkers of all phases of the hemostatic cascade.
Patients were categorized according to the Abbreviated Injury Scale (AIS): Group 1 - isolated severe TBI (AIS
head > 3 + AIS non-head < 3); Group 2 - severe multisystem trauma associated with severe TBI (AIS head > 3 +
AIS non-head > 3); Group 3 - severe multisystem trauma without TBI (AIS head < 3 + AIS non-head > 3). Primary
outcome was the development of coagulopathy and in-hospital mortality.
Results
345 patients were included, 48 patients in Group 1, 137 in Group 2, and 160 in Group 3. Group 1 had lower rates of
coagulopathy (12.5% vs. 30.5 vs. 22.5, p < 0.05) and disseminated intravascular coagulopathy (6.25% vs. 13.9 vs.
11.2, p < 0.05) when compared to Group 2 or 3. TEG parameters and CF levels did not differ statistically among
the three groups. Isolated severe TBI was not an independent risk factor for coagulopathy (OR 1.06; 0.35-3.22 CI,
p= 0.92). However, severe TBI patients (Group 1 and 2) who developed coagulopathy had higher mortality rates
than coagulopathic Group 3 patients (50% vs. 19%, p < 0.05). The presence of coagulopathy (OR 5.61; 2.65 11.86 CI, p < 0.0001) and isolated severe TBI (OR 11.51; 3.9 - 34.2 CI, p < 0.0001) were independent risk factors
for in-hospital mortality.
Conclusions
Isolated severe traumatic brain injury is not an independent risk factor for the development of coagulopathy.
However, severe TBI patients who develop coagulopathy have extremely high mortality rates.
Financial Support: None
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NOVEL METHOD USING CEREBRAL ANGIOPLASTY AND MILRINONE IN MANAGEMENT OF CLINICAL
CEREBRAL VASOSPASM AFTER SEVERE TRAUMATIC BRAIN INJURY
Leonides Bermejo, Jaclyn D Duvall, Emmaculate M Fields, Ankur Garg, Bappaditya Ray
The University of Oklahoma Health Sciences Center/ Neurology, Oklahoma City, OK, USA
Introduction
Incidence of vasospasm following traumatic brain injury (TBI) is one-third as compared to aneurysmal
subarachnoid hemorrhage (aSAH). Since pathophysiology and clinical course are different for cerebral vasospasm
(CVsm) in TBI patients, there are less established clinical guidelines to treat this condition. Cerebral angioplasty
and milrinone based hyperdynamic therapy is gaining acceptance in management of clinical CVsm after aSAH. But
similar protocol to treat CVsm after TBI is absent.
Methods
Retrospective chart review of a patient with severe TBI who developed clinical vasospasm and treated with
cerebral angioplasty and milrinone infusion.
Results
A 28-year-old African man was admitted with GCS of 7 after fall from golf cart, sustaining skull base fracture,
traumatic subarachnoid hemorrhage and bifrontal and left temporal contusions. Cerebral angiogram performed at
admission ruled out aneurysm. Neurological deterioration on post-bleed day (PBD) 2 correlated with increased
cerebral edema in association with evolving cerebral contusions and treated with hyperosmolar therapy using
mannitol. His clinical improvement documented as spontaneous eye opening and acknowledging examiner's
presence led to extubation on PBD 3. On PBD 8 and 9, patient developed new onset progressive right-sided face
and arm weaknesses that led to clinical suspicion of CVsm. Severe CVsm was observed in left anterior and middle
cerebral arteries on cerebral angiography that was treated with angioplasty in addition to intra-arterial milrinone
therapy. This was followed by intravenous infusion of milrinone with maintenance of mean arterial pressure at 8095 mm Hg and hypertonic hyperosmolar therapy to maintain serum sodium at 145-150 meq/L. Patient
subsequently regained right upper extremity strength and resolution of facial weakness. He had minimal expressive
aphasia at discharge.
Conclusions
CVsm should be considered in patients with severe TBI who have late neurological deterioration. Cerebral
angioplasty and milrinone infusion with maintenance of normotension to borderline hypertension appears safe in
patients with cerebral contusions.
Financial Support: None
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NON-NEUROLOGICAL COMPLICATIONS IN TRAUMATIC NEUROSURGICAL PATIENTS IN NEURO ICU: A
PROSPECTIVE OBSERVATIONAL STUDY
Dr Keshav Goyal, Dr Amarjyoti Hazarika, Dr Navdeep Sokhal, Dr Parmod Bithal
Critical and intensive care, Neuroanaesthesiology, JPNATC, All India Institute Of Medical Sciences, New Delhi,
India
Introduction
Non-neurological complications involving a single or multiple organ systems during intensive medical care in
critically ill patients of traumatic brain and spine injuries is significant as a cause of poor prognosis but often
neglected. The aim of this study was to assess the frequency of such complications in neuro ICU and analyze their
impact on morbidity and mortality.
Methods
A prospective observational study on 200 patients of varied demographic profile admitted in neuro ICU over a
period of 6 months for conservative /operative management, with traumatic brain and spinal cord injury and
associated multisystem involvement was conducted. Significant predefined parameters addressing the nonneurological complications occurring during their ICU stay were recorded including respiratory, cardiovascular,
Infection, acute kidney injury (AKI), gastrointestinal complications, electrolyte disturbances and bleeding
complications. The study period was from admission to the ICU till the discharge from the ICU or demise.
Results
63% of patients developed respiratory complications in the form of chest infiltrate (50%) and atelectasis (10.31%).
35.5% of patients suffered from cardiovascular compications. 37% of patients had dyselectrolytemia, commonest
being hypernatremia due to hypovolemia (70%). Sepsis was observed in 23.5%. Bleeding diathesis and acute
renal injury were observed in 22% & 3.5% of patients respectively. 17% of the patients succumbed to injury out of
which 64.7% was due to non -neurological cause. Further results will be dealt in detail with inferences at the
meeting.
Conclusions
Intensivists in neuro ICU must consistently assess the non-neurological complications in traumatic brain and spine
injured patients and deliver appropriate care to bring down the mortality and morbidity.
Financial Support: None
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POINT-OF-CARE TESTING IN THE ACUTE MANAGEMENT OF MILD TRAUMATIC BRAIN INJURY:
IDENTIFYING THE COAGULOPATHIC PATIENT
Yair Gozal1, Christopher P Carroll1, Bryan Krueger1, Norberto Andaluz1,2,3
1
Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA, 2University of Cincinnati Neuroscience
Institute, Cincinnati, OH, USA, 3Mayfield Clinic, Cincinnati, OH, USA
Introduction
The use of anticoagulant or antiplatelet medications has become increasingly common and is a well-established
risk factor for worsening of hemorrhage in trauma patients. Moreover, traumatic intracranial hemorrhage may also
present with concomitant dysfunction of coagulation. To date, the use of point-of-care (POC) tests to assess patient
coagulation status has not been extensively investigated in mild traumatic brain injury (TBI).
Methods
A retrospective review of 190 mild TBI patients who underwent both conventional and POC testing as part of their
admission coagulopathy workup was conducted. Coagulation deficiency was defined as an INR > 1.4, a reaction
time (r-value) on rapid thromboelastography (r-TEG) > 50s, or a therapeutic Verify Now Aspirin (VN-ASA) level of <
550 ARU.
Results
Analysis of 190 patients was completed with 91 (48%) disclosing a history of either Coumadin or antiplatelet use or
having a documented INR > 1.4. Using POC testing only, 128 (67%) patients were noted to be coagulopathic either
based on elevated r-value or therapeutic VN-ASA. Of the 9% of patients who reported Coumadin use, 83% had
elevated INR while 61% had elevated r-value. However, 41% of the patients not reporting anticoagulant usage
revealed significantly elevated r-value consistent with a post-traumatic hypocoagulable state. Analysis of 64
patients (34%) who reported taking ASA demonstrated therapeutic VN-ASA in 80%. Interestingly, 25% of the
patients not reporting ASA use were also noted to have therapeutic VN-ASA suggestive of platelet dysfunction.
Conclusions
The coagulopathy POC panel consisting of r-TEG and VN-ASA successfully identified patients with self-reported
anticoagulant or antiplatelet usage. In addition, POC testing also distinguished a subset of mild TBI patients with an
occult coagulopathy that would have otherwise been missed. Standardization of these POC assays on admission
in TBI may help guide patient resuscitation in the acute setting.
Financial Support: Mayfield Education and Research Fund Grant
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PREDICTORS OF RADIOGRAPHIC PROGRESSION OF INTRACRANIAL HEMORRHAGE IN MILD
TRAUMATIC BRAIN INJURY
Yair M Gozal1, Jonathan D York1, Shawn Vuong1, Smruti Patel1, Steven L. Gogela1, Andrew Look1, Norberto
Andaluz1,2,3
1
Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA, 2University of Cincinnati Neuroscience
Institute, Cincinnati, OH, USA, 3Mayfield Clinic, Cincinnati, OH, USA
Introduction
The vast majority of the 1.7 million traumatic brain injuries (TBI) in the U.S. annually are considered mild. While
mortality or need for neurosurgical intervention is rare in the mild TBI population, a small number of patients may
progress with potentially devastating clinical consequences. Here, we propose to clarify which patient or injuryspecific factors are most predictive of disease progression
Methods
Retrospective review of 625 adult patients who presented following a reported trauma with a GCS 13-15 and an
abnormal non-contrast head CT. Additionally, all patients underwent a follow up head CT to assess interval
progression. Medical history, with particular emphasis on the mechanism of injury, use of anticoagulant or
antiplatelet medications, as well as type and location of hemorrhages, was recorded.
Results
Of the 625 patients included for analysis, 142 (22.7%) demonstrated radiographic findings consistent with
progression of their intracranial hemorrhage. In these patients, the types of intracranial hemorrhages with the
highest likelihood of progression were intraparenchymal contusions (incidence of 53% vs 19% in patients with
stable follow up CT) and intraventricular hemorrhages (19% vs 6.6%). Interestingly, patients with concomitant skull
fracture were almost twice as likely to have progression of their intracranial hemorrhage regardless of the
underlying hemorrhagic subtype (39% vs 22%). Finally, almost half the patients demonstrating progression
presented with a GCS 13-14, while more that 75% of patients with stable repeat head CT presented with GCS 15.
Conclusions
A significant minority of mid TBI patients will have progression of their intracranial injury on interval imaging. In our
cohort, the patient's presenting GCS and subtype of hemorrhage appear to most closely correlate with a higher risk
of progression. Improved characterization of the factors that underlie this phenomenon will help establish
guidelines for the disposition and acute management of high risk patients.
Financial Support: work funded by a grant from the Mayfield Education and Research Fund
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PROGNOSTIC VALUE OF QUANTITATIVE WHOLE BRAIN DIFFUSION WEIGHTED MRI IN TRAUMATIC
BRAIN INJURY
Karen G Hirsch1,3, Afaaf Shakir2, Didem Aksoy1, Michael Mlynash1
1
Stanford University, Department of Neurology and Neurological Sciences, Stanford, CA, USA, 2Stanford University
School of Medicine, Stanford, CA, USA, 3Stanford University, Department of Neurosurgery, Stanford, CA, USA
Introduction
The ability to predict outcomes in the acute period after moderate or severe traumatic brain injury (TBI) is limited.
The amount of tissue below certain apparent diffusion coefficient (ADC) thresholds on diffusion weighted magnetic
resonance imaging (DWI MRI) has been shown to correlate with patient prognosis in other neurological diseases,
but data in TBI patients is lacking.
Methods
This retrospective observational study investigated patients with moderate or severe TBI. The MRIs obtained postinjury days 1-13 were analyzed. The brain was automatically outlined using a brain extraction tool implemented in
MRIcron software, and the ADC value of each voxel within the brain was determined. The percentage of voxels
below different ADC thresholds within brain tissue was calculated. The timing of MRI after injury and the correlation
with outcome were analyzed. A good outcome was defined as discharge to home or a rehabilitation facility.
Results
Seventy-six patients were analyzed. Thirty-five patients (46%) had a good outcome. The timing of MRI scans did
not differ between groups, but the mean age did (43±18 yrs vs. 55±20 yrs, p< 0.01, good vs. poor outcome).
Patients with poor outcome had significantly higher percentage of brain volume with ADC < 400x10-6mm2/sec
(0.88±0.7% vs. 0.62±0.28%, first MRI for each patient with poor vs good outcome, p< 0.05). Using a ROC curve
analysis and Youden's index, an ADC < 400x10-6mm2/sec in 0.5% of brain was 80% sensitive and 43% specific
for poor outcome (p< 0.05). Quantitative DWI MRI was better able to differentiate outcome groups when performed
on post-injury day 1-4.
Conclusions
Quantitative MRI offers additional prognostic information in acute TBI. A whole brain tissue ADC threshold of <
400x10-6mm2/sec in 0.5% of brain may be a novel prognostic biomarker. The optimal timing of MRI after injury to
use this quantitative technique appears to be at post-injury day 1-4.
Financial Support: None
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LACK OF RACE/ETHNICITY DIFFERENCES IN SEVERE TRAUMATIC BRAIN INJURY MORTALITY
Sea-Mi Park1, Ya-lin Chiu2, Linda Gerber2, Ko-Eun Choi1, Jamshid Ghajar3, Axel Rosengart1
1
Departments of Neurology, Neuroscience and Neurosurgery Weill Cornell Medical College-New York Presbyterian
Hospital, New York, NY, USA, 2Department of Healthcare Policy and Research Division of Biostatistics and
Epidemiology Weill Cornell Medical College, New York, NY, USA, 3Department of Neurosurgery Stanford
University School of Medicine, Stanford, CA, USA
Introduction
Studies examining outcome in acute brain injury of vascular origin (i.e., ICH, ischemic stroke) as well as
investigations on treatment performance in acute coronary patients identified significant racial disparities across
various medical specialties and care settings. We were interested in ethnicity-related differences in adult brain
trauma patients with respect to variance in admission demographics and treatment course during the acute
hospitalization phase.
Methods
A total 3,125 TBI patients from the prospective New York State TBI-Trac® database (20 Level I and 2 Level II
trauma centers in New York State; June 2000 to December 2009) were studied. Of those, 632 patients were
excluded because of missing data. 2,370 patients were analyzed to identify race/ethnicity differences using two
week mortality and by generating 3 independent outcome models: A dichotomized outcome dead versus alive; B
stratified outcome by outcomes scenarios: death, GCS 3-5, GCS 6-8 or GCS >9; and C in-hospital course as either
worsening, anticipated, or improved. For all binary variables chi-square analysis was employed (mean ± SD) and
associations were evaluated using multivariate logistic regression analysis (OR; 95% CI) (SAS 9).
Results
Whites accounted for 64% (n=1597), Blacks 14% (n=351), Hispanics 16% (n=396) and others 2% (n=26).
Prognosticator frequencies were areflexic pupils (30%), abnormal admission CT (84%), male gender (77%), age
>60 years (17%), and hypotension on admission (19%). At 14 days 23% (n=638) had died. Analysis of Blacks
(15%) versus non-Blacks (85%), Whites (74%) versus non-Whites (26%), and Hispanics (16%) versus nonHispanics (84%) did not show a statically significant difference along racial and ethnic subgroups after adjustment
for all admission prognosticators.
Conclusions
While several studies demonstrated race/ethnicity difference in TBI long-term outcome, mostly due to
socioeconomic challenges, low education, uninsured status, non-English speaking, and lack of community
integration, we identified no outcome discrimination during the acute phase of TBI treatment.
Financial Support: None
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NOT SUCH A LONG SHOT: MORTALITY, DISCHARGE FUNCTION AND ORGAN DONATION IN
PENETRAINING BRAIN INJURY
Tara A. Paterson 1, Daniel J. Haase1,2, Amit Dhanda1,3, Margaret H. Lauerman1, Thomas M. Scalea1, Deborah M.
Stein 1
1
R Adams Cowley Shock Trauma Center, Baltimore, MD, USA, 2University of Pittsburgh, Pittsburgh, PA, USA,
3
University of Maryland School of Medicine, Baltimore, MD, USA
Introduction
Penetrating brain injury (PBI) is traditionally associated with high mortality. Despite the grave prognosis, it remains
poorly described. The goal of this study was to observe outcomes and trends in PBI.
Methods
A retrospective review was performed of PBI over 5 years. The primary outcome was mortality. Secondary
outcomes included organ donation and discharge GCS.
Results
There were 307 patients with PBI. Overall mortality was 62.9% (45 brain and 144 cardiac deaths). 36.6% of PBI
presented with systolic blood pressure (SBP)< 90mmHg. 72.3% presented with a Glascow Coma Score (GCS)< 8
and 23.1% with a GCS from 13-15. Lateralizing signs were present in 12% and dilated pupils in 62.7%. Overall
organ donation rate was 16%. Within the first 24 hours, mortality was 85.5%. As compared to survivors, of patients
who died; 85% presented with GCS of 3(vs. 19.3%, p< 0.001), 92% with abnormal pupils (vs. 28.9%,p< 0.001), and
75.1% with SBP< 90mmHg(vs. 3.5%,p< 0.001). 53.6% of PBI survived to ICU compared to 39.4% who ultimately
died in ICU. Among 61 survivors to ICU, organ donation rate was 53.6%. Amongst 113 survivors, 19.3% had a
GCS of 3 on presentation. Functional outcomes were excellent in survivors; 69.9% had discharge GCS of 13-15,
93.8% had a discharge motor GCS of 6. 3.5% of the survivors were hypotensive in the Emergency
Department(ED). Of survivors, 3.5% had cardiac arrest in the ED and 3.5% arrested pre-admission. Pupillary
abnormalities were often seen in survivors, with lateralizing signs in 19.6% and dilated pupils in 15%.
Conclusions
Despite a historically high case-fatality rate, many patients with PBI survive with good functional outcome. While
attempts can be made at prognosticating survival on admission, decreased admission GCS and cardiac arrest
were seen in survivors. Overall organ donation rate was low, but in those who survive the initial post-injury period,
donation rates were substantial.
Financial Support: None
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INTRATHECAL INHIBITION OF TNF REDUCES INFLAMMATION-MEDIATED SECONDARY INJURY IN A RAT
MODEL OF CERVICAL SPINAL CORD INJURY
Neel S Singhal, Jonathan Z Pan, Amity Lin, Jaqueline C Bresnahan, Michael S Beattie
Univesity of California, San Francisco, CA, USA
Introduction
Spinal cord injury initiates a cascade of local and systemic persistent inflammatory processes that lead to
secondary injury and impair functional recovery. Tumor necrosis alpha (TNFa) is an important mediator of
secondary injury. Inhibition of TNFa with a sequestering agent, soluble TNF-receptor 1 (sTNFR1), results in a
dose-dependent improvement in behavioral outcome in a rodent model of cervical spinal cord injury as well a
reduction in peri-lesional microglial activation (Huie et al., in preparation). The present study investigated the
effects of delayed intrathecal administration of sTNFR1 on peripheral inflammatory profiles.
Methods
Long-Evans female rats (n=52) received intrathecal delivery of 350 ng sTNFR1 90 minutes following unilateral C5
contusion injury (75 kdyne) or C5 laminectomy without injury. Animals were sacrificed at 3h, 24h or 7d after injury.
In two groups, spinal cord, serum and spleen samples were harvested and analyzed for inflammatory markers by
Luminex multiplex assay or quantitative PCR. In other groups, animals were used for spinal cord histological
assessment and flow cytometric analysis of peripheral leukocytes.
Results
Intrathecal sTNFR1 was found to reduce levels of key pro-inflammatory cytokines in serum as well as expression of
pro-inflammatory genes and downstream mediators in spleen. Reduction in peripheral inflammation was correlated
with decreased spinal cord TNFa levels and reduced infiltration of activated macrophages at the injury site on
histology. Further, by flow cytometry, we find decreased CD11b high monocytes in peripheral blood following
sTNFR1 treatment.
Conclusions
Our data demonstrate both local and systemic inflammatory responses are activated following SCI and improved
functional outcome with TNFa inhibition is associated with modulation of the local inflammatory responses in the
spinal cord. Intrathecal TNFa inhibition also results in reduced expression of peripheral inflammatory markers and
mediates a reduction in the circulating pool of inflammatory monocytes.
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RISK FACTORS FOR CONTUSION EXPANSION IN ACUTE TRAUMATIC BRAIN INJURY
Lara L. Zimmermann, MD1,2, Gregory Hawryluk, MD, PhD.1, Geoffrey T. Manley, MD, PhD.1, J. Claude Hemphill III,
MD1,2
1
San Francisco General Hospital, Department of Neurology, San Francisco, CA, USA, 2University of California San
Francisco, Department of Neurology, San Francisco, CA, USA
Introduction
Traumatic brain injury (TBI) affects ~1.7 million Americans and costs ~$60 billion in the United States annually.
Contusion expansion is a common cause of secondary brain injury in TBI and is associated with increased
mortality. The mechanism of contusion expansion is poorly understood. The purpose of this study was to identify
risk factors that predict contusion expansion.
Methods
We undertook a retrospective observational study of all patients with acute TBI and cerebral contusion who
underwent serial CT imaging and intracranial pressure monitoring at San Francisco General Hospital from 20042010. Contusion expansion was defined as any increase in size based on radiology reports or visual review by an
investigator. Demographics, imaging, coagulation parameters, and status on the Glasgow Outcome Scale (GOS) at
hospital discharge were also assessed.
Results
241 patients with traumatic cerebral contusions were identified. The median age was 45 years, 73% were male,
and median Glasgow Coma Scale (GCS) was 9. Contusion expansion occurred in 74.7% of patients and was
associated with a poor discharge GOS 1 or 2 (46% vs. 23% without contusion expansion; p=0.002). In univariate
analysis, contusion expansion was significantly associated with age (p< 0.01), platelet count (p=0.02), presence of
a subdural hematoma (p< 0.01) or traumatic subarachnoid hemorrhage (tSAH)(p < 0.01), and interval
hemicraniectomy or craniotomy (p=0.054); but not with sex, emergency department GCS, initial PTT, initial INR, or
time between CT scans. In multivariable analysis, contusion expansion was independently associated with age (p <
0.01), tSAH (p< 0.01) and interval hemicraniectomy (p=0.036) but not with sex, time between CT scans, GCS,
subdural hematoma, or coagulation parameters.
Conclusions
Contusion expansion is a common form of secondary brain injury and is associated with poor outcome. Identifying
predictors of contusion expansion may lead to modifiable targets for intervention.
Financial Support: None
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WEIGHT-BASED DOSE-RESPONSE CURVE OF HTS VERSUS MANNITOL IN THE MANAGEMENT OF
ELEVATED ICP
Lauren Koffman1, Christine Ahrens2, Matthew Koenig3, Julio A Chalela4, Susan Asai3, Ron Neyens4, Joao Gomes1
1
Cleveland Clinic Cerebrovascular Center, Cleveland, OH, United States; 2Cleveland Clinic Department of
Pharmacy, Cleveland, OH, United States; 3Neuroscience Institute The Queen's Medical Center, Honolulu, HI,
United States; 4Neurology and Neurosurgery Medical University of South Carolina , Charleston, SC, United States
Introduction
Head-to-head studies comparing the effectiveness of mannitol (MAN) and 23.4% hypertonic saline (HTS) in
reducing elevated intracranial pressure (ICP) are lacking. We sought to develop a drug-response curve (DRC) for
HTS and compare it to that of MAN.
Methods
Retrospective review of 88 patients admitted to the neuro-ICU of three academic medical centers between 4/2011
and 3/2013, who experienced elevated ICP and received 23.4% HTS. Mannitol data from 172 patients were
abstracted from a meta-analysis published by Sorani et al. in 2008. Regression analysis was performed for MAN
and HTS to construct DRC, and the slope of the respective lines compared. Student's t and Wilcoxon rank sum
tests were used according to the normality of the data.
Results
The mean age of the HTS group was 42.8 +/- 15 years and 64% were males. Traumatic brain injury, subarachnoid
hemorrhage and intracerebral hemorrhage were the most common diagnoses (89%). The median drug dose was
2.94 (IQR: 1) Vs. 3.1 (IQR: 1.9) mOsm/Kg (p= 0.9), while absolute ICP reduction was 14 (IQR: 11) Vs. 11 (IQR:
12.5) mmHg (p= 0.3) in the HTS and MAN groups, respectively. Regression analysis showed a significant
relationship between HTS dose and ICP reduction (p= 0.01), but not with MAN (p= 0.5). Doses of HTS of >3
mOsm/Kg showed a linear association with ICP reduction (p= 0.01), whereas doses of 3 mOsm/Kg or less did not
(p= 0.056).
Conclusions
There appears to be a linear relationship between HTS dose and ICP reduction. Furthermore, at doses >3
mOsm/Kg equiosmolar amounts of HTS seem to be superior to MAN at reducing ICP. We hypothesize that HTS
follows linear kinetics at doses >3 mOsm/Kg, but non-linear below that threshold.
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VARIABILITY OF BRAIN DEATH DETERMINATION GUIDELINES IN OHIO TRAUMA CENTERS
Farid F Muakkassa, Ari Wachsman, Mackenzie Marley, Ann Salvator, Robert Marley
Akron General Medical Center, Akron, OH, USA
Introduction
Guidelines for brain death determination (BDD), developed at an institutional level, lead to variability of practice
between trauma centers.
Methods
Policies for BDD were requested from all Ohio Trauma Centers (OTC). Guidelines were divided into four
categories: guideline performance, preclinical, clinical and confirmatory testing. Policies were compared with AAN
guidelines (AANG) for discrepancies and for differences between Levels I, II and III OTC.
Results
Response rate was 66% out of 44 OTC (64% Level I, 69% Level II and 59% Level III). Criteria most consistent with
AANG (over 80%) were: absence hypothermia (93%); coma (89%), pupillary reflex (93%), corneal reflex (93%),
gag reflex (93%), ocular movements (93%), response to cranial pain (86%); apnea testing (100%), EEG (96%)
cerebral angiography (82%) and neuromuscular blocking (93%). Criteria 60-80% compliant: sedatives absence
(68%), endocrine disorder (68%), acid-base disorder (68%) electrolyte disorder (68%); normal blood pressure
(68%); presence of cough reflex (79%); and radionuclide scintigraphy (79%). Criteria 40-60% compliant: multiple
exams (57%) waiting period between exams (43%); absence hypotension (43%) and hypoxemia (43%); response
to pain (57%); and TCD performance (46%). Criteria < 40% compliant: absence of shock (36%), alcohol (32%) and
hypovolemia (36%); presence of jaw jerk reflex (21%) and facial movements (32%); perform CT angiography
(39%), SSEP (29%), MRI/MRA (21%), and atropine challenge (7%). A trend towards significant differences
between the Level I, II and III OTC were: absence of hypothermia (89% vs 100% vs 60%, p=0.06), presence of
cough reflex (100% vs 78% vs 60%, p=0.10) and radionuclide scintigraphy (100% vs78% vs 60%, p=0.10).
Conclusions
Wide variation exists in brain death policy in different OTC. Highest variability was confirmatory testing between the
OTC. Highest variability from AANG was in clinical examinations. We recommend that the American College
Surgeons Committee on Trauma develop uniform guidelines for BDD for verified trauma centers.
Financial Support: None
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WILLINGNESS TO FAVOR AGGRESSIVE CARE AND LIVE WITH DISABILITY FOLLOWING SEVERE
TRAUMATIC BRAIN INJURY: A SURVEY OF HEALTHY YOUNG ADULTS IN HAWAII
Kazuma Nakagawa1,2, Kyle K. Obana3
1
University of Hawaii, Honolulu, HI, USA, 2The Queen's Medical Center, Honolulu, HI, USA, 3Brown University,
Providence, RI, USA
Introduction
Traumatic brain injury (TBI) is a major public health problem that impacts young adults. Since severe TBI patients
lack decision-making capacity, the providers and patient surrogates are often faced with the challenging task of
deciding whether to continue with aggressive life-prolonging care or to transition to comfort-focused care with an
expected outcome of natural death. The assumption is often made that aggressive care is appropriate for young
patients who suffer severe TBI despite the high likelihood of a poor outcome. However, the young community's
attitude towards goals of care after severe TBI has not been studied.
Methods
A questionnaire-based survey study on young adults was conducted to assess their attitude towards aggressive
care after a hypothetical case of severe TBI. To simulate a realistic clinical decision-making dilemma, the
respondent's willingness to receive aggressive care despite a high likelihood of moderately severe-to-severe longterm neurological disability after the treatment was specifically assessed. The highest degree of neurological
disability they would be "willing to live with" was based upon the descriptions from the modified Rankin Scale.
Logistic regression was performed to determine the factors associated with the decision to favor aggressive care.
Results
Among a total of 120 community-dwelling young adults (mean age: 19±1 years) who were surveyed, 79 (66%)
were willing to live with severe motor disability, 78 (65%) were willing to live with expressive aphasia, and 53 (44%)
were willing to live with receptive aphasia. Despite being presented with a high likelihood of long-term moderately
severe-to-severe disability, 65 of the 115 respondents (57%) favored aggressive care. A willingness to live with
receptive aphasia was the only independent factor that predicted aggressive care (OR 2.50, 95% CI: 1.15 to 5.46).
Conclusions
Even among the young adults, preference of care was divided between aggressive and conservative approaches
when presented with a hypothetical case of severe TBI.
Financial Support: None
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SLEEP FEATURES ON CONTINUOUS EEG PREDICT NEUROLOGICAL RECOVERY FROM SEVERE
TRAUMATIC BRAIN INJURY
Danielle K Sandsmark1, Monisha A Kumar1, Catherine Woodward1, Miranda Lim2, Sarah Schmitt1, Soojin Park1
1
Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA, 2Department of Pulmonary and
Critical Care Medicine, Oregon Health Sciences University, Portland, OR, USA
Introduction
Studies suggest that sleep characteristics detected by electroencephalography (EEG) may be predictive of
neurological recovery after traumatic brain injury (TBI). We sought to determine whether sleep features were
associated with functional outcome after severe TBI.
Methods
Medical records of patients admitted with severe TBI from 2009-2013 who underwent 24 hours of continuous EEG
(cEEG) monitoring within 14 days from injury were reviewed retrospectively. EEG reports were reviewed for sleep
elements (vertex waves, sleep spindles, and K complexes) and epileptiform activity. Patient outcomes included
discharge disposition and modified Rankin Scale (mRS). Logistic regression analysis and Fisher's exact tests were
used to determine differences in outcome between patients with and without sleep characteristic
Results
Mean patient age was 50.2 (range 15-97) years. 83% were men. 64 patients underwent cEEG monitoring (range
24-168 (mean 50.6) hours). Sleep features could be determined for 58 patients (90%). 9 (14%) displayed status
epilepticus, 5 (8%) electrographic seizures and 12 (19%) epileptiform discharges. Status epilepticus or
electrographic seizures were universally associated with a poor outcome (mRS4). Sleep characteristics, including
vertex waves, sleep spindles, and K complexes, were present in 17 patients (30%) and were associated with better
outcome (88% discharged to home or acute rehabilitation- OR 13.0; 95%CI 2.6-64.8); 41% had an mRS< 4; p =
0.01). Lack of sleep elements on cEEG correlated with a poor outcome at hospital discharge (mRS4: OR 3.93,
p=0.049; 95%CI 1.01-15.4). Similarly, 63% of patients without sleep characteristics died or required transfer to a
skilled care facility (p < 0.001).
Conclusions
These data suggest that the presence of sleep features on EEG in the acute period following severe TBI predict
better recovery, while the absence of normal sleep characteristics portend a poor prognosis for hospital discharge.
Whether sleep elements detected by EEG may predict longer-term prognosis remains to be determined.
Financial Support: None
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TRAUMATIC BRAIN INJURY SHIFTS BRAIN DRUG TRANSPORTER LEVELS: IMPLICATIONS FOR DRUG
THERAPIES
Frederick A Willyerd1, Ryan G Hart2
1
Phoenix Children's Hospital and University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA, 2Phoenix
Children's Hospital, Phoenix, AZ, USA
Introduction
ATP-binding cassette (ABC) transporters function to selectively regulate the brain milieu through active efflux of
substrates. Little is known about how traumatic brain injury (TBI) shifts the levels of these transporters and alters
microenvironments. Similarly, changes in the expression of ABC transporters after TBI could influence therapeutic
drug penetration and outcomes. We hypothesize that quantifiable changes occur in ABC transporter expression
after TBI.
Methods
Adult male Sprague-Dawley rats (n=3/group) underwent moderate TBI midline fluid percussion injury (FPI) then
were killed at eight time points post-injury. Tissue from parietal cortex, hippocampus, and thalamus was analyzed
via Western blot and compared to sham injured animals (n=4) using student t-test.
Results
Bcrp decreased (P< 0.05) compared to sham at days 5, 7, 14, and 56 post-injury in parietal cortex. Bcrp
hippocampal and thalamic expression decreased (P< 0.05) at all points except day 3 post-injury. Mrp1 increased
(P< 0.05) compared to sham at days 1, 2, 7, and 14 post-injury in parietal cortex and thalamus. Mrp1 hippocampal
expression increased (P< 0.05) at days 7 and 14 post-injury. P-gp increased (P< 0.05) compared to sham at days
1, 2, 3, and 5 post-injury in parietal cortex but increased (P< 0.05) on days 1 and 2 post-injury in hippocampus. Pgp in thalamic tissue increased (P< 0.05) on day 1 post-injury.
Conclusions
We found Bcrp decreased significantly at both early and late time point's post-TBI. This could cause decreased
efflux of substrates like glutathione and estradiol. We found an increase in Mrp1 and P-gp expression acutely.
Increased ABC transporters could cause elevated efflux of substrates like opioids, anti-seizure medication, and
prostaglandins. These data could influence clinical care because TBI therapeutic drugs may not reach therapeutic
brain levels if administered during a period of overexpression. ABC transporter expression may serve as a
biomarker for personalized medicine in tailoring therapeutic delivery to individual patients.
Financial Support: None
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INTRAVENOUS RT-PA PLUS EPTIFIBATIDE VERSUS INTRAVENOUS RTPA ALONE IN SEVERE ISCHEMIC
STROKES: A POST HOC ANALYSIS
Opeolu Adeoye1,2,3, Jane Khoury4, Heidi Sucharew4, Thomas Tomsick5, Pooja Khatri1,6, Yuko Palesch7, Pamela A
Schmit2, Arthur Pancioli1,2, Joseph Broderick1,6
1
University of Cincinnati Neuroscience Institute, Cincinnati, OH, USA, 2Department of Emergency Medicine,
University of Cincinnati, Cincinnati, OH, USA, 3Division of Neurocritical Care, University of Cincinnati, Cincinnati,
OH, USA, 4Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA, 5Department of Radiology,
University of Cincinnati, Cincinnati, OH, USA, 6Department of Neurology, University of Cincinnati, Cincinnati, OH,
USA, 7Department of Biostatistics, Medical University of South Carolina, Charleston, SC, USA
Introduction
The CLEAR-ER trial demonstrated safety of the combination of eptifibatide plus intravenous (IV) rt-PA in acute
ischemic stroke (AIS). We compared outcomes for patients with severe strokes in the combination therapy arm of
CLEAR-ER to IV rt-PA control patients from the contemporaneously enrolling IMS III trial.
Methods
CLEAR-ER was a phase II safety trial that randomized AIS patients (5:1) to 0.6mg/kg rt-PA plus eptifibatide versus
standard rt-PA (0.9mg/kg). IMS III was a phase III efficacy trial comparing IV rt-PA plus endovascular therapy
versus standard rt-PA. For this analysis, we compared the severe cohort (NIH stroke scale 10) of CLEAR-ER
combination therapy patients to the standard rt-PA arm of the IMS III trial patients with NIH stroke scale 10. All
patients had baseline modified Rankin score (mRS) of zero or one. Four approaches to outcomes were evaluated:
mRS dichotomization as "excellent" (mRS 0-1); mRS dichotomization as "good" (mRS 0-2); severity-adjusted mRS
dichotomization based on baseline NIHSS; and, a shift analysis.
Results
Fifty-three combination arm CLEAR-ER patients and 209 IV rt-PA arm IMS III patients had baseline NIH stroke
scale 10. Combination arm patients showed a trend toward improved outcomes over rt-PA patients at 90 days:
39.6% vs 27.3% for dichotomized excellent outcomes (P=0.08); 47.2% vs 39.2% for dichotomized good outcomes
(P=0.29); 43.4% vs 32.5% for severity-adjusted dichotomized good outcomes (P=0.14); and, a favorable shift
(Cochran-Mantel-Haenszel P=0.09).
Conclusions
In patients with severe AIS, IV rt-PA plus eptifibatide may improve outcomes over IV rt-PA alone. This trend was
consistent across multiple approaches that have been proposed for outcome evaluation in acute stroke trials. A
phase III trial to establish the efficacy of eptifibatide plus rt-PA for improving AIS outcomes, including those with
severe strokes at baseline, is warranted.
Financial Support: Dr. Adeoye – research support from Genentech Dr. Khatri – PI of the PRISMS and THERAPY
trials research support from Genentech and Penumbra
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INTRAVENOUS THROMBOLYSIS FOR CEREBRAL VENOUS THROMBOSIS: REPORT OF 2 CASES
Fahad S Al-Ajlan, M Zuheir Al-Kawi
Department of Neurosciences (Neurology), King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi
Arabia
Introduction
Cerebral venous thrombosis (CVT) is an uncommon type of stroke in many countries (1-2%). This is not the case in
many arid hot-climate countries such as Saudi Arabia. CVT has extremely varied clinical presentations, and the
mode of onset is also highly variable, with anything from sudden to progressive over weeks, so that CVT can mimic
a host of conditions, such as ischemic or hemorrhagic stroke. However, it is unclear whether thrombolytic therapy
is associated with adverse outcomes in this population. We report the clinical characteristics and outcomes of
patients treated with intravenous tissue plasminogen activator (IV-tPA) with the confirmed diagnosis of
CVT. Treatment with IV-tPA may lead to potentially serious complications, the most devastating being intracranial
hemorrhage.
Methods
We identified CVT patients who received IV-tPA with initial diagnosis of acute ischemic stroke. Clinical and
radiological findings were collected, including early neurological worsening and hemorrhagic transformation on
unenhanced computed tomography at 24 hours. Clinical outcome was divided into three categories: complete
recovery, partial recovery, and major disability or death.
Results
Two patients presenting with acute stroke-like symptoms within the window for IV-tPA were identified.
Both received IV-tPAwhich was followed 24 hours later by intravenous heparin infusion with significant clinical
improvement. Minor cerebellar hemorrhagic infarction was seen in the follow-up computed tomography scan
(located within the area of subacute infarction). There was no early neurological deterioration, and complete
recovery was observed in both of the patients.
Conclusions
In our study, we identified two patients who receivedIV-tPA with final diagnosis of CVT. IV-tPA therapy was
complicated in one patient by a minor cerebellar hemorrhage, without obvious neurological worsening. More
studies are needed to explore the safety of tissue-type plasminogen activator in the context of CVT.
Financial Support: None
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CURRENT PRACTICE SURVEY REGARDING THE UTILIZATION OF SAFETY SCANS POST-THROMBOLYSIS
(TPA) IN ACUTE ISCHEMIC STROKE
Khalid A Alsherbini, Dawn Kleindorfer
University of Cincinnati/ Neurology, Cincinnati, OH, USA
Introduction
The purpose of this survey is to describe the current variations in practice patterns among stroke physicians
regarding the use of CT scans 24-hours post-tPA.
Methods
A Survey Monkey survey was distributed to the stroke experts within strokeNET, a new NIH stroke network with
over 200 hospitals.
Results
59 responses have been received to date. Neurologists, vascular neurologists, neurointensivists and emergency
physicians responded. 36% of the responders treat more than 50 strokes per year. When asked their practice in
obtaining a 24-hour post-tPA brain imaging as a "safety scan" as part of routine practice without clinical change,
50% always obtain a scan, 16% most of the time, 12% often do, while 21% rarely or never do. However, 59% of
those who routinely obtain the scan felt it didn't change their management more than 90% of the time, and no
expert felt it changed their management more than 40% of the time. Holding antithrombotic therapy, the most
commonly cited potential change in management based on the CT, was most likely in those with large infarct size
and/or hemorrhagic transformation (HT). If a safety scan showed HT, 49% of experts would delay transfer of the
patient out of the ICU, even without clinical change. When given specific patient scenarios without clinical change,
however, 85% would get a 24-hour scan in patients with atrial fibrillation and a plan to start warfarin, and 52%
would scan for high grade carotid disease with planned early endarterectomy.
Conclusions
This survey demonstrates a wide variation in practice patterns among stroke experts regarding the utility of routine
safety scans 24 hours post-tPA. Assuming there is a potential risk of harm with radiation, in addition to the cost of
such scans; further evaluation and study of the utility, cost effectiveness and the safety of such scans is
recommended.
Financial Support: None
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DOES STATIN INFLUENCE IN PATIENT HOSPITAL MORTALITY IN STROKE POPULATION?
Saef Izzy1, Yunis Mayasi1, Aditi Ahlawat3, Abduljabbar Dheyab2, Majaz Moonis1
1
Neurology department, Umass Medical School, Worcester, MA, USA, 2Internal Medicine department, Umass
Medical School, Worcester, MA, USA, 3Umass Medical School, Worcester, MA, USA
Introduction
Literature review shows that very limited data is available on factors predicting mortality after onset of Acute
Ischemic Stroke (AIS). Presently, there is little known about the influence of pre-stroke medications on subsequent
AIS in-patient hospital mortality. Lipid lowering agents (LLA), antiplatelet and antihypertensive are known to reduce
stroke recurrence and may improve outcome amongst AIS survivors. Yet, LLA influence on AIS hospital mortality is
not clearly studied. Using a multicenter prospectively collected database we analyzed the possible predictors that
might impact AIS hospital mortality.
Methods
Pooled data was collected using the University health consortium database from 1999 to 2004. Patients were
dichotomized to 2 groups: Death during initial hospitalization post stroke and discharged from hospital (home,
rehab, long term care). Using Chi square and T-tests, univariate analysis was performed on the following:
demographics, stroke types and severity, cardiovascular, pulmonary and neurological co-morbidities, pre-stroke
medications including: LLA, antihypertensives, anticoagulants and antiplatelet agents, as well as post stroke
complications. Multivariate stepwise logistic regression analysis was used to determine which univariate predictor
variables independently predict mortality during initial hospitalization after AIS.
Results
Of the 3522 patients, 201 died after AIS. Cohort mean age was 67 years. Univariate predictors of mortality were
stroke severity and post stroke complications. ASA, other antiplatelet agents were associated with reduced
mortality. LLA demonstrated a trend (p=0.08). In the final multivariate analysis, stroke severity and post stroke
complications were associated with increased mortality while ASA and other antiplatelet drugs were negative
predictors of mortality. LLA, antihypertensives and anticoagulants were not predictive of mortality.
Conclusions
After AIS, unlike previous reports from smaller studies, LLA were not predictive of AIS in patient hospital mortality.
Yet, severity of stroke and post stroke complications were most predictive of inpatient hospital mortality.
Financial Support: None
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DUAL ANTIPLATELET THERAPY IS ASSOCIATED WITH COAGULOPATHY DETECTABLE BY
THROMBELASTOGRAPHY IN ACUTE STROKE
Mark M McDonald1, Tareq S Almaghrabi2, Chunyan Cai3, Mohammad H Rahbar3, Nancy J Edwards1,2, H Alex
Choi1,2, Kiwon Lee1,2, James C Grotta4, Tiffany R Chang1,2
1
University of Texas Medical School at Houston Department of Neurology, Houston, TX, USA, 2University of Texas
Medical School at Houston Department of Neurosurgery, Houston, TX, USA, 3University of Texas Medical School
at Houston Department of Internal Medicine, Houston, TX, USA, 4Memorial Hermann Texas Medical Center,
Houston, TX, USA
Introduction
Thrombelastography (TEG) provides a global, dynamic measure of coagulation. We examined the effect of
antiplatelet (AP) medications on coagulability in acute stroke patients as measured by TEG.
Methods
We prospectively enrolled patients presenting with acute ischemic stroke (AIS) and spontaneous intracerebral
hemorrhage (ICH) to a single academic medical center between 2009 and 2014. Venous blood was collected from
patients upon arrival to the emergency department and analyzed with TEG. Patient demographics and baseline
TEG values were compared among 4 different drug use groups: aspirin only, clopidogrel only, both aspirin and
clopidogrel, and no AP. Multivariable regression models were conducted to compare the differences of TEG
components after adjusting for potential confounding and interactive effects.
Results
202 patients were included, 139 with AIS and 63 with ICH. 48 patients (24%) were taking aspirin alone, 12 (6%)
were taking clopidogrel, 16 (8%) were on dual AP therapy, and 126 (62%) were not on AP medications. Dual
antiplatelet use was associated with prolonged mean R time (time to initiate clotting) of 5.5 min as compared to no
antiplatelet use (4.6 min, p=0.04). Additionally, mean MA (final clot strength) and angle (rate of clot formation) were
decreased in the dual AP group (MA=59.3 mm, angle=57.8 degrees) as compared to the no antiplatelet use group
(MA=64.5 mm, angle=64.5 degrees; p=0.04 and p=0.01 respectively). Patients on single antiplatelet therapy (either
aspirin or clopidogrel) did not differ from the no AP therapy group in any TEG parameters measured.
Conclusions
Dual antiplatelet therapy with aspirin and clopidogrel is associated with a detectable coagulopathy which may have
implications in the management of acute ischemic and hemorrhagic stroke patients. The effects of single
antiplatelet therapy may not be demonstrated by TEG, and alternative tests such as platelet mapping or platelet
function assays should be considered in these patients.
Financial Support: J Grotta: Supported by Tissue and Data Cores of National Institutes of Health 5P50NS04422708. Haemonetics Corporation loaned a TEG coagulation analyzer Model 5000 and provided supplies.
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DELAYED BASILAR ARTERY OCCLUSION DIAGNOSIS: FIVE CASES AND THE LESSONS WE HAVE
LEARNED
Natalie Organek, Megan Donohue, Irene Katzan
Cleveland Clinic, Cleveland, OH, USA
Introduction
Basilar artery occlusion (BAO) is a rare and often disabling if not fatal cause of stroke. Endovascular recanalization
has the potential to improve outcomes in patients with BAO but intervention must be done before extensive
infarction occurs. Early recognition and timely diagnosis are critical.
Methods
We describe 5 cases of delayed BAO diagnosis presenting to a tertiary care center between 2010 and 2013 and
share lessons learned from these cases.
Results
The 5 patients with delayed BAO diagnosis ranged in age from 37-57 years; 3 were female and 2 were male. Time
from symptom onset to presentation at the tertiary facility ranged from 1 hour to 2 weeks. Three patients were
transferred from other hospitals; one presented to our ED for a second opinion; and one patient presented initially
to our ED. Presenting symptoms varied widely, and consisted of: (1) neck pain with headache, hemiparesis,
dysarthria; (2) subacute vertigo with acute headache; (3) nausea/vomiting with headache; (4) syncope with
hemifacial numbness; (5) unresponsiveness. Four patients initially had transient symptoms ultimately attributed to
BAO. All patients had negative acute head CTs. All patients decompensated requiring Neurointensive Care. Prior
to BAO diagnoses, patients were treated for presumed seizures, complicated migraine, meningitis, encephalitis and
CNS Lupus. The time of ED presentation to imaging demonstrating BAO ranged from 8-43 hours. Ultimately one
patient died and the other 4 required tracheostomy/PEG and were discharged to long term acute care facilities.
Conclusions
Delay in BAO diagnosis can have devastating consequences. Young age, initially mild deficits and prolonged
symptom duration (up to 2 weeks) contributed to the delay in diagnosis in these cases. BAO should be considered
in all patients presenting with symptoms potentially referable to posterior circulation regardless of patient age and
symptom duration. In these patients imaging that includes cerebral vasculature should be performed expeditiously.
Financial Support: None
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FACTORS INFLUENCING TRACHEOSTOMY IN ISCHEMIC STROKE PATIENTS OF THE NSICU
Jignesh S Patel, James Lee, Sean Shahamiri, Stanislaw Sobotka, Errol L Gordon, Stephan A Mayer
Mount Sinai Medical Center, New York, NY, USA
Introduction
Tracheostomy is one of the most commonly performed procedures for critically ill patients; however, variations in
practice are inconsistent amongst clinicians and across institutions. The primary objective of our study is to survey
the levels of care received by ischemic stroke patients admitted to the neurosurgical intensive care unit (NSICU),
and ascertain the frequency and clinical parameters associated with tracheostomy placement.
Methods
A retrospective database was generated using ICD-9 billing codes to identify patients with cerebral infarction who
were admitted to the NSICU over a two-year period (2012-2013). We evaluated each patient's medical record for
placement of tracheostomy, age, gender, size and location of stroke, vessel involvement, NIHSS, length of ICU
stay, PEG placement, comorbidities, and treatment intervention. Any tracheostomies placed at outside institutions
or prior to NSICU admission were excluded. Statistical analysis was performed to assess the variables that
contributed to placement of a tracheostomy.
Results
We identified 72 patients (36 male, 36 female) admitted to the NSICU with a diagnosis of ischemic stroke. From
this population, we found 8 that received a tracheostomy during their NSICU stay, correlating to 11% of such
patients. Using statistical analysis, we identified significance with increased ICU length of stay for tracheostomy vs
non-tracheostomy (17.8 vs 7.0 days) and PEG placement, and positive trends with high admission NIHSS score
(20 vs 14), and infarct territory greater than 50%, as conditions that were favorable for inpatient tracheostomy. The
average day of tracheostomy was 11.9 ±3.6 days.
Conclusions
Further studies will need to be performed to accurately assess the variables contributing to early tracheostomy.
Increasing the study population may improve our ability to determine the clinical parameters that portend a greater
need for its placement, and lead to the formation of early NSICU tracheostomy guidelines.
Financial Support: None
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COCAINE USE IS ASSOCIATED WITH MORE RAPID CLOT FORMATION AND WEAKER CLOT STRENGTH
IN ACUTE STROKE
Tareq S Almaghrabi1, Mark M Mcdonald 2, Chunyan Cai3, Mohammed H Rahbar3, Nancy J Edwards1,2, H Alex
Choi1,2, Kiwon Lee1,2, Neeraj S Naval 4, James C Grotta5, Tiffany R Chang1,2
1
University of Texas Mediacl School at houston/ Neurosurgery, Houston, TX, USA, 2University of Texas Medical
School at Houston/ Neurology, Houston, TX, USA, 3University of Texas medical school at Houston/ Internal
Medicine, Houston, TX, USA, 4Johns Hopkins School of Medicine, Departments of Neurology, Neurosurgery, and
Anesthesia and Critical Care Medicine, Baltimore, MD, USA, 5Memorial Hermann Hospital Texas Medical center/
Neurology, Houston, TX, USA
Introduction
Cocaine use is a known risk factor for stroke and has been associated with worse outcomes. Cocaine may cause
a procoagulable state by a number of different proposed mechanisms, including platelet activation, endothelial
injury, and tissue factor expression. This study analyzes the effect of cocaine use on thrombelastography (TEG) in
acute stroke patients.
Methods
Patients presenting with acute ischemic stroke (AIS) and spontaneous intracerebral hemorrhage (ICH) to a single
academic center between 2009 and 2014 were prospectively enrolled. Blood was collected for TEG analysis at the
time of presentation. Patient demographics and baseline TEG values were compared between two groups: cocaine
and non-cocaine users. Multivariable Quantile regression models were used to compare the median TEG
components between groups after controlling for the effect of confounders.
Results
91 patients were included, 53 with AIS and 38 with ICH. 8 (8.7%) patients were positive for cocaine, 4 (50%) with
AIS, and 4 (50%) with ICH. There were no significant differences in age, blood pressure, platelet count, or PT/PTT
between the two groups. Following multivariable analysis, cocaine use was associated with shortened median R
time (time to initiate clotting) of 3.8 minutes compared to 4.8 minutes in non-cocaine users (p=0.04). Delta
(thrombin burst) was also earlier among cocaine users (0.4 minutes) compared with non-cocaine users (0.5 min,
p=0.04). The median MA and G (measurements of final clot strength) were reduced in cocaine users (MA=62.5
mm, G=7.8 dynes/cm2) compared to non-cocaine users (MA=66.5 mm, G=10.1 dynes/cm2; p=0.047, p=0.04,
respectively).
Conclusions
Cocaine users demonstrate more rapid clot formation but reduced overall clot strength based on admission TEG
values. These findings suggest cocaine may induce thrombin generation through tissue factor release or other
mechanism, resulting in a relatively weaker thrombin-rich clot. Further studies are needed to examine the impact
on bleeding risk in acute stroke.
Financial Support: James C Grotta: Supported by Tissue and Data Cores of National Institutes of Health
5P50NS044227-08. Haemonetics Corporation loaned a TEG coagulation analyzer Model 5000 and provided
supplies.
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IV CLEVIDIPINE (CLEVIPREXR) RAPIDLY CONTROLS BLOOD PRESSURE (BP) IN ACUTE ISCHEMIC
STROKE (AIS)
Kees H Polderman1, Danielle Bajus1, Joseph Varon2
1
Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA, 2The
University of Texas Health Science Center at Houston, Houston, TX, USA
Introduction
Rapid control of blood pressure (BP) is an important treatment goal in patients with (AIS), as severe hypertension
has been linked to adverse outcomes. However, "overshoot" (hypotension due to long-acting IV antihypertensives)
is a significant risk, and a recent study linked excessive BP reduction to adverse outcomes in neurological injuries.1
We tested Clevidipine, a new IV calcium channel antagonist with extremely rapid onset (90 seconds) and offset (510 minutes), in neuro-ICU patients with AIS.
Methods
Patients with systolic blood pressure >180 mmHg received IV clevidipine with BP targets (highest acceptable
pressure = cap, lowest acceptable pressure = floor) set by the treatment team. Pressure was measured
continuously using an arterial line. Initial dose was 4-8 mg/hr, increased in a stepwise fashion every 90 seconds
until target was achieved. Primary outcome measures were median time to BP within target and % of patients
achieving BP within target range. Secondary parameters included time within range during administration of the
drug. Safety parameters included percentage of patients with "overshoot" below the set blood pressure floor, and
time to recovery above the set floor. Biochemical parameters including triglycerides were monitored in all patients.
Results
The study is ongoing; 18 patients have been enrolled. BP targets were achieved in all patients. Median time to
target was 4 minutes (average 3.2±4.2). Average dose required to achieve target was 13.0 mg/hr. Time within BP
target range until discontinuation was 99%. No patient (0%) had overshoot below the set floor.
Conclusions
Clevidipine is an ultra-rapid and effective method to control BP in patients with AIS, without the drawbacks of
alternatives like nitroprusside (ICP increase, cerebral/coronary steal), nicardipine, hydralazine and labetolol (high
infusion volume required, longer onset/offset times). Clevidipine should be considered in the treatment of
hypertension in patients with acute neurological injuries. Reference. 1. Mayer SA et al. Crit Care Med
2011;39:2330-36
Financial Support: None
ISCHEMIC STROKE
ePoster 154
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ePoster 155
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EVALUATION OF INTRAVENOUS RECOMBINANT TISSUE PLASMINOGEN ACTIVATOR DOSING
CHARACTERISTICS AND PATIENT OUTCOMES AT AN ACADEMIC MEDICAL CENTER
Jody C Rocker1, Jacquelyn Bryant1, Shweta Woodsmall2, Jeffrey A Switzer1, Susan C Fagan2
1
Georgia Regents Medical Center, Augusta, GA, USA, 2University of Georgia College of Pharmacy, Augusta, GA,
USA
Introduction
The purpose of this review was to evaluate the likelihood of a positive stroke outcome from intravenous (IV)
recombinant tissue plasminogen activator (r-tPA) in patients >100 kg when compared with patients 100kg.
Methods
This was a retrospective chart review of patients receiving IV r-tPA at an academic medical center from January 1,
2011 to January 1, 2014. Data evaluated included dosing characteristics of r-tPA and effects on patient outcomes
including hospital length of stay (LOS), baseline National Institute of Health stroke scale score, discharge
disposition, incidence of hemorrhagic conversion, and death/hospice.
Results
A total of 110 patients (28 patients >100kg and 82 patients 100kg) with diagnosis of ischemic stroke and >18
years were included. Hospital LOS (patients >100kg mean: 7.6 days and patients 100kg mean: 6.88 days) and
baseline NIHSS (patients >100kg mean: 11.9 and patients 100kg mean: 11.76) was comparable between both
groups. In the group with patients >100kg, 64.3% were discharged home compared to patients 100kg, 56.1%
were discharged home. Patients >100kg had total r-tPA dose average of 87.1mg (0.73mg/kg total r-tPA dose
average, 0.08 mg/kg loading dose, 0.65mg/kg continuous infusion average); patients 100kg total r-tPA dose
average was 68.42mg (0.0898 mg/kg total r-tPA dose average, 0.089 mg/kg loading dose average, 0.808 mg/kg
continuous infusion average). Zero patients in >100kg group had hemorrhagic conversion versus 7 (8.54%)
patients in 100kg group had hemorrhagic conversion. Two patients in >100kg group died versus 7 patients had an
outcome of death or hospice in 100kg group.
Conclusions
There is not an increase in unfavorable outcome from stroke in patients with >100kg even though these patients
received total r-tPA dose that is less than 0.9mg/kg due to maximum allowable dose limit of 90mg.
Financial Support: None
Neurocrit Care
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IMPROVING DOOR TO NEEDLE TIMES AND SAFETY IN CVA PATIENTS: THE NCRN ROLE
Robyn L. Stillian 1, Abbey Rios1, Raveca Pintea1, Brenna Graham1, Debra Bauguess1, Rebecca Benasa1, Judy
Crouch2, Jason Murray3
1
Mercy San Juan Medical Center/Neurovascular ICU, Carmichael, CA, USA, 2Mercy San Juan Medical Center/
Nurse Education, Carmichael, CA, USA, 3Mercy San Juan Medical Center/ Dignity Health Neurological Institute of
Northern California, Carmichael, CA, USA
Introduction
Time is brain. A process to improve door to needle times for CVA patients who are eligible for thrombolytic
therapies and interventional radiology treatments is vital for improving a CVA patient's quality of life. In order to
increase these times, processes need to be in place to streamline care efficiently. We created the neurocritical care
RN (NCRN) role to aid in this process.
Methods
In order to aid the ER in providing efficient care to CVA patients, the NCRN role was created. The NCRN is a
neurocritical care trained RN who responds to stroke alerts in the ER and throughout the hospital. The NCRN
coordinates with the on-call neurologist, interventional neuroradiologist, neurointensivist, and imaging services to
facilitate efficient care and correct hospital unit placement of CVA patients. Other duties of the NCRN are to
coordinate transfers of neurocritically ill patients from outside facilities to the Neurovascular ICU, as well as help aid
RNs around the facility in caring for neurological critical care patients.
Results
Since the creation of the NCRN role door to needle times have decreased while our neurocritical care patient
population has increased. The patients have been appropriately allocated to the Neurovascular ICU to receive the
care, rather than being placed in any open ICU bed.
Conclusions
The NCRN Role is a vital component in the care of our neurocritical care patients. It has shown to improve door to
needle times, transfers into the neurovascular ICU, and overall outcome of our neurocritical care population. It
facilitates transition from the ER to the Neurovascular ICU and provides the family and patient with care continuity.
With NCRN presence starting in the ER to the ICU it has also improved patient hand-off between caregivers and
dual neurological assessments to provide the highest level of patient safety.
Financial Support: None
ISCHEMIC STROKE
ePoster 156
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164
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ISCHEMIC STROKE
ePoster 157
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COLLATERAL BLOOD FLOW IN LARGE VESSEL EMBOLISM: A PREDICTOR OF CORE AND
FINAL INFARCT VOLUMES, CT PERFUSION ABNORMALITIES, AND PATIENT OUTCOME
Joseph P. Whitlock1, Prasanna Vibhute1, Julia B. Whitlock2, Vivek Gupta1
1
Department of Radiology Mayo Clinic Florida, Jacksonville, FL, USA, 2Department of Neurology Mayo Clinic
Florida, Jacksonville, FL, USA
Introduction
Multiple factors determine outcome and infarct volume in acute stroke. While CT angiography (CTA) and CT
perfusion (CTP) are routinely used for diagnosis, treatment planning, and prognosis, the processing and
interpretation of CTP requires valuable additional time potentially delaying earliest possible reperfusion. The
presence of collateral blood flow (CF) to the ischemic region is crucial for neuronal survival in acute large vessel
occlusion. While prior studies have shown that better CF results in smaller core infarct size at presentation, we
undertook this study to systematically investigate correlation between CF and cerebral blood volume (CBV) and
cerebral blood flow (CBF) abnormalities on CT perfusion in addition to the relationship between CF, final infarct
size, and patient outcome.
Methods
Retrospective chart review of patients presenting with acute stroke due to middle cerebral artery and/or internal
carotid artery terminus embolus was performed by two trained neuroradiologists blinded to outcome using a
prospective database from 2012-2014. Fifty patients met inclusion criteria; unenhanced CT (UCT), CTA, and CTP
of these patients were reviewed. Using CTA, collateral blood flow on affected side was graded relative to the
contralateral unaffected hemisphere using a scale of 0-3 with score of 0 = no collaterals, 1 = < 50%, 2 = > 50% but
< 100%, and 3 = greater than or equal to 100%. The CBV and CBF were measured in the vessel territory and
compared with the CF score.
Results
We found a strong inverse correlation between CF score, core infarct volume, and both the extent and degree of
CBV and CBF reduction on CTP. Our findings suggest that CF score combined with absence or presence of early
ischemic changes on UCT is sufficiently predictive of perfusion abnormalities and core infarct volume.
Conclusions
Collateral blood flow scoring is a predictor of core infarct volume, final infarct size and clinical outcome.
Financial Support: None
Neurocrit Care
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ASSOCIATION OF RT-PA AND ACUTE MYOCARDIAL INFARCTION WITH SURVIVAL OF STROKE
PATIENTS DURING A DECADE IN UNITED STATES.
Kevin Carr1, Mitchell Maltenfort2, Ali Seifi1
1
University of Texas Health Science Center, Department of Neurosurgery, San Antonio, TX, USA, 2Rothman
Institute, Thomas Jefferson University, Philadelphia, PA, USA
Introduction
To determine the impact of acute myocardial infarction (AMI) and administration of rt-PA on survival of patients with
acute cerebral ischemia( ACI) in United States during 2002-2001.
Methods
Data from Nationwide Inpatient Sample (NIS) was queried from 2002 - 2011 for inpatient admissions with a primary
diagnosis of ACI using International Classification of Diseases, 9th Revision, Clinical Modification (CM) coding (ICD9). A multivariate stepwise regression analysis was used to assess the significance of variables affecting overall
survival.
Results
During a decade the NIS recorded 886,094 ACI admissions with 26693 rTPA administration (3.015 %) and 17,526
diagnoses of AMI (1.98%). The overall cumulative mortality of cohort was 5.65%. The shortest median time to
death was in patients with AMI and no rTPA (31 days, 95%CI: 29-34), followed by patients with AMI and rTPA (61
days, 95%CI: 44-NA), and patients who didn't develop AMI and had no rTPA (101 days 95%CI: 90-114). The
longest median time to death was in the group that didn't have AMI but received rt-PA (166 days, 95% CI: 92-NA).
On Kaplan-Meier analysis, the survival fractions for the AMI and non-AMI groups diverged significantly over time in
ACI patients (log-rank p< 0.0001).
Conclusions
Our study demonstrates strong associations between rTPA administration and AMI and decreasing median time to
death of ACI patients. AMI has a more significant association than rTPA with decreasing survival in these patients.
These observations may be related to increased cardiovascular disease burden in a subset of patients.
Considering the high clinical burden of AMI on mortality of ACI patients, prompt diagnosis and treatment of
associated cardiovascular diseases may improve outcome and warrant further study.
Financial Support: None
ISCHEMIC STROKE
ePoster 134
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ePoster 137
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A POPULATION-BASED STUDY OF INCIDENCE, ASSOCIATIONS, AND OUTCOME OF MECHANICAL
VENTILATION IN LIFE-THREATENING STROKE
Shouri Lahiri1, Axel Rosengart1, Halinder S. Mangat1, Alan Segal1, Jan Claassen1, Stephan Mayer2, Hooman
Kamel1
1
New York Presbyterian/Columbia and Cornell Medical Center, New York, NY, USA, 2Icahn School of Medicine at
Mount Sinai, New York, NY, USA
Introduction
Mechanical ventilation (MV) and tracheostomy are frequently performed in ischemic stroke (IS), intracerebral
hemorrhage (ICH), and subarachnoid hemorrhage (SAH). Little is known about the incidence, associated
conditions, and outcome of these patients at a population level.
Methods
The incidence of MV and tracheostomy for stroke (IS/ICH/SAH) were examined using California statewide
administrative claims data (1/1/2005 to 12/31/2011). The ICD-9-CM codes for tracheostomy (31.1-31.2) were
validated by blinded retrospective chart review of 50 patient encounters (sensitivity: 100%, specificity: 96%).
Previously validated ICD-9-CM codes were used to identify patients admitted with IS (433.x1, 434.x1, and 436),
ICH (431), and SAH (430), and whether they underwent MV (96.70-96.72) and tracheostomy. Descriptive statistics
(95% confidence intervals) were used to report incidence and mortality rates. We examined associations with
previously reported risk factors for MV using multiple logistic regression with backward stepwise elimination of
variables not associated with MV (p< 0.20).
Results
There were 387,591 hospital admissions with either IS, ICH, or SAH. 38,867 or 10.0% (9.9-10.1%) underwent MV
(IS = 6.3% [6.2-6.4%]; ICH = 30.5% [29.9-31.2%]; SAH = 23.7% [23.4-24.1%]). In a multivariable analysis, MV was
more likely in ICH (OR, 5.9 [5.6-6.1]) or SAH (OR, 4.7 [4.6-4.8]) compared with IS. MV was more likely in
association with pneumonia (OR, 8.6 [8.2-9.1]), sepsis (OR, 6.8 [6.6-7.0]) and status epilepticus (OR, 7.7 [6.5-9.0]).
Increased age was associated with decreased odds of MV (OR/decade, 0.88 [0.88-0.89]). Of MV patients, 14.2%
(13.8-14.5%) underwent tracheostomy (IS=15.1% [14.6-15.6%]); ICH=14.0% [13.2-14.9%]; SAH=12.8% [12.213.3%]). Mortality rates for mechanically ventilated patients with IS, ICH, and SAH were 50.9%, 58%, and 64%
respectively.
Conclusions
Ten percent of stroke patients receive MV. Over half of these patients die, despite the fact that younger patients
are more likely to receive MV. Further studies are needed to better understand optimal management for this
common, yet poorly studied intervention in stroke.
Financial Support: None
Neurocrit Care
167
HIGH-FIDELITY SIMULATION VERSUS TRADITIONAL DIDACTIC TECHNIQUES FOR TEACHING
NEUROLOGICAL EMERGENCIES TO NEUROLOGY RESIDENTS: A FEASIBILITY STUDY
Sachin Agarwal1, Neha Dangayach1, Priyank Patel1, Ashley Roque1, Brendan Ford1, Dennis Fowler1, Jan
Claassen1, Stephan A. Mayer2
1
Columbia University, new york, NY, USA, 2Icahn School of Medicine at Mount Sinai, new york, NY, USA
Introduction
The exposure to neurocritical care among neurology residents is highly variable. In spite of proven success of
Simulation based learning (SBL) in teaching critical care, emergency medicine, and anesthesiology, studies
evaluating SBL in neurocritical care are still lacking.
Methods
Eligible PGY-2 neurology residents (N=10) from Columbia university and Weill-Cornell were randomized into SBL
and traditional didactic teaching groups. High-fidelity Sim-Man 3G was used to simulate realistic scenarios of acute
ischemic stroke, intracranial pressure (ICP) crisis, and status epilepticus. Learning objectives were assessed using
crisis resource management (CRM) assessment tools including identification of key actions (0=no, 1=with prompt,
2=never), Ottawa CRM checklist, and knowledge based pre- and post-intervention tests. Mean±SD, median, and
Wilcoxon rank-sum tests were calculated.
Results
Acute stroke case: mean key action scores (maximum score 28) were 17.8±1.5 & 16.4±2.9, difference in gain on
post-test scores were 0.32±0.3 & 0.2±0.3 after simulation and didactics interventions respectively. ICP crisis case:
mean key action scores (maximum score 24) were 16.4±4.6 & 17.3±0.6, difference in gain on post-test scores were
0.14±0.19 & 0.13±0.11, for simulation and didactics groups respectively. Status epilepticus case: mean key action
scores (maximum score 38) were 31.8±3.4 & 28±3.9, difference in gain on post-test scores were 0.2±0.24 &
0.28±0.4 after simulation and didactics interventions respectively. Median CRM score were 6 & 4 for stroke and
ICP crisis cases, 6 & 6 for status epilepticus cases when comparing SBL and didactic groups. There were no
statistically significant differences found between groups for either of the pre-specified outcomes.
Conclusions
Simulation based learning offers promise as a tool for objectively assessing some of the ACGME competencies
that are more difficult to evaluate via traditional means. Studies with larger N and longer follow-up are needed to
assess the efficacy, learner-retention and satisfaction rates among groups.
Financial Support: None
ICU ORG AND TECH
ePoster 158
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ICU ORG AND TECH
ePoster 159
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IMPROVING BEDSIDE RN PRACTICE AND MORALE: THE IMPLEMENTATION OF THE UNIT BASED
PRACTICE COUNCIL
Robyn L. Stillian1, Abbey Rios1, Raveca Pintea1, Brenna Graham1, Debra Bauguess1, Rebecca Benasa1, Judy
Crouch2
1
Mercy San Juan Medical Center/ Neurovascular ICU, Carmichael, CA, USA, 2Mercy San Juan Medical Center/
Nursing Education, Carmichael, CA, USA
Introduction
RN burnout is a problem within the nursing community and leads to decrease in staff morale and quality of patient
care. Research shows that implementing shared governance in the hospital setting, at a hospital wide or unit wide
level improves patient care and staff morale.
Methods
We implemented a Unit Based Practice Council (UBPC) in our Neurovascular ICU.
Results
The Neurovascular ICU UBPC is made up of bedside RNs who identify problems in practice and work with
physicians and nursing management to find a solution and implement it. The UBPC coordinates educational
opportunities for the staff and identifies areas of education that staff needs. Since implementation of the UBPC, RN
staff morale has increased. The UBPC has also implemented process improvements to improve patient care
outcomes. In the beginnings of the UBPC the staff was asked to take the "AACN Healthy Work Environment
Survey", follow-up surveys will be available to staff annually to track progress.
Conclusions
Implementation of a UBPC improves RN staff morale and patient outcomes in the Neurovascular ICU. It allows
bedside RNs to be in control of their practice and keep up-to-date in evidence based guidelines. The RNs can
improve processes associated in caring for neurocritical care patients in collaboration with MDs and nursing
management. Having this control over their practice increases morale and improves patient outcomes.
Financial Support: None
Neurocrit Care
169
EVALUATING THE QUALITY OF RN REPORT AFTER THE INITIATION OF A NEUROSCIENCE SPECIFIC
HANDOFF
Nancy L Fitzwater, Dorina D Harper
The Ohio State University Wexner Medical Center, Columbus, OH, USA
Introduction
The Neurosciences Critical Care Unit (NCCU) is a developing unit which remains in the process of onboarding RN
staff. A 2013 survey identified inconsistencies in how neurological specific assessments and interventions were
communicated in RN handoff. It was concluded that the use of a standardized template would be helpful in the
exchange of communication between RNs. A template creates repetition that allows for a large amount of complex
information to be conveyed in a concise manner. Additionally, a standardized format allows for pattern recognition
and shifts the focus from a task oriented report to one of intention. Therefore, a neuroscience specific handoff
template was created.
Methods
The 12 point questionnaire was repeated seven months after the initiation of a handoff template.
Comprehensiveness in report remained the focus in order to deliver a thorough exchange of information
subsequently providing an arena for safe and optimal patient care. We queried 46 RNs over a 4 week period of
time. Of those, 29 were NCCU RNs and 17 Surgical Intensive Care Unit RNs who floated into NCCU.
Results
Using the handoff template improved information provided in RN report in the key areas previously identified:
knowledge of 1) primary diagnosis, 2) information to assume responsibility for patient care, and 3) the plan of care.
The response of "always" increased by 9%, 30%, and 30% respectively with a resultant decrease in "usually".
Conclusions
We are moving towards a focus of intention demonstrated by the significant increase in percentages in key areas.
With consistent use of the template, we can anticipate continued improvement in all areas of handoff.
Financial Support: None
ICU ORG AND TECH
ePoster 160
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170
Neurocrit Care
ICU ORG AND TECH
ePoster 161
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IMPROVING THE QUALITY OF PRIMARY PALLIATIVE CARE DELIVERY IN THE NEUROSCIENCE
INTENSIVE CARE UNIT
Krista M. Garner1,3, Carolyn K. Clevenger2, Zachary O. Binney4, Jessica A. Taylor2, Tammie E. Quest4, Elizabeth L.
Starke1, Ashley M. Martin1, Anne W. Alexandrov3, Owen B. Samuels1
1
Emory University Hospital/Neuroscience Critical Care, Atlanta, GA, USA, 2Emory University/Nell Hodgson
Woodruff School of Nursing, Atlanta, GA, USA, 3University of Alabama at Birmingham, Birmingham, AL, USA,
4
Emory University/Palliative Care Center, Atlanta, GA, USA
Introduction
High-quality healthcare for patients and their families includes effective and comprehensive palliative care. The
integration of critical care and palliative care is increasingly recognized as a necessary component of healthcare
services for the critically ill. The outcomes of palliative care delivery by neurocritical care teams have not been
extensively discussed. Following the implementation of a palliative care bundle, we will be evaluating data from
patients, families, and providers in a neuroscience intensive care unit (NICU) to determine satisfaction with
palliative care delivery and staff adherence to the intervention.
Methods
Patients with an admitting diagnosis of subarachnoid hemorrhage (SAH), intracranial hemorrhage (ICH), and
subdural hemorrhage (SDH), are greater than nineteen years of age, and are hospitalized more than seventy-two
hours are included to receive the palliative care bundle. The bundle requires documentation of the patient's ability
to make independent decisions, presence of a legal surrogate decision-maker (SDM), possession of an advanced
directive (AD), and completion of a structured family meeting between hospital days three and five. Patients and
their families are voluntarily interviewed using a modified version of the Veteran's Affairs Post Bereavement Survey
to determine satisfaction. Medical and nursing staff bundle adherence is analyzed on a monthly basis.
Results
This project will be completed in summer 2014. It is anticipated that there will be high overall patient and family
satisfaction scores, an increase in the percentage of adherence rates from initial bundle implementation to project
end, and qualitative data from patients, families, and providers supporting the use of a primary palliative care
bundle in the NICU.
Conclusions
Provision of palliative care is an essential and meaningful service that defines patient and family centered care in
the NICU. Implementation of a standardized palliative care bundle should promote delivery of high quality services
to patients and their families.
Financial Support: HRSA Palliative Care Grant
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RIDING THE WAVE: A PILOT STUDY OF NEUROCRITICAL CARE NURSE PRACTITIONER SIMULATION
TRAINING FOR CENTRAL LINE PLACEMENT
Thomas N. Lawson, Susan Yeager
The Ohio State University Wexner Medical Center, Columbus, USA
Introduction
The well rounded neurocritical care nurse practitioner (NP) should possess the skill set to safely place a central
venous catheter in any of the three standard locations: subclavian, internal jugular (IJ), and femoral sites. To
improve ease of internal jugular and femoral placement and to minimize complications, ultrasound guidance is
considered the standard of care. To support our neurocritical care unit's (NCCU) NP's comfort with ultrasound
guided central access placement techniques, didactic and simulated training tools were created to enhance NP
learning.
Methods
Before and after measurements were obtained utilizing an evaluation tool. The evaluation tool incorporated a series
of questions surrounding comfort with: performing ultrasound techniques; identifying anatomic and ultrasound
anatomy; determining NP comfort and competence with ultrasound and central catheter equipment; identifying the
suitability of an insonated vein for cannulation; and determining the ability of the NP to plan a safe needle course. A
thirty minute didactic overview of ultrasound principles, anatomic structures, and equipment utilization was followed
by 60 minutes of simulation training and practice.
Results
Four NCCU NPs participated in ultrasound guided IJ and femoral central line training. The mean score on the
competency section rose from 71% to 84% on preliminary data (n=2). An increase in the mean cumulative scores
of the self-reported comfort level of these items was noted (20 to 35.5 out of 50 possible points). Each of the NPs
felt comfortable progressing to proctored placement on live patients at the end of the educational activities.
Conclusions
Structured learning utilizing ultrasound guided simulation training for central line placement is feasible and may
lead to improved competency and comfort of neurocritical care NPs. Future research needs to occur with larger
groups of practitioners
Financial Support: None
ICU ORG AND TECH
ePoster 162
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172
Neurocrit Care
ICU ORG AND TECH
ePoster 163
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OPTIMIZATION OF IDEAL NSICU PATIENT-TO-NURSING STAFF RATIOS THROUGH UTILIZATION OF
PORTABLE CT
James Lee, Regina M Won, Stanislaw Sobotka, Errol L Gordon, Stephan A Mayer
Mount Sinai Medical Center, New York, NY, USA
Introduction
Nurses, who comprise over 55% of the health care workforce, play a critical role in health care, as a review of the
literature demonstrates that optimal nursing staff ratios correlate with decreased mortality, lower rates of adverse
events, and shorter lengths of stay. To our knowledge, few studies have evaluated nursing staff ratios within the
neurosurgical intensive care unit (NSICU), which utilizes more invasive hemodynamic monitoring than general
ICUs. The aim of this study is to analyze nursing ratios within the NSICU, pre and post acquisition of a portable CT
scanner, to evaluate how well optimal rates are maintained.
Methods
We surveyed the patient and nursing populations in our 16-bed NSICU over a 4 week period before and after
implementation of a portable CT scanner, by recording the respective censuses at 30 minute intervals for each of
the day and night shifts. From this, patient-to-nurse ratios were extrapolated and plotted in Excel. Staffing levels,
CT scan volume, and average patient volume were analyzed to account for sample size differences. Statistical
analysis was used to assess the significance of the results.
Results
We found that there was a statistically significant decrease in patient-to-nurse ratios (2.14ĺ 2.00) after acquisition
of the portable CT scanner (p=0.0003, Mann-Whitney test). 137 in-radiology CT scans were performed prior to
portable CT, and 96 in-radiology and 17 portable afterwards, corresponding to an average of about 4 scans per
day, respectively. There were no statistical difference between day and night shifts, CT scan volume, average
patient volume, and overall staffing levels for both timeframes.
Conclusions
Technologies, such as portable CT, demonstrate utility in improving optimal patient-to-nurse ratios in the NSICU.
This, in effect, will allow for reduced nursing burden and greater availability for patient care. Further studies will
need to be performed to analyze associations between staffing levels and patient outcomes.
Financial Support: None
Neurocrit Care
173
HOW TO USE A NEUROCRITICAL CARE DASHBOARD TO DRIVE OPERATIONAL EFFICIENCIES AND
IMPROVE PATIENT CARE
Austen T. Lefebvre1, Eema Hemmen2, Josh L. Duckworth3, Brian P. Lemkuil4, Anushirvan Minokadeh4, Navaz
Karanjia3
1
UC San Diego/Department of Neurosciences, San Diego, CA, USA, 2UC San Diego/Department of Clinical Quality
Improvement, San Diego, CA, USA, 3UC San Diego/Department of Neurosciences, Division of Neurocritical Care,
San Diego, CA, USA, 4UC San Diego/Department of Anesthesiology, Division of Neurocritical Care, San Diego,
CA, USA
Introduction
There is no nationally recognized tool currently available to monitor key outcome and process measures in an
intensive care setting, a place where 59% of all in-house mortality occur in or include a stay. Additionally, patient
care services rendered in these units account for 20% of overall hospital costs. The Neurocritical Care Service
(NCC) at University of California San Diego Health System developed a dashboard to monitor, track and report key
outcome and process measures relevant to our NCC ICU utilizing the University HealthSystem Consortium Clinical
Database (UHC CDB).
Methods
We identified metrics important to the NCC aimed at improving quality of care, including mortality, ventilator
associated pneumonia, ventricular catheter meningitis, length of stay, as well as MRI and CT utilization and
hospital direct cost. We then extracted this data from the UHC CDB and developed an NCC specific dashboard
that is updated on a quarterly basis.
Results
At UCSD Health System we found that during the life of the dashboard, we experienced an increase in NCC cases
per year (+125, +50), a decrease in mean ICU length of stay (LOS) (-2 days, -33%, p=0.001), decreased O/E inhospital LOS (-0.19, -14%, p=0.002), decreased O/E in-hospital mortality (-0.21, -21%, p=0.960) and decreased
O/E direct cost (-0.04, -3%, p=0.828).
Conclusions
The NCC ICU dashboard at UCSD has been a powerful tool allowing us to routinely monitor and track compliance
with key neurocritical care outcomes that have then driven operational efficiencies and improved patient care. Our
dashboard can serve as a demonstration for how other healthcare organizations can leverage UHC CDB to
develop similar tools to improve health care delivery and patient outcomes in the intensive care setting.
Financial Support: None
ICU ORG AND TECH
ePoster 164
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174
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ICU ORG AND TECH
ePoster 165
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NEUROCRITICAL CARE SERVICE IMPACT ON HEMORRHAGIC STROKE OUTCOMES
Austen T. Lefebvre1, Eema Hemmen2, Josh L. Duckworth4, Brian P. Lemkuil3, Anushirvan Minokadeh3, Navaz
Karanjia4
1
UC San Diego/Department of Neurosciences, San Diego, CA, USA, 2UC San Diego/Department of Clinical Quality
Improvement, San Diego, CA, USA, 3UC San Diego/Department of Neurosciences, Division of Neurocritical Care,
San Diego, CA, USA, 4UC San Diego/Department of Anesthesiology, Division of Neurocritical Care, San Diego,
CA, USA
Introduction
The University of California San Diego Health System initiated a Neurocritical Care (NCC) service, under the
direction of an NCC fellowship-trained/board-certified neurointensivist in January 2012. The NCC service consists
of an NCC team (three NCC-trained attendings with continuous resident coverage) that admits and provides
primary management for all ICU-level neurosurgical/neurological patients. The majority of NCC patients are housed
in one ICU with nurses NCC-educated by the NCC director.
Methods
We analyzed the University HealthSystem Consortium (UHC) data for all NCC patients with a primary diagnosis of
hemorrhagic stroke (both intracranial hemorrhage (ICH) and subarachoid hemorrhage) from 2013, compared with
neurosurgical/neurological ICU patients from 2011, prior to NCC establishment. We also evaluated hemorrhagic
patients from all academic hospitals in California with established NCC units over the same time period as a control
group.
Results
At UCSD Health System, we found that observed in-hospital hemorrhagic mortality decreased from 24.7% in 2011
to 21.9% in 2013(-2.8, -11%), with risk-adjusted in-hospital mortality index (observed/expected mortality)
decreasing from 1.22 to 0.92 (-0.3, -25%). In addition, ICU length of stay (LOS) for these patients decreased from
8.4 to 6.2 days (-2.2 days, -26%). During this same time, other academic California hospitals with NCC units
observed an increase in observed mortality from 17.8% to 19.5% and a decrease in in-hospital mortality index from
1.07 to 0.99 (-0.1, -7.5%). There was also a decrease in ICU LOS from 8.9 to 7.9 days (-1 day, -11%).
Conclusions
Implementation of a primary NCC service at UCSD has been followed by decreased risk-adjusted in-hospital
mortality index and ICU length of stay in hemorrhagic stroke patients over baseline and to a level at or better than
other academic California hospitals with established NCC units. With increasing focus on outcomes-based
reimbursement, our experience provides an example of infrastructural methods that improve outcomes.
Financial Support: None
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175
MANDATORY INTENSIVIST CONSULTATIONS DECREASE ICU LENGTH OF STAY AND ALLOW FOR AN
INCREASE IN ADMISSIONS TO A NEUROCRITICAL CARE UNIT
Michael B. Rodricks1, 2, Sarah E. Napolitano3, Gabriella A. Anderson3, Cherlynn Basignani3,4, Misti Tuppeny1
1
Florida Hospital Orlando, Neurocritical Care, Orlando, FL, USA, 2Florida State University, College of Medicine,
Orlando, FL, USA, 3Florida Hospital Orlando, Neuroscience Research Institute, Orlando, FL, USA, 4University of
Central Florida, College of Medicine, Orlando, FL, USA
Introduction
Few studies have examined the effect of an intensivist in a Neurocritical Care (NCC) unit. The purpose of this study
was to identify both patient and economic benefits of a new requirement for a mandatory intensivist consultation on
admittance into the NCC unit. In November 2010, our hospital changed the NCC unit to a partially closed unit,
which required patients to have a mandatory intensivist consultation upon admittance. Previously, the intensivist
consultation was optional. The objective of this study was to compare patient length of stay (LOS), complications
and outcomes before and after implementation of mandatory intensivist consults.
Methods
A retrospective review comparing 1,551 patients admitted to the NCC unit from November 2009-October 2010
(prior to the new requirement) with 1,702 patients admitted from January-December 2011 (after the new
requirement) was performed. This included examining patient LOS, Acute Physiology and Chronic Health
Evaluation (APACHE) scores, service line closure rates for the unit, ICU readmission rates, and mortality. The
number of consults during each of the two time periods was also analyzed.
Results
The analysis revealed that despite comparable APACHE scores, implementation of mandatory intensivist consults
reduced overall NCC length of stay, 4.6 days vs. 3.7 days, (p< 0.001) and increased number of patients admitted to
the unit per month, 129 patients vs. 142 patients, (p=0.017) based on APACHE monthly counts. In addition, the
percentage of patients declined for transfer due to a closed service line decreased, 12.36% to 5.66%, (p=0.020).
Mortality rates remained below national predicted values and infection rates remained unchanged.
Conclusions
Implementation of mandatory intensivist consults in the NCC decreased LOS and allowed an increased number of
NCC unit admissions while maintaining overall quality of care.
Financial Support: None
ICU ORG AND TECH
ePoster 166
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ICU ORG AND TECH
ePoster 167
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FREQUENCY AND RESPONSE TIMES TO CLINICAL AND DEVICE ALARMS IN A NEUROLOGICAL
INTENSIVE CARE UNIT
J. Michael Schmidt1, Emma Meyers1, Daby Sow3, Sachin Agarwal1,2, E. Sander Connolly2, Jan Claassen1,2
1
Columbia University, Department of Neurology, New York, NY, USA, 2Columbia University, Department of
Neurosurgery, New York, NY, USA, 3IBM T.J. Watson Research, Ossining, NY, USA
Introduction
Studies have shown that 85% to 99% of medical device alarm signals are false and/or clinically insignificant
resulting in desensitization and alarm fatigue. The Joint Commission now requires hospitals to have a plan
regarding alarm management. We sought to determine the frequency and duration of alarms in our neurological
intensive care unit (NICU).
Methods
Device alarms generated by 604 patient admissions between February, 2009 and January, 2013 were collected
using the Bedmaster EX data acquisition system (Excel Medical, Jupiter, FL). Data collected include the alarm
acuity levels 1 (lowest) to 7 (highest), alarm duration, and details of the alarm trigger. Analyses were conducted
using general linear models.
Results
In total 1,147,617 device alarms were recorded over 5,624 patient days (min: 1, 25%: 55, 50%: 143, 75%: 279,
max: 4434 alarms generated per patient day). The most frequent alarms were high (403,096) and low (105,991)
blood pressure, unlabeled low pressure (72,899), tachycardia (61,637), check adapter (47,908), RR leads failure
(41,031), bradycardia (38,174), low (36,843) and high (32,162) heart rate, high (27,403) and low (22,066) central
venous pressure, and high respiration (20,427). Response time varied significantly with the type of alarm (P <
0.001) and level of acuity (P< 0.001). Low acuity device warning alarms (e.g., RR leads failure) took the longest to
respond to (mean: 256 seconds, SD: 3581 seconds). Clinical alarms regarding cardiac functioning (e.g., asystole)
were responded to most quickly (mean: 16.5 seconds, SD: 144 seconds) whereas intracranial pressure alarms
took approximately 1 minute to respond to (mean: 67 seconds, SD: 287 seconds).
Conclusions
Alarms are frequent in the neurological intensive care unit and device alarms may alert continuously for over an
hour adding to noise levels. Strategies to analyze alarms in real time should be devised to reduce the overall
frequency of alerts clinicians receive.
Financial Support: None
Neurocrit Care
177
EVALUATION OF A NOVEL BRAIN TISSUE PROBE FOR COMBINED INTRACRANIAL PRESSURE, BRAIN
TEMPERATURE, AND CEREBRAL BLOOD FLOW MONITORING: A PROSPECTIVE, MULTICENTER STUDY
Martin Seule1,2,3, von Campe Gord4, Sakowitz Oliver2, Sikorski Christopher1, Unterberg Andreas2, Keller Emanuela1
1
University Hospital Zurich/Neurointensive Care Unit, Zurich, Switzerland, 2Departemnt of Neurosurgery/University
Heidelberg, Heidelberg, Germany, 3Department of Neurosurgery/Kantonsspital St. Gallen, St. Gallen, Switzerland,
4
Department of Neurosurgery/University Hospital Graz, Graz, Austria
Introduction
Intracranial pressure (ICP) monitoring is recommended in most comatose patients with acute brain injury. We
aimed to evaluate a new brain tissue probe for combined ICP, brain temperature (Temp), cerebral blood volume
(CBV), and cerebral blood flow (CBF) monitoring.
Methods
The NeMo Probe® (NeMoDevices AG, Switzerland) is a conventional ICP probe supplied with a temperature
sensor and optical fibers for near infrared spectroscopy (NIRS). After central venous injection of indocyanine green
(ICG), the mean transit time of ICG (mttICG), CBV, and CBF are calculated. Combined NIRS-ICG measurements
were performed in 13 patients with subarachnoid hemorrhage (n=12) and traumatic brain injury (n=1). The useracceptance was compared with conventional brain tissue probes using a 3-graded questionnaire (better, equal,
worse). At least 2 repetitive NIRS-ICG measurements were performed daily to calculate the coefficients of
variation.
Results
The monitoring duration was on average 148 ± 61 hours. The user-friendliness of the NeMo Probe® was estimated
to be better or equal to conventional brain tissue probes in all cases. No serious adverse device-related events
occurred. There was a good correlation between ICPNeMo and ICPControl (r=0.758, p=0.01) as well as between
TempNeMo and TempControl (r=0.848, p=0.01). Mean values for mttICG was 6.8 ± 0.2 seconds, CBV 3.3 ± 0.3
ml/100g, and CBF 30.9 ± 2.6 ml/100g/min. The coefficients of variation for repetitive mttICG, CBV, and CBF
measurements were 3.7%, 9.7%, and 9.1%, respectively.
Conclusions
The results demonstrate a high acceptance rate concerning the user-friendliness of the NeMo Probe®. As a first
step, the accuracy of the measurement values was investigated by repeated measurements. The reproducibility of
the results was satisfactory for decision making in the clinical environment. Future studies are needed to validate
the measurement values with a standard method for CBF-monitoring as well as to estimate the sensitivity and
specificity to detect secondary ischemia after acute brain injury.
Financial Support: This project is supported by the the Swiss Innovation Promotion Agency (CTI) project no.
13553.1PFFLM-LS and the Eurostars project no. E!6526 OPTO-BRAIN, as well as by the Velux foundation.
NeMoDevices provided technical equipment for this clinical trial.M. Seule received grant support by the "StiefelZangger Foundation" of the University Zurich, Switzerland. E. Keller has a financial interest as founder and
member of board of NeMoDevices AG.
ICU ORG AND TECH
ePoster 168
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ICU ORG AND TECH
ePoster 169
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SAFETY OF PERIPHERAL PHENYLEPHRINE ADMINISTRATION IN THE NEUROCRITICAL CARE UNIT
Brianne M. Wolfe1, Timothy N. Delgado2, Julie K. Martinez2, Gary E. Davis1, Safdar A. Ansari2
1
University of Utah, Pharmacy, Salt Lake City, UT, USA, 2University of Utah, Neurology, Salt Lake City, UT, USA
Introduction
Phenylephrine is an alpha-adrenergic receptor agonist that is used commonly in the neurocritical care unit (NCCU)
to treat hypotension and induce therapeutic hypertension with the goal of optimizing cerebral and spinal perfusion
pressures.
Methods
After appropriate approval from the institutional IRB and Pharmacy and Therapeutics Committee, the authors
implemented the use of peripheral phenylephrine in a concentration of 40 mcg/mL at a rate not to exceed 2
mcg/kg/min for a maximum of 12 hours. The clinical indications for peripheral phenylephrine use was restricted to
select brain injured patients: 1. Augmentation of cerebral and spinal perfusion pressures 2. Emergent management
of hypotension in patients without central venous access to avoid drop in cerebral/spinal perfusion pressures. A
medication use evaluation and retrospective chart review was conducted to assess the practice of peripheral
phenylephrine administration. Objectives of the review were to evaluate for major and minor complications of
peripheral phenylephrine use. Minor adverse events were defined as erythema, swelling, and pain at the site of the
peripheral IV, and major adverse events as IV infiltration, thrombophlebitis and skin necrosis.
Results
20 patients were identified as having received peripheral phenylephrine during their admission to the NCCU from
August 16th, 2013 to February 16th, 2014. The average duration of infusion was 14.3 hours. One of the 20 patients
experienced a minor adverse event. This IV was removed and the patient proceeded to receive peripheral
phenylephrine for an additional 13 hours without further complication. There were no major adverse events.
Conclusions
After analysis of the data, use of peripheral phenylephrine infusion at this concentration, appears to be safe and
without major adverse events when used for an average of 14.3 hours in carefully selected patients, and with ICU
monitoring.
Financial Support: None
Neurocrit Care
179
THE INCIDENCE AND DETERMINANTS OF BRAIN TISSUE HYPOXIA IN CARDIAC ARREST SURVIVORS
WITH SEVERE NEUROLOGICAL INJURY
Jonathan Elmer1,2,6, Lori Shutter1,3,4, David Okonkwo4, Jon C. Rittenberger2,6, Clifton W. Callaway2,5,6, Cameron
Dezfulian1,6,7
1
Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA,
Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA,
3
Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA, 4Department of
Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA, 5Safar Center for Resuscitation
Research, Pittsburgh, PA, USA, 6Pittsburgh Post-Cardiac Arrest Service, Pittsburgh, PA, USA, 7Vascular Medicine
Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
2
Introduction
After cardiac arrest (CA), the American Heart Association recommends weaning inspired oxygen (FiO2) "to
achieve an arterial oxygen saturation [SaO2]94%...to avoid potential oxygen toxicity." This risks inadequate
cerebral oxygen delivery. We hypothesized that brain tissue hypoxia (BTH) would occur commonly in severely
brain injured post-CA patients and be more frequent when SaO2 was < 98%. We further hypothesized that arterial
oxygen tension (PaO2) and mean arterial pressure (MAP) would be determinants of brain tissue oxygen (PbtO2).
Methods
We monitor intracranial pressure (ICP), temperature, PbtO2 and jugular venous oxygen saturation in patients with
severe neurological injury (extensor posturing or worse) after CA. We collected data hourly and defined BTH as
PbtO2< 20mmHg. We calculated median frequency and duration of BTH events, and compared the frequency with
SaO2 >98% vs 94-98%. We used generalized estimating equations to test the correlation of ICP, temperature, time
from arrest, PaO2, MAP, arterial oxygen content and PaCO2 with PbtO2, then constructed an adjusted model
using predictors with an unadjusted P< 0.1. Finally, we calculated arterial-brain oxygen (a-B) gradient and repeated
correlation test procedures.
Results
Seven patients were monitored for 750 hours. All patients experienced BTH (median 6.5 episodes/patient (range 110), median duration 1.8 hours/episode (range 0.5-48)). BTH was present in 31% of hours overall (range 2.5-77%),
61% of hours when SaO2 was 94-98% and 29% when SaO2 was >98% (P< 0.001). Predictors of PbtO2 that
persisted after adjustment (P < 0.01) were time, PaO2 and MAP. The median a-B gradient was 119mmHg (IQR 83162mmHg) but fell rapidly over the first 24h.
Conclusions
In severely injured post-CA patients, BTH occurs frequently, appears to be delivery responsive, and occurs more
commonly when SaO2 is 94-98%. The risk-benefit ratio between limiting BTH vs. limiting hyperoxia must be
carefully considered in light of existing guidelines in these severely injured patients.
Financial Support: None
ICU ORG AND TECH
ePoster 135
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ICU ORG AND TECH
ePoster 138
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THE DIGITAL INTERN: EVALUATION OF COMPUTER CONTROLLED ALGORITHMS IN THE
NEUROCRITICAL CARE UNIT
Joshua E Medow, Susan Hamilton, Chirstopher M Nickele
University of Wisconsin, Madison, WI, USA
Introduction
Critical care units are responsible for an enormous number of cost saving, metric driven initiatives and at the same
time that they are expected to provide optimal patient care. Busy units are often under staffed and the physicians
have to ration their time to each patient based on need. When there are conflicting needs it may be a difficult
choice as to which patient gets that necessary level of attention. This conundrum is most evident with the organ
donor population. When a physician has a "crashing" patient that is likely to survive and one that is not, resources
are typically shunted to the survivable patient. Neurocritical care physicians and engineers at the University of
Wisconsin developed the Digital Intern to tackle this problem head-on. The software was embeded into the
electronic medical reocrd (EMR) to directly communicate orders to allied health professionals.
Methods
The number of organs recovered and the cost to recover them from the standpoint of critical care time billed were
compared between the control year and the treatment year when the Digital Intern was operational.
Results
The organs recovered per donor (excluding research) were 2.83 in the control year and 3.54 in the treatment year.
The results were statistically significant (p< 0.0359). In the control year the critical care hours billed averaged 5.9
per donor and 2.3 in the treatment year. These results were statistically significant (p< 0.001). Cost savings
averaged $2685 per donor.
Conclusions
The Digital Intern is designed to manage complex patients where simple PRN orders wouldn't be effective and
detailed PRN orders might be too confusing to follow. It is fast, effective, and efficient. Future iterations may extend
care to other patient populations where defined metrics can be used to optimize medical management. In the
meantime, the neurocritical care physician has no worry of being sidelined.
Financial Support: None
Neurocrit Care
181
THE USE OF ANTICOAGULATION AND ANTIPLATELET AGENTS BEFORE REMOVAL OF EVDS - HOW
SAFE IS IT?
Catherine Miller, Paramita Das, Daniel Guillaume, Ramachandra Tummala
University of Minnesota Department of Neurosurgery, Minneapolis, MN, USA
Introduction
External ventricular drains (EVDs) are both a therapeutic and diagnostic tool used every day by neurosurgeons.
Hemorrhage is a common complication of EVD placement and has recently been recognized to occur more
frequently than originally believed. Risk of hemorrhage with removal of an EVD has not been well described, and
no universal recommendations exist regarding timing of anticoagulation and/or antiplatelet agents before removal
of an EVD. We investigated the affect of anticoagulation and antiplatelet agents on hemorrhage caused by removal
of an EVD.
Methods
After obtaining IRB approval, a database was created to all who required EVD placement from January 2012 to
December 2013 at our institution. A retrospective chart review was completed and all imaging was reviewed for
evidence of hemorrhage on placement and removal of the EVD.
Results
179 EVDs were placed in 134 patients during the designated time period. Hemorrhage occurred in 46 patients
(26%) on placement with an average volume of 0.82cm3 ± 2.44cm3, while 17 patients (9.5%) had hemorrhage on
EVD removal, with an average volume of 7.34cm3 ± 19.86cm3. Anticoagulation or antiplatelet agents were started
in 60 "high risk" patients (45%) prior to EVD removal. Imaging was performed on 91 patients after removal, with
hemorrhage in 6 (14.40cm3 ± 33.18cm3) of the high risk group and 11(3.49cm3 ± 5.87cm3) in the normal group, OR
0.8 (CI 0.27-2.40, P = 0.98).
Conclusions
Multiple studies have investigated hemorrhage related to EVD placement with rates varying from 0-42%, while very
few studies have described hemorrhage secondary to EVD removal. The risk factors associated with EVD removal
have not been investigated. We found no correlation between the use of anticoagulation and antiplatelet agents
and an increased risk of hemorrhage on EVD removal.
Financial Support: None
ICU ORG AND TECH
ePoster 139
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182
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ICU ORG AND TECH
ePoster 140
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UNDERSTANDING DISCHARGE DELAYS IN THE NEUROSCIENCE INTENSIVE CARE UNIT
Nicholas A Morris, Ayush Batra, Adam B Cohen
Massachusetts General Hospital, Harvard Medical School/ Department of Neurology, Boston, MA, USA
Introduction
Neurocritical care beds are a valuable, but scarce resource. The purpose of this study was to quantify discharge
delays from the neuroscience intensive care unit (NICU) at a tertiary-care teaching hospital and examine the
impact on overall hospital length of stay (LOS). Secondary goals were to evaluate the effect of NICU delays on
patient physical/occupational therapy services and accuracy of initial clinician estimates of NICU and hospital LOS.
Methods
We conducted a prospective cohort study of consecutive patients discharged from NICU at Massachusetts General
Hospital from March 6th, 2013 through April 14th, 2013. Patients admitted for primary neurosurgical interventions
were excluded from the study. Patients were defined to have experienced a discharge delay when deemed ready
for transfer/discharge from the NICU but not physically transferred/discharged from the unit within 8 hours of time
first ready.
Results
65 patients were transferred from the NICU with an average transfer delay of 25 hrs 51 min (median = 13 hrs 3
min) of which 42% of patients were delayed at least 8 hours, while 23% were delayed at least 48 hours. The
primary reason for delay was identified as lack of bed availability. Transfer delay had no effect on hospital LOS.
Clinician estimates regarding date of transfer were inaccurate (within 24 hours in only 16% of patients) and
underestimated NICU LOS in ~95% of patients. Prediction of NICU LOS was most accurate in patients with
diagnoses of brain tumor compared to other common diagnoses (seizure, ischemic stroke, or intracerebral
hemorrhage).
Conclusions
Discharge delays from the NICU were a common problem, but did not affect overall hospital LOS. Delays had a
negative effect on total physical therapy time patients received. Clinician estimates of NICU LOS must be improved
for discharge planning and resource allocation such as physical therapy.
Financial Support: None
Neurocrit Care
183
WEB-BASED ASSESSMENT OF OUTCOMES AFTER INTRACRANIAL HEMORRHAGE
Andrew M Naidech1, Jennifer M Beaumont1, Michael Berman1, Eric M Liotta1, James C Guth1, Matthew B Maas1,
Shyam Prabhakaran1, Konrad Kording2, Jane Holl1, David Cella1
1
Northwestern Medicine, Chicago, IL, USA, 2Rehabilitation Institute of Chicago, Chicago, IL, USA
Introduction
Clinical outcomes assessment requires trained staff. We tested the hypothesis that patient-reported outcomes on
the web would be correlated with a validated interview.
Methods
We assessed patients with intracerebral and subarachnoid hemorrhage at one, three and 12 months follow-up with
a validated interview for the modified Rankin Scale (mRS, a validated ordinal scale from 0, no symptoms to 5,
severe disability). Health-related quality of life (HRQoL) was assessed on the web with NIH Patient Reported
Outcomes Measurement Information System (PROMIS) and Neuro-QOL using computer adaptive testing by the
patient, proxy reporting by a caregiver, or proxy entry by study staff.
Results
A coincident mRS and HRQoL assessment were available for 149 (71%) of 209 patients at one, three or 12
months. There were 89 assessments with proxy entry by study staff, 89 by the patient on the web, and 58 with
proxy report by a caregiver on the web. PROMIS physical function assessments were completed in median of 4
questions, and T Scores were associated with the mRS (P< 0.001), regardless of respondent. Mean T scores in
every category of the mRS were different from every other category (P0.003 for all). Results were similar for
Neuro-QOL mobility.
Conclusions
Web-based HRQoL assessment with NIH PROMIS and Neuro-QOL is feasible and correlated with a validated
interview for the mRS. T scores distinguished between individual categories of the mRS, detecting modest
differences in physical function and mobility HRQoL. PROMIS and Neuro-QOL provide powerful and sensitive
outcomes for potentially large cohorts.
Financial Support: None
ICU ORG AND TECH
ePoster 142
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INTRACEREBRAL HEMORRHAGE
184
Neurocrit Care
ePoster 170
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SIMULATION OF BEST-CONSENT AND FAILED-CONSENT ELEMENTS FROM CLEAR-III: A RANDOMIZED,
PLACEBO CONTROLLED TRIAL
William D Freeman1, Mark Macek2, Karen Lane2, Lesia Mooney3, Eugene Richie4, Thomas Brott5, Sothear Luke6,
Steven Mayo7, Ryan Majkowski8, Dan Hanley9
1
Departments of Neurology, Neurosurgery, and Critical Care. Mayo Clinic Florida, Jacksonville, FL, USA, 2Brain
Injury OutcomeS (BIOS) Division, The Johns Hopkins University, Baltimore, MD, USA, 3Department of Nursing,
Mayo Clinic Florida, Jacksonville, FL, USA, 4Simulation Center. Mayo Clinic Florida., Jacksonville, FL, USA,
5
Applebaum Professor, Director of Research, Department of Neurology, Mayo Clinic Florida, Jacksonville, FL,
USA, 6Neuroscience Research Division, Coordinator, Jacksonville, FL, USA, 7Chief Executive, Emissary
International CRO, Austin, TX, USA, 8Regulatory Coordinator, BIOS, Baltimore, MD, USA, 9Harriett Legum
Professor, Brain Injury OutcomeS (BIOS) Division, The Johns Hopkins University, Baltimore, MD, USA
Introduction
We prospectively studied the consent patterns of a prospective, randomized, placebo-controlled trial in terms of
best-practice and failed-consent elements, and simulated them to enhance future recruitment among the clinical
trial.
Methods
CLEAR-III trial is a prospective, randomized, placebo-controlled trial studying the effect of recombinant
intraventricular tissue plasminogen activator (rtPA) versus saline (placebo) injections in terms of intraventricular
hemorrhage (IVH) reduction and safety. Data was collected on "best" and "failed" consent practices during the
clinical trial. These best and failed consent practices were then simulated into a Simulation Center video
presentation as an education intervention to educate all study sites to improve consent conversion. Pre - and postpresentation screen failures and refusal of consent were analyzed by Fisher's exact test for significance.
Results
The overall conversion rate rose from 4.5% to 5.8% after the presentation. The year prior to the presentation the
study had 100 randomizations out of 2225 screen failures, compared to 116 randomizations out of 2007 screen
failures after presentation (P=0.08). While this trend did not reach statistical significance, anecdotal reports from
site managers suggest the presentation was useful and helped 'salvage' some consents. The number of 'refused
consent over 'other failures' to enroll in the study pre intervention (n=33/2192) compared post- intervention
(n=25/1982) was not significant (P=0.59). In the subset of sites that participated in the live webinar presentation,
the incidence of consent refusal out of total screen failures dropped from 2.5% (23/923) at baseline to 1.8%
(15/834) after the presentation (p=0.33).
Conclusions
Randomized, placebo-controlled trial consent process may be improved by identification of best-practice and failed
consent elements, followed by simulated video portrayals of these elements to provide quality improvement to
study sites, principal investigators and coordinators. However this intervention did not change the rate of refused
consent in the trial which requires further study and likely due to multiple confounding factors.
Financial Support: None
185
ePoster 171
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THE EXCESS COST OF INTER-ISLAND TRANSFER OF PATIENTS WITH SPONTANEOUS INTRACEREBRAL
HEMORRHAGE
Kazuma Nakagawa1,2, Alexandra Galati1, Megan Vento2, Marissa Ing2, Deborah Juarez1
1
University of Hawaii, Honolulu, HI, USA, 2The Queen's Medical Center, Honolulu, HI, USA
Introduction
The current guidelines recommend all intracerebral hemorrhage (ICH) patients be managed in a facility with
capacity to perform neurosurgical and neuro-interventional procedures. However, many transferred ICH patients do
not receive these interventions. Therefore, we sought to assess the annual excess cost of inter-island transfer (IT)
of ICH patients who were transferred to a tertiary center with such capacity.
Methods
Consecutive patients with ICH between June 2011 and January 2014 were enrolled into a prospective cohort
study. Patients were considered to have received subspecialized tertiary care (STC) if any neurosurgical procedure
(craniotomy, craniectomy, and/or ventriculostomy) or cerebral angiogram (diagnostic and/or therapeutic) were
performed. Minimum cost of IT for ICH patients was estimated based on the informal survey of a local company
that provides IT. Total excess cost was estimated as excess cost per IT multiplied by the portion of IT patients not
receiving any STC. Univariate and multivariable analyses were performed to identify factors significantly related to
the likelihood of receiving STC.
Results
Among a total of 200 ICH patients enrolled in the cohort study, 38 patients (19%) were admitted from the neighbor
islands through IT. Among them, only 13 patients (34%) received STC. Since the remaining 25 IT patients did not
receive any STC, this translates to approximately $250,000 of total excess cost over 2.5 year period (approximately
$100,000/year) that could have been avoided if these patients had not been transferred. None of the clinical factors
in our model were significantly associated with the likelihood of receiving STC.
Conclusions
Approximately two-thirds of ICH patients with IT did not receive any STC and could have potentially received
similar care at their initial hospital. The estimated excess cost of IT was $100,000 per year. Further study is needed
to better assess factors that could identify patients most likely to benefit from IT.
Financial Support: Dr. Nakagawa was supported in part by the National Institute on Minority Health and Health
Disparities of the National Institutes of Health under Award Number P20MD000173.
INTRACEREBRAL HEMORRHAGE
Neurocrit Care
INTRACEREBRAL HEMORRHAGE
186
Neurocrit Care
ePoster 172
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THE ASSOCIATION BETWEEN TRANSFUSION AND OUTCOMES IN INTRACEREBRAL HEMORRHAGE
PATIENTS WITH AND WITHOUT CORONARY ARTERY DISEASE: A RETROSPECTIVE ANALYSIS
Ayaz M Khawaja1, Amelia K Boehme1, 2, Karen C Albright1, 2, 3, Michael J Lyerly1, 3, Mark Harrigan3, 4, Sheryl MartinSchild5, David W Miller6, 7
1
Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA, 2Department of
Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA, 3Division of Cerebrovascular disease,
University of Alabama at Birmingham, Birmingham, AL, USA, 4Department of Neurosurgery, University of Alabama
at Birmingham, Birmingham, AL, USA, 5Division of Cerebrovascular disease, Tulane University School of Medicine,
New Orleans, LA, USA, 6Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, AL,
USA, 7Division of Neurocritical Care, University of Alabama at Birmingham, Birmingham, AL, USA
Introduction
In patients with intracerebral hemorrhage (ICH), packed-RBC transfusion may be detrimental whereas platelettransfusion's effects are controversial. Prior studies suggest different transfusion thresholds in patients with
coronary artery disease (CAD). This study examines the association between transfusion and outcomes in ICH
patients with and without CAD.
Methods
ICH patients admitted to the Tulane Stroke Center from 07/08-01/14 were included. Patients with age< 18 years,
in-hospital strokes and outside hospital transfers were excluded. Demographic and clinical data were analyzed in
patients with and without CAD using Chi-square and Wilcoxon Rank-Sum tests. Primary outcome measure was
discharge modified-Rankin score of 5-6 (dmRS=5-6). The association between transfusion and outcomes was
assessed with logistic regression.
Results
Out of 214 ICH patients identified, 25 (11.7%) had CAD on admission. CAD patients were younger than non-CAD
patients (60 vs. 67; p=0.007) and had a higher frequency of antiplatelet use (AP-use) (68% vs. 24%; p< 0.001).
There was no difference in pRBC-transfusion between patients with CAD compared to those without (8% vs. 13%;
p=0.500). CAD patients had a higher odds of receiving a platelet-transfusion (OR=3.69, 95%-CI=1.47-9.25,
p=0.005); however, this association was no longer statistically significant after accounting for age and AP-use
(OR=2.55, 95%-CI=0.66-9.89, p=0.170). ICH Patients who received pRBC-transfusion had greater odds of
dmRS=5-6 (OR=6.11, 95%-CI=2.38-15.80, p< 0.001) than those without transfusion. After adjusting for age,
admission hematocrit, admission ICH score, CAD, and intubation, this association was no longer statistically
significant (OR=4.11, 95%-CI=0.80-21.00, p=0.090). After accounting for the same covariates including CAD, ICH
patients who received a platelet-transfusion had a higher odds of dmRS=5-6 (OR=2.17, 95%-CI=0.66-7.16,
p=0.20), however this association was statistically insignificant.
Conclusions
Transfusion is not a significant independent predictor of poor outcomes (dmRS=5-6) in ICH patients regardless of
CAD history. It may serve as a marker of the severity of overall medical illness in ICH patients.
Financial Support: None
187
ePoster 173
___________________________________________________________________________________
SERUM ALBUMIN LEVELS IN INTRACRANIAL HEMORRHAGES: CORRELATION WITH OUTCOME
Kaustubh Limaye, Archana Hinduja
University of Arkansas for Medical Sciences, Little Rock, AR, USA
Introduction
Low serum albumin has been correlated with poor outcomes in various diseases. Albumin is a chief component of
plasma protein and is required to maintain normal permeability, prevent platelet aggregation besides having other
important properties. Hypoalbuminemia, is a frequent finding in acute ischemic stroke and is associated with more
severe stroke and poor clinical outcome. There is limited data on its impact on outcome in patients with
intracerebral hemorrhage.
Methods
We reviewed our prospective database of patients admitted to our tertiary care medical center with intracerebral
hemorrhage between January 2009-June 2012. All consecutive patients with intracerebral hemorrhage who had
serum albumin levels upon admission were included. We analyzed the demographics, risk factors, etiology,
location, volume of intracerebral hemorrhage, clinical and laboratory parameters, complications, mortality and
outcome at discharge. Patients were divided into two groups based on the serum albumin levels. A cut of level of
3.4 g/dl and lower was considered as hypoalbuminemia. Both groups were compared using the Fisher's exact test.
Poor outcome was defined as in-hospital death, hospice and discharge to nursing home.
Results
During this study period 90 patients met our inclusion criteria (42 patients had normal levels and 48 had
hypoalbuminemia). The baseline characteristics, risk factors, hematoma, etiology, location, volume, laboratory
parameters, length of hospital stay, length of intensive care unit stay, complication were similar between both
groups. Although hypoalbuminemia, did not impact mortality, there was a significant impact on poor outcome (57%
vs 31%, p=0.019) (O.R 3.0; 95% CI: 1.2-7.2).
Conclusions
Serum albumin is a readily available test that may be helpful in correlating outcomes in patients with intracerebral
hemorrhage. Larger prospective studies are required to confirm these results.
Financial Support: None
INTRACEREBRAL HEMORRHAGE
Neurocrit Care
INTRACEREBRAL HEMORRHAGE
188
Neurocrit Care
ePoster 174
___________________________________________________________________________________
THROMBOSIS OF INTRAVENTRICULAR CATHETER PLACED AFTER INTRAVENTRICULAR
HEMORRHAGE: INTRA-CATHETER RT-PA THROMBOLYSIS
Chandan Mehta1, Mauricio Cuero1, Tamer Abdelhak1,2, Mohammed Rehman1,2, Marianna Spanaki1, Panayiotis
Varelas1,2
1
Henry Ford Hospital, Department of Neurology, Detroit, MI, USA, 2Henry Ford Hospital, Department of
Neurosurgery, Detroit, MI, USA
Introduction
Placement of intraventricular catheter (IVC) after intraventricular hemorrhage (IVH) is often life-saving, but carries
the risks of hemorrhage and misplacement. If an IVC stops draining cerebrospinal fluid (CSF) due to clotting, it
must be replaced, increasing the complication risk. We report intra-IVC instillation of rt-pA to lyse obstructing
thrombi and avoid removal and replacement of the catheter.
Methods
We reviewed all patients with IVC placement admitted to a tertiary center Neuro-ICU over 6 years, who received rtpA due to intra-catheter thrombosis. Intraventricular catheter position was confirmed by head CT before rt-pA was
administered. The protocol mandated instillation of 1-2 mg rt-pA (volume 1-2 ml) into the IVC under sterile
conditions, without additional flush in order to avoid extra-IVC leakage of the drug. IVC was then clamped for 1
hour and subsequently opened to drain. If no clinical improvement was noted after IVC patency was established
with CSF drainage, emergent head CT was obtained to exclude hemorrhagic complication.
Results
Nine patients (mean age 55, 33% female) were included. IVH resulted from subarachnoid (67%) and intracerebral
hemorrhage (33%). No reliable ICP waveform was present before the instillation of the drug. Two patients received
rt-pA on 2 separate occasions. The mean instilled dose was 1.46mg (range 1-2mg). No IVC was unclamped early
on. Gradual return of ICP waveform during the clamping period was noted and all IVCs drained bloody CSF after
reopening. The post-unclamping initial mean ICP was 14.6mm Hg and the first-hour mean CSF drainage was
14.7ml. No patient developed hemorrhagic complications and no IVC was changed after this procedure. One
patient developed CSF infection one month later, which was deemed unrelated to rt-pA administration.
Conclusions
In this small case series, intracatheter rt-pA instillation was an efficient and safe way to lyse intra-catheter thrombi,
reinstitute reliable ICP measurements and CSF drainage and avoid IVC replacement.
Financial Support: None
189
ePoster 175
___________________________________________________________________________________
SIGNIFICANCE OF HEMODYNAMIC AND HEART RATE VARIABILITY IN ACUTE PHASE OF SPONTANEOUS
INTRA-CEREBRAL HEMORRHAGE: A SINGLE CENTER STUDY
Michael S Mendoza, Sameer Sharma, Umair Afzal, Julius Gene Latorre
Neurocritical care Unit/Department of Neurology, SUNY Upstate Medical University, Syracuse, NY, USA
Introduction
Systolic blood pressure guided management of spontaneous intra-cerebral hemorrhage (sICH) has been
demonstrated to be safe and clinically feasible. Secondary injury caused by the hematoma such as perilesional
ischemia impairs cerebral auto-regulation. We hypothesize that the first 24 hours Systolic, Diastolic, Mean arterial
pressure and heart rate variability have effect on these processes and can influence outcome of patients.
Methods
Retrospective review of patients with sICH admitted from June 2010 to 2011 at the Neuro-critical care unit of the
University Hospital. Demographics, ICH score, Blood pressure and heart rate recordings in the first 24 hours from
onset, and clinical outcomes using 30 day mortality, length of ICU stay, and ability to transfer from bed to chair after
ICU discharge were studied. Variability was measured using variance P (VARP) and Interquartile range (IQR)
Results
In 80 patients, there were 47.5% males with a mean age of 69.47. Fifty percent admitted to the ED and medically
managed. Sixty one percent were hypertensive, 22.5% atrial fibrillation, 26.25% taking ASA, 18.75% taking anticoagulation. Patients with higher ICH score at admission (3.68 vs. 1.84 p< 0.05), Variable Diastolic blood pressure
(DBP IQR 23.11 vs. 17.70 p = 0.008), Heart Rate (HR IQR 20.935 vs. 13.735 p = 0.034) and Mean arterial
pressure (VARP 2630 vs 1762 p = < 0.05) were associated with 30 days mortality. Surrogate markers of functional
outcome such as discharge to home and able to perform transfers with minimum assistance were associated
with less Heart rate variability (HR IQR 12.93 vs 16.95 p= 0.058).
Conclusions
Controlling variability of other hemodynamic parameters such as MAP and HR, other than systolic blood pressure
may reduce secondary injury from sICH in the acute phase hence improving functional outcome.
Financial Support: None
INTRACEREBRAL HEMORRHAGE
Neurocrit Care
INTRACEREBRAL HEMORRHAGE
190
Neurocrit Care
ePoster 176
___________________________________________________________________________________
UTILITY OF CT ANGIOGRAPHY IN MANAGEMENT OF INTRACEREBRAL HEMORRHAGE
Swarna Rajagopalan, Laura Cifrese, Ausim Azizi
Temple University Hospital, Philadelphia, PA, USA
Introduction
Intracerebral hemorrhage (ICH) is defined as intra-parenchymal bleeding with or without intra-ventricular extension.
CT angiography (CTA) is widely used as a screening tool to identify a source. CTA can have adverse effects such
as contrast-induced nephropathy, allergic reactions and radiation exposure. The utility of CTA in altering
management of patients with spontaneous ICH may be restricted to a small subset.
Methods
A retrospective review was done of 944 patients admitted to Temple University Hospital with a diagnosis code of
ICH. Patients who had antecedent history of trauma, subarachnoid hemorrhage, hemorrhagic conversion of an
infarct, or hemorrhage within a brain tumor were excluded.
Results
From the cohort of 940 patients with ICH, 207 (22%) underwent a CTA during hospitalization. Of these, 202
(97.5%) were negative. In this group, the mean age was 62 and 73.2% had hypertension; 52% of the ICH involved
the basal ganglia and 30% involved the thalamus. Five of 209 (2.4%) had a positive CTA demonstrating an
underlying vascular abnormality that caused the ICH; Two had aneurysms, one a venous angioma, one an AVM
and one a pseudo-aneurysm. In this group, the mean age was 58, and 60% had hypertension. Two were frontoparietal, one temporo-parietal, one periventricular and one cerebellar in location. CTA changed management in
three of these five patients: two had aneurysm coiling or embolization and one underwent a surgical treatment of
AVM. Patients with a positive CTA tended to be younger and have cortical involvement, whereas those with a
negative CTA were older, with hemorrhage affecting deeper brain structures.
Conclusions
CTA in older hypertensive patients with hemorrhages in deeper brain structures is a low yield procedure and does
not change treatment or confidence in diagnosis. The similarity in prevalence of hypertension in the two groups
could be reflective of the inner city population.
Financial Support: None
191
ePoster 177
___________________________________________________________________________________
RENAL REPLACEMENT THERAPY MODE AND TIMING IN PATIENTS WITH ACUTE SPONTANEOUS
INTRACEREBRAL HEMORRHAGE IN THE NEUROCRITICAL CARE UNIT
CHRISTA O'HANA V. SAN LUIS MD1,2, PATRICK FILBERT O. NOBLEZA RN4, WENDY C. ZIAI MD, MPH1,2,3
1
Johns Hopkins University Department of Anesthesia and Critical Care Medicine Division of Neurosciences and
Critical Care, Baltimore, MD, USA, 2Johns Hopkins University Department of Neurology, Baltimore, MD, USA,
3
Johns Hopkins Hospital, Baltimore, MD, USA, 4Johns Hopkins Bayview Medical Center Department of
Nephrology, Baltimore, MD, USA
Introduction
Timing and mode of renal replacement therapy (RRT) among patients with renal failure (RF) and spontaneous
intracerebral hemorrhage (sICH) varies due to concern for rapid osmolar shifts. We aim to describe clinical
characteristics, timing and complications in patients with RF and sICH undergoing continuous RRT (CRRT) versus
intermittent hemodialysis (IHD) in an academic Neurocritical Care Unit (NCCU).
Methods
Retrospective study of 112 patients admitted to an NCCU from 2000 to 2013, with sICH and RF (ICD 584.4-9,
585.1-9). Thirty-seven patients underwent RRT during NCCU admission and were included for analysis and
grouped by initial RRT mode (CRRT vs. IHD). We analyzed timing and factors associated with mode of RRT
selected and neurologic/non-neurologic complications associated with each mode.
Results
Mean(±SEM) age in all 112 patients was 59±15 years. 75 patients who did not undergo RRT had peak creatinine of
2.66±1.59. CRRT was the initial mode in 62% of those who underwent RRT. The most common reason for RRT
initiation was acute RF(44%) in the CRRT group while it was "chronic RF on IHD" in the IHD group
(64%)(p=0.045). CRRT patients had lower admission GCS(9[IQR5]vs14[4];p=.002), better admission renal
function(GFR 28.77±19.26vs10.22±3.99;p=.008), higher use of external ventricular drains(52%vs0%;p=0.001), and
higher intubation rates (74%vs14%;p< .001). CRRT patients had non-significantly higher median ICH volume
(9.83[28.63]vs5.15[29.91];p=0.385), and more midline shift(44%vs29%;p=0.49). CRRT and IHD were initiated at
9±11and6±8 days respectively from sICH onset (p=0.32). 11(48%) CRRT patients transitioned to IHD at 19±11
days after sICH onset. Only one patient transitioned to CRRT from IHD. Complication rates were similar in both
groups.
Conclusions
sICH patients initiated on CRRT in the NCCU have lower GCS, higher EVD usage, but better renal function
compared to patients started on IHD. Better understanding of compartmental shifts, change in edema volume and
intracranial pressure during RRT may guide decision making regarding RRT among sICH patients.
Financial Support: None
INTRACEREBRAL HEMORRHAGE
Neurocrit Care
INTRACEREBRAL HEMORRHAGE
192
Neurocrit Care
ePoster 178
___________________________________________________________________________________
YOUNGER AGE AMONG NATIVE HAWAIIANS AND OTHER PACIFIC ISLANDERS IMPACTS THE RACIAL
DIFFERENCES IN THE PROCESS OF WITHDRAWAL OF LIFE SUPPORT AFTER INTRACEREBRAL
HEMORRHAGE
Kristen M. Shaw1,2, Matthew J. Gallek2, Leslie Ritter2, Kate G. Sheppard2, Megan A. Vento1, Susan M. Asai1,
Kazuma Nakagawa1,3
1
The Queen's Medical Center, Honolulu, HI, USA, 2University of Arizona, College of Nursing, Tucson, AZ, USA,
3
University of Hawaii, Honolulu, HI, USA
Introduction
Studies show that racial/ethnic minorities are less likely to terminate life-sustaining treatment after an acute medical
condition compared to non-Hispanic whites. However, the end-of-life decision-making process among Native
Hawaiians and other Pacific Islanders (NHOPI) has not been described. Therefore, we sought to assess the racial
differences in the prevalence and rate of withdrawal of life support (WOLS) after acute intracerebral hemorrhage
(ICH), a hemorrhagic stroke with high rate of mortality and morbidity.
Methods
A retrospective study was conducted on patients admitted to a primary stroke center in Honolulu with diagnosis of
spontaneous ICH. Medical records were reviewed for occurrence of withdrawal of life support (WOLS) and time-toWOLS. Unadjusted and multivariable logistic regression models, accounting for age, sex, treating providers, risk
factors and ICH severity, were performed to determine associations between race and WOLS after ICH. Kaplan
Meier analysis and Cox Regression were performed to estimate and compare differences in time-to-WOLS.
Results
A total of 396 ICH patients (non-Hispanic whites 15%, NHOPI 18%, Asians 63%, others 4%) were studied. Overall,
NHOPI were significantly younger compared to non-Hispanic whites (55±16 vs. 68±16 years, respectively, p <
.001) although ICH severity and presentation were similar. In the univariate analysis, NHOPI had lower prevalence
of WOLS compared to non-Hispanic whites (OR 0.35, 95% CI: 0.15, 0.80). Kaplan Meier analysis showed a
significantly longer time-to-WOLS among NHOPI compared to non-Hispanic whites (p = < .01). However, in
multivariate analysis, NHOPI race was no longer a significant predictor of WOLS when adjusted for age (OR 0.59,
95% CI 0.25, 1.43) and in the fully adjusted model (OR 0.68, 95% CI 0.20, 2.39).
Conclusions
Native Hawaiians and other Pacific Islanders were less likely than non-Hispanic whites to withdraw life support
after ICH. However, this difference was mainly driven by the young age of NHOPI and not from an independent
racial/cultural factor.
Financial Support: None
193
ePoster 179
___________________________________________________________________________________
TROPONIN ELEVATION IN SPONTANEOUS INTRACRANIAL HEMORRHAGE
Pavan Tummala, Nabil Makhlouf, Abhay Kumar
St. Louis University, St. Louis, MO, USA
Introduction
Troponin elevation in ischemic stroke and subarachnoid hemorrhage is well studied and is an independent
prognostic factor for mortality. However, the significance of troponin elevation in spontaneous intracranial
hemorrhage (sICH) is not well studied. This study describes troponin elevation in patients with sICH and explores
underlying associations.
Methods
This is a retrospective analysis of 208 patients from July 2012 to October 2013 who presented to our hospital with
sICH. Of these, 145 patients with sICH (without AVM, Aneurysm, hemorrhagic conversion of ischemic infarct,
trauma) were included in the study. Bleeds were categorized by their sidedness (right/left) and location (lobar,
deep, or posterior fossa). ICH volume was measured by ABC/2 method after testing for inter-rater reliability.
Categorical and continuous variables were tested using appropriate statistical methods.
Results
The mean age of patients was 64.0 ± 15.3 years. Troponin was measured in 133 patients and it was elevated in
49% of the patients (range 0.033- 3.36 ng/ml). EKG changes reflecting possible ischemia was present in 28%
(40/145) patients, although ST-T changes associated with troponin elevation was noted in 5% (8/145) patients only.
Troponin elevation did not have any significant association with side of the bleed, location, and initial hematoma
volume or hematoma expansion. Troponin elevation was however significantly associated with mortality status of
the patient at the time of discharge (p= 0.004, OR= 3.69, 95% CI 1.5, 9.0)
Conclusions
Troponin elevation in sICH does not appear to be associated with hematoma characteristics. However, it is
significantly associated with mortality status of the patients at discharge. Whether troponin elevation independently
contributes to mortality in sICH requires further investigation.
Financial Support: None
INTRACEREBRAL HEMORRHAGE
Neurocrit Care
INTRACEREBRAL HEMORRHAGE
194
Neurocrit Care
ePoster 180
___________________________________________________________________________________
RATE OF PERI-HEMATOMAL EDEMA EXPANSION PREDICTS MORTALITY AFTER INTRACEREBRAL
HEMORRHAGE
Sebastian Urday1, Lauren A Beslow1, Anastasia Vashkevich 2, Alison M Ayres 2, Thomas WK Battey 2, Magdy
Selim 3, Jonathan Rosand 2, W Taylor Kimberly2, Kevin N Sheth1
1
Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New
Haven, CT, USA, 2Center for Human Genetic Research and Division of Neurocritical Care and Emergency
Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 3Beth Israel Deaconess
Medical Center, Stroke Division, Boston, MA, USA
Introduction
Prognostic significance of peri-hematomal edema (PHE) after intracerebral hemorrhage (ICH) is unclear. We
investigated whether PHE expansion rate from baseline to 24 hours predicts mortality after ICH.
Methods
ICH, PHE and intraventricular hemorrhage (IVH) volumes were measured for 110 subjects who presented with
primary supratentorial ICH and received head computed tomography (CT) scans at baseline and 24-hours postICH. Logistic regression was performed to evaluate the relationship between PHE expansion rate and 90-day
mortality.
Results
Patients who died had an average expansion rate of 0.74 mL/h compared to 0.17 mL/h in survivors. There was a
strong association between PHE expansion rate and 90-day mortality (OR 2.99, 95% CI 1.48-6.03, p = 0.002). In a
multivariable model accounting for presence of significant hematoma expansion, defined as more than 12.5 mL
growth, PHE expansion rate was a significant predictor of 90-day mortality (OR 2.79, 95% CI 1.38-5.64, p = 0.004).
This association remained in a multivariable model accounting for hematoma expansion, baseline ICH volume, and
baseline Glasgow Coma Scale score (OR 2.19, CI 1.08-4.45, p = 0.03).
Conclusions
PHE expansion rate predicts mortality in ICH and may represent a novel therapeutic target.
Financial Support: Leon Rosenberg, MD Medical Student Research Fund in Genetics at Yale School of Medicine,
NIH-K12-NS049453, NINDS K23NS076597
Neurocrit Care
195
Saturday, September 13
Session III
5:15 – 6:45 pm
Kiosks 1 - 5 located in 5th Ave
Kiosks 6 - 7 located in Grand Crescent
Subarachnoid hemorrhage – Kiosk 1
#
Time
182 5:15
183 5:22
184 5:29
185 5:36
186 5:43
187 5:50
188 5:57
189 6:04
190 6:11
191 6:18
192 6:25
193 6:32
Title
RandomizedControlledTrialoftheCerebrovascularHemodynamicEffectsof
SimvastatininStatinNaïvePatientswithAcuteSubarachnoidHemorrhage
PatientͲPoweredReportingofModifiedRankinScaleOutcomesviathe
Internet:AValidAlternativetotheTelephonicStructuredInterview
OutcomeofWFNSGradeVSubarachnoidHemorrhage.DoGCS3PatientsFare
WorseThanGCS4to6Patients?
SpontaneousSubarachnoidHemorrhage(SSAH)CasesAdmittedina
NeurocriticalIntensiveandIntermediateCareUnitin2years
ProtocolbasedrealͲtimecontinuouselectroencephalogramfordetecting
vasospasminsubarachnoidhemorrhage
RoleofTranscranialDopplerintheManagementofWarͲTimeTraumaticBrain
Injury
RoutineDepressionScreeningIsFeasibleInSubarachnoidHemorrhagePatients
PerformanceofContinuousElectroencephalography(cEEG)Ischemia
MonitoringinClinicalPracticefortheProspectiveDetectionofNeurologic
DeclinefollowingSubarachnoidHemorrhage(SAH)
SAHPatientswithFocalProcessesLeadingtoElevatedIntracranialPressure
RespondsBettertoHypertonicSalinethanThosewithGlobalProcesses
Spontaneoushyperventilationiscommoninsubarachnoidhemorrhageand
associatedwithdelayedcerebralischemiaandpoorfunctionaloutcome
Severecerebralvasospasminapatientwithatraumaticsubarachnoid
hemorrhage
Simvastatinversuspravastatinforthepreventionofvasospasmafter
aneurysmalsubarachnoidhemorrhage
Presenting
Author
M.Diringer
S.Lahiri
H.Kobata
L.Guimaraes
JͲHHong
A.Razumovsky
N.Rezanejad
E.Rosenthal
S.
SuwatcharangͲ
koon
C.Williamson
B.
Witherspoon
M.Wright
Subarachnoid hemorrhage (overflow) – Kiosk 2
#
Time
196 5:29
198 5:43
199 5:50
201 6:04
207 6:46
Title
VolumetricanalysisofGlobalCerebralEdemaafterAneurysmalSubarachnoid
Hemorrhage:CorrelationswithInflammatoryMarkersandImpacton
Outcome
UltraͲearlycognitiverehabilitationinpatientswithhemorrhagicstrokeusing
anonlinecognitivetrainingprogram:AFeasibilitypilot
TheMotorComponentofGlasgowComaScalePredictsPoorOutcomeafter
SubarachnoidHemorrhage
StatinEffectsonOutcomesafterAneurysmalSubarachnoidHemorrhage
TissueOxygenIsNotaMonitorofCerebralBloodFlow
Presenting
Author
S.Bajgur
N.Dangayach
A.L.deOliveira
Manoel
S.Keegan
H.Yonas
SEPTEMBER 13
ePoster Presentations
196
Neurocrit Care
SEPTEMBER 13
Medical Issues in NeuroICU - Kiosk 3
#
Time
208 5:15
209 5:22
210 5:29
211 5:36
212 5:43
213 5:50
214 5:57
215 6:04
216 6:11
217 6:18
218 6:25
219 6:32
Title
Trendsinhospitalizationsamongadultswithacuteherpessimplexencephalitis
intheUnitedStates(2001Ͳ2010)
ValproicAcidasaTriggeringFactorforPropofolInfusionSyndromeinCritically
IllPatients
PulmonaryGlialCells:NovelMediatorsofInflammationfollowingAcuteLung
Injury
SympatheticExcessDrivesSystemicResponseSyndromeAfterBrainInjury
TheEffectofInhaledPulmonaryVasodilatorsonIntracranialHemodynamics
Zebrasthatwalkamongstus:achallengingcaseofDuralVenousSinus
Thrombosiswithheparinresistance.
UseofClevidipine(CleviprexÒ)tocontrolbloodpressure(BP)inpatientswith
intracerebralhemorrhage(ICH)andsubarachnoidhemorrhage(SAH)
UseofTolvaptantotreatSIADHͲinducedhyponatremiainselectedpatients
withacuteneurologicalinjuries
ThinkFast:EEGasanAdjunctiveMonitortoGuideHyperosmolarTherapyin
IntracranialHypertension?
PrevalenceofPentobarbitalAssociatedHypoxiaintheNeuroscienceIntensive
CareUnit
SevereNeurogenicMyocardialStunningFromColloidCystͲAnAlternative
MechanismForSuddenDeath
WheretoTargetCatheterAssociatedUrinaryTractInfectionPreventioninthe
NeurocriticalCareUnit
Presenting
Author
A.Asemota
K.Bledsoe
M.Buckwalter
KͲEChoi
C.Hopkins
A.Kumar
K.Polderman
K.Polderman
Z.Threlkeld
M.Zacchetti
S.Lahiri
E.Zink
Medical Issues in NeuroICU (overflow) - Kiosk 2
#
Time
197 5:36
200 5:57
203 6:18
206 6:39
Title
NeurocriticalCareofAdultswithFontanRepairofComplexCongenitalHeart
Disease:IdentifyingMechanismsforNeurologicMorbidityintheICU
OptimalCPPmanagementatbedside:medicalandnursingcompliancetoCPP
targetbasedoncontinuousevaluationofautoregulation
Outcomeofsimultaneoustracheostomyandpercutaneousendoscopic
gastrostomytubeplacementintheneurocriticalcareunit.
MultidisciplinaryQualityRoundsReduceCAUTIRatesInTheNSICU
Presenting
Author
E.Broomall
C.Dias
C.SanLuis
F.Steinkuller
Intracerebral hemorrhage – Kiosk 4
#
Time
220 5:15
221 5:22
222 5:29
223 5:36
224 5:43
Title
EffectofKcentra®(ProthrombinComplexConcentrate,PCC)onhematoma
expansioninintracranialhemorrhage
DiffusionͲWeightedImaging(DWI)AfterSpontaneousIntracerebral
Hemorrhage:ClinicalandTreatmentCorrelations.
MeasurementofExternalͲVentricularDrainTractHemorrhageintheCLEARͲIII
Trial:AComparisonofSemiͲQuantitativevs.ComputerizedQuantitative
Measurements.
ExtracorporealMembraneOxygenationandthebrain:findingsonintracranial
imaging.
FeverandICUAcquiredInfectionsareAssociatedwithProlongedMechanical
VentilationandTracheostomy.
Presenting
Author
C.Ahrens
L.DalfiorJr.
W.Freeman
V.Grover
L.McWilliams
Neurocrit Care
226 5:57
227 6:04
228 6:11
229 6:18
230 6:25
231 6:32
InͲHospitalOutcomesandResourceUtilizationafterIntraventricular
ThrombolysisinIntracerebralHemorrhageRequiringVentriculostomy:a
DecadeͲLongRealͲWorldExperience
PalliativeCareUtilizationinNonͲTraumaticIntracerebralHemorrhageinthe
UnitedStates
PresenceofHaptoglobinAlleleͲ2isAssociatedwithWorseFunctionalOutcomes
FollowingSpontaneousIntracerebralHemorrhage
HematomaLocationsPredictingDeliriumSymptomsAfterIntracerebral
Hemorrhage
GuidelineAdherenceandOutcomesinSpontaneousIntracerebralHemorrhage
INRReversalMoreFrequentlyAchievedinPatientsReceivingPCCͲ4vsPCCͲ3for
theTreatmentofWarfarinRelatedHemorrhages
Outcomesofelderlypatientswithsymptomaticsubduralhematomafollowing
surgicalevacuationorconservativetreatment
Y.Moradiya
S.Murthy
S.Murthy
A.Naidech
E.Owen
I.Rybak
M.Su
Intracerebral hemorrhage (overflow) – Kiosk 2
#
Time
194 5:15
195 5:22
202 6:11
204 6:25
205 6:32
Title
ClinicalOutcomesofMetastaticIntraͲcerebralHemorrhageandRoleofAcute
Radiotherapy
DelayedIntracerebralHemorrhageafterIrradiationofArteriovenous
MalformationinaPatientwithAtrialFibrillationonRivaroxaban
ComparisonofICHVolumeEstimationTechniquesinSpontaneous
SupratentorialIntracerebralHemorrhageofVaryingShapesandSites
DiffuseCerebralMicrohemorrhagesinapatientwithadultonset
Pompe’sDisease:Acasereport
DecompressiveHemicraniectomyinPrimaryIntracerebralHemorrhage
Presenting
Author
U.Afzal
F.Chaudhry
L.RiveraͲLara
D.Sandhu
S.Shah
Muscle and Nerve Disorders – Kiosk 5
#
Time
238 5:57
242 6:25
Title
RetreatmentoftheGuillainͲBarréSyndrome
PainfulCervicalLymphadenopathy,Eosinophilia,andHighEpsteinͲBarrViral
Load:AnUnusualPresentationofGuillainͲBarréSyndrome
Presenting
Author
M.Rubin
F.Chaudhry
Pediatric NeuroICU – Kiosk 5
#
Time
233 5:22
234 5:29
Title
AdaptationofApneaTestforBrainDeathDeterminationinPatientson
ExtracorporealMembraneOxygenation
AgeͲdependentdifferencesintheeffectofmicroglialinhibitionafterhypoxiaͲ
ischemiainthedevelopingbrain
Presenting
Author
N.Dean
P.Ferrazzano
Peri-Operative Management – Kiosk 5
#
Time
235 5:36
Title
AcoustoͲOpticCerebralBloodFlow(CBF)MonitoringDuringInductionof
AnesthesiainHumans
Presenting
Author
W.A.Kofke
SEPTEMBER 13
225 5:50
197
198
Neurocrit Care
SEPTEMBER 13
237 5:50
239 6:04
241 6:18
Safety,FeasibilityandClinicalOutcomeOfPatientsWhoUnderwent
V.Reddy
EnterpriseStentAssistedRepairOfIntracranialAneurysmUsingLoadingDose
OfAspirinAndClopidogrelͲaSingleCenterExperience
AcuteComaDuringCesareanSectionandEpiduralAnesthesia
P.Shirvalkar
TeachingInstitutionsͲImpactonCraniotomyMortality:aNationalAssessment G.Stenoien
onMeasuresofHealthCareQuality
Disorders of Consciousness – Kiosk 6
#
Time
244 5:15
245 5:22
246 5:29
247 5:36
248
249
250
251
252
5:43
5:50
5:57
6:04
6:11
253 6:18
254 6:25
255 6:32
Title
EvolutionandclinicalrelevanceofreactivityandcontinuityofEEGbackground
inCardiacArrestPatientsTreatedwithTherapeuticHypothermia
EffectofAdvancedComaEvaluationandCareformedicaleducation:A
proposalofanoveltrainingsystemforneurologicalemergencies.
Anatypicalpresentationofanatypicalsyndrome:AnearlyͲfatalcaseof
HaNDL:SyndromeofTransientHeadacheandNeurologicDeficitswith
CerebrospinalFluidLymphocytosis:ACaseReport
AlbuminocytologicDissociationinPosteriorReversibleEncephalopathy
Syndrome
Decreasedgrowthofarachnoidcellsexposedtofibroblastsandbilirubin
InterraterReliabilityofPupillaryAssessmentsAmongPhysiciansandNurses
NonͲherpeticacutelimbicencephalitis:ACaseSeriesandReview
EventͲRelatedPotentials:ComatosePatientsandPredictionofAwakening
EEGGammaBandEnergyasanOutcomeIndicatorafterCardiacArrestinan
AnimalModel
ACaseofPeroxysmalSympatheticHyperactivityduetoBasilarArtery
Dissection
RecoveringConsciousnessinComatoseSurvivorsofCardiacArrestwith
Seizures:EEGMarkersRevisited
EyeͲOpeningMyoclonusisaPoorPrognosticSignafterCardiacArrest.
Presenting
Author
S.Agarwal
Y.Ajimi
M.A.Babi
S.Datar
C.Miller
D.Olson
A.Rizvi
S.Shepherd
D.Sherman
H.Kobata
B.Waterhouse
J.Whitlock
Disorders of Consciousness (overflow) – Kiosk 5
#
Time
232 5:15
236 5:43
240 6:11
243 6:32
Title
Structuralinjuryandtimetorecoveryofconsciousnessfollowinghemorrhagic
stroke
StimulantUsetoImproveWakefulnessFollowingBrainInjuryintheNeuroͲ
ICU.ResultsofanOnͲLineSurveyThroughtheNeurocriticalCareSociety
TransorbitalSonographicEvaluationofNormalOpticNerveSheathDiameter
inHealthyNepaleseAdults
UseofSanguinateinencephalopathyfromseveresicklecelldiseaseanemia
Presenting
Author
J.Claassen
J.Peoples
G.Shrestha
P.Varelas
Seizures – Kiosk 7
#
Time
256 5:15
257 5:22
Title
SurvivingcardiacarrestdespitethepresenceofmalignantEEGpatterns:acase
series
ProposalforaProspective,SingleCenter,Randomized,Controlled,PilotStudyto
EvaluatetheFeasibility,EffectivenessandSafetyofContinuousIntravenous
Presenting
Author
E.Amorim
I.DeJesus
Neurocrit Care
260 5:43
261 5:50
262 5:57
263 6:04
264 6:11
265 6:18
266 6:25
267 6:32
InsulinInfusionasAddͲOnStrategytoStandardTreatmentforRefractoryStatus
EpilepticusinAdults
SeizuresandEpileptiformDischargesinHepaticDysfunction
ShouldaKetogenicDietbeConsideredEarlierintheTreatmentCourseof
AdultswithSuperͲrefractoryStatusEpilepticus?
Race,AnoxicBrainDamage,HypothermiaandMetabolicAbnormalitiesare
AssociatedwithStatusEpilepticusinPatientsPostCardiacArrest:Findingsfrom
theNationwideInpatientSample(NIS)2011Database
TheimpactofcontinuousEEG(cEEG)monitoringonoutcomesinpatients
admittedtoICU:Aprospectiveobservationalstudy
SuccessfulTreatmentofProlongedRefractoryStatusEpilepticuswithPlasma
ExchangeandRituximab
ShortͲActingNeuromuscularBlockadeinPatientsWithPostͲAnoxicMyoclonus
ImprovesContinuousElectroencephalograph(cEEG)Recordings
SubtherapeuticLevetiracetamConcentrationsinTraumaticBrainInjuryPatients
RequiringPostͲTraumaticSeizureProphylaxis
TheSignificanceofEquivocalVersusUnequivocalEEGPatternsinCardiacArrest
NonconvulsiveSeizuresinsubarachnoidhemorrhagelinkinflammationand
outcome
ThePrognosticSignificanceofMyoclonusafterCardiacArrest
J.Guth
R.Hakimi
N.Jadeja
A.Khawaja
N.Madisi
C.Newey
F.Sadaka
N.
Tabibzadeh
J.Claassen
T.Youn
SEPTEMBER 13
258 5:29
259 5:36
199
SUBARACHNOID HEMORRHAGE
200
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RANDOMIZED CONTROLLED TRIAL OF THE CEREBROVASCULAR HEMODYNAMIC EFFECTS OF
SIMVASTATIN IN STATIN NAïVE PATIENTS WITH ACUTE SUBARACHNOID HEMORRHAGE
Michael N Diringer1, Raj Dhar1, Allyson R Zazulia1
1
Washington University, St Louis, MO, USA, 2Washington University, St. Louis, MO, USA, 3Washington University,
St. Louis, MO, USA
Introduction
Statins may be a promising therapy after SAH and act through several mechanisms, including upregulation of
eNOS promoting vasodilation and increasing CBF. We sought to determine if the initiation of statin therapy after
acute SAH increases CBF and the response to induced hypertension during the peak period of risk for delayed
cerebral ischemia (DCI).
Methods
Statin naïve patients admitted < 3 days of aneurysmal SAH with WFNS 2 were eligible. They were randomly
assigned to receive 80 mg simvastatin/day or placebo for 21 days. On post SAH day 7-9 CBF, metabolism
(CMRO2) and oxygen extraction (OEF) were measured with PET before and after raising MAP by 25±5%.
Angiography was performed ±24 hours of PET. Cerebrovascular resistance (CVR) (MAP/CBF) and autoregulatory
index (AI) (%ǻMAP/%ǻCVR) were calculated; AI 2 was considered normal. Clinical DCI, hospital disposition and
90 day modified Rankin Scale score were recorded. Results are presented as simvastatin vs. placebo, CBF and
CMRO2 in ml/100g/min and MAP in mmHg
Results
We studied 13 patients in the simvastatin and 12 in the placebo groups 8.6±1.3 and 8.0±1.8 days after SAH. Age
was similar (59±12 vs. 60±10 years); there were fewer poor grade (WFNS 3-5) patients in the statin group
(13%; 42%; p=0.28). Baseline MAP was 110±10; 110 ± 12. Global CBF, OEF and CVR did not differ (40 ± 12;
43±13); (0.35±0.08; 0.37±0.11); (3.00±1.0; 2.81±1.0). At MAP of 135±7;137± 5 mmHg, global CBF, OEF and
CMRO2 did not change in either group. AI did not differ; 1.39±0.90; 1.32±0.80. Two patients in each group had AI
slightly above the upper limit of normal (2.2-3.6). Moderate or worse angiographic vasospasm was present in 42%
vs.45%; DCI developed in 14%; 55% (p=0.074). Good outcome (mRS 0-2) occurred in 75% vs. 80%.
Conclusions
We conclude that statins may reduce DCI after SAH but do not act via a cerebrovascular hemodynamic
mechanism.
Financial Support: NIH P50 NS055977
201
ePoster 183
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PATIENT-POWERED REPORTING OF MODIFIED RANKIN SCALE OUTCOMES VIA THE INTERNET: A VALID
ALTERNATIVE TO THE TELEPHONIC STRUCTURED INTERVIEW
Shouri Lahiri1, Emma Meyers1, Fawaz Al-Mufti1, Jan Claassen1, Stephan Mayer2
1
Columbia University Medical Center, New York, NY, USA, 2Icahn School of Medicine at Mount Sinai, New York,
NY, USA
Introduction
The modified Rankin scale (mRS) is the most common measure of functional outcomes in stroke-related
conditions. This resource intensive assessment requires multiple one-on-one encounters with trained personnel to
follow long-term functional outcomes. We hypothesized that a simple, rapid, on-line survey completed by a patient
or surrogate could generate an accurate mRS score compared to trained personnel in patients discharged after
subarachnoid hemorrhage (SAH).
Methods
51 SAH patients were consented and included in the study. The survey (ranging from 2-14 questions) had an
adaptive hierarchical design to minimize the number of responses required to generate the mRS score.
Patient/surrogate self-reported mRS scores were compared to the mRS scores obtained by trained personnel via
telephonic structured interview. Assessments occurred at 14, 90, or 365 days. A weighted kappa (kw) was
calculated.
Results
The kw between patient/surrogate and trained personnel scores was 0.85 (p< 0.001). Patients responded directly
to the survey 53% of time; surrogates responded 47% of the time. 41% had a survey mRS of 0, 27% had a 1, 14%
had a 3, 12% had a 4, 4% had a 5. 59% were Hunt Hess (HH) 1-2, 20% HH 3, and 21% HH 4-5. Age range was 19
to 83. Exact agreement occurred in 71% of cases. 53% of disagreements occurred with surrogate entries. 80% of
surveys were completed in less than 5 minutes.
Conclusions
In this sample of SAH patients, there was very good inter-rater reliability between the patient/surrogate group and
trained personnel group. The percent of exact agreements (71%) is similar to previously published studies of interobserver reliability using similar interview methodology. The results of our study suggest that patient/surrogate
survey responses can reliably and efficiently generate mRS scores compared to trained personnel after SAH and
other forms of stroke.
Financial Support: None
SUBARACHNOID HEMORRHAGE
Neurocrit Care
SUBARACHNOID HEMORRHAGE
202
Neurocrit Care
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OUTCOME OF WFNS GRADE V SUBARACHNOID HEMORRHAGE. DO GCS 3 PATIENTS FARE WORSE
THAN GCS 4 TO 6 PATIENTS?
Hitoshi Kobata, Akira Sugie, Erina Yoritsune, Koji Takeuchi
Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan
Introduction
Owing to the recent advance of emergency medical system, moribund subarachnoid hemorrhage (SAH) patients
have a chance to be rescued when they arrive immediately after onset. According to the World Federation of
Neurological Surgeons (WFNS) committee, Glasgow Coma Scale (GCS) of 3 to 6 are classified into Grade V,
however, little is known whether patients with lower GCS score fare worse or not in Grade V category.
Methods
A consecutive series of 190 WFNS V SAH patients since 2002 were retrospectively reviewed to analyze their
Glasgow Outcome Scale (GOS) at 6 months in relation to their admission GCS score and other clinical parameters.
All of these patients were sedated and intubated immediately after arrival.
Results
The patients distribution in accordance with the GCS scores in descending order from 6 to 3 was: 50, 22, 27, and
91, respectively, and aneurysm obliteration was completed in 45, 21, 17, and 61, respectively, with 139 of them by
clipping. The median time form onset to arrival was 38 minutes in 140 patients in whom onset time was identified.
Rate (%) of good recovery (GR)/moderate disability (MD) was 9.9/13.2, 0/18.5, 4.6/27.3, 14.0/16.0, respectively.
There was no difference in favorable outcome (GR + MD) by the GCS score, but GR ratio was higher in GCS 3 and
6 subgroup compared with GCS 4 and 5 subgroup (p=0.037, Fisher's exact test). Parameters associated with
favorable outcome were younger age (p=0.0005), presence of light reaction (p=0.033), absence of
cerebral/intraventricular hematoma (p=0.018), low serum d-dimer level (p=0.0032), and shorter time from onset to
arrival (p=0.036) (Student's t-test). No patients arrived after 100 minutes or later after SAH onset had favorable
outcome.
Conclusions
GR ratio was higher in GCS 3 and 6 subgroup than that of GCS 4 and 5 subgroup for those arrived very early after
onset.
Financial Support: None
203
ePoster 185
___________________________________________________________________________________
SPONTANEOUS SUBARACHNOID HEMORRHAGE (SSAH) CASES ADMITTED IN A NEUROCRITICAL
INTENSIVE AND INTERMEDIATE CARE UNIT IN 2 YEARS
Luisa E. Guimaraes1, Claudia Rosado2, Sofia R Silva3, Elisabete Monteiro3, Celeste Dias3, Jose A Paiva3
1
Centro Hospitalar Póvoa de Varzim/Vila do Conde, Vila do Conde, Portugal, 2Centro Hospitalar Baixo Vouga,
Aveiro, Portugal, 3Centro Hopitalar São João, Porto, Portugal
Introduction
Our aim was to evaluate patients with SSAH with admittance in a neurocritical intensive and intermediate care unit
and trying to understand which factors at admission have an impact in the outcome and time of stay in unit and
also to document if our population of patients corresponds to what has already been published.
Methods
In this work we've characterized our population of SSAH in the years of 2012 and 2013. To complete this task we
made a retrospective study and analyzed the data using SPSS (Statistical program for social sciences version 20)
using the appropriate statistical test depending on the variables used.
Results
We've found that our sample was composed of 90 cases mainly of women (62,2%), aneurism was the etiology in
74,4% of cases and we had only one case of arterial-venous malformation. The most frequent complications were
hydrocephalus 37,7% and vasospasm 29,9%, an intra ventricular hemorrhagic component existed in 52,3% of all
cases, 30% were submitted to endovascular treatment and 30% were submitted to aneurism clipping, 40% had a
Glasgow coma scale (GCS) at admittance of 15. Ten patients passed away and these were older, had a higher
probability of death according SAPSII score, lower GCS and less time spent in unit (p< 0,05), we verified that there
was no difference between the alive and dead groups concerning the time between the onset of symptoms and the
first medical observation and the time from the first medical observation until hospital admittance.
Conclusions
In sum our study shows similar results to those found on literature concerning gender, age and etiology. Scores
used namely Hunt & Hess, Fischer, GCS and SAPS II and III were able to predict higher risk of mortality. Timing of
medical observation and admittance may have less importance in the outcome than would be expected.
Financial Support: None
SUBARACHNOID HEMORRHAGE
Neurocrit Care
SUBARACHNOID HEMORRHAGE
204
Neurocrit Care
ePoster 186
___________________________________________________________________________________
PROTOCOL BASED REAL-TIME CONTINUOUS ELECTROENCEPHALOGRAM FOR DETECTING
VASOSPASM IN SUBARACHNOID HEMORRHAGE
Jeong-Ho Hong1, Moon-Ku Han2, Kwang-Soo Lee3
1
Keimyung University Dongsan Medical Center/Department of Neurology, Daegu, South Korea, 2Seoul National
University Bundang Hospital/Department of Neurology, Gyeonggido, South Korea, 3The Catholic University of
Korea/Department of Neurology, Seoul, South Korea
Introduction
Continuous electroencephalogram (cEEG) can be helpful to detect for vasospasm and delayed cerebral ischemia
in aneurysmal subarachnoid hemorrhage (SAH). We describe a patient with vasospasm detected very early using
real-time cEEG in aneurysmal SAH and treated by successful chemical angioplasty.
Methods
A 50-year-old woman without any past medical history presented with a severe bifrontal headache, which was
found to be due to SAH with ruptured aneurysm on anterior communicating artery (Fisher grade 3). cEEG and daily
transcranial doppler (TCD) for detecting vasospasm were carried out from post-bleed day (the first day of SAH is
day 0) 5 to 9 according to predetermined cEEG protocol. Our cEEG protocol for vasospasm is as follows; 1) cEEG
monitoring was performed using a 21 electrode longitudinal bipolar montage according to the international 10-20
system. 2) Check the real-time quantitative cEEG (ADR, alpha power, delta power, amplitude EEG and density
spectral array) at least every 2 hours during the working time, 3) Send captured quantitative cEEG monitor screen
without any kind of patient's information to neurointensivist every 2 hours during the non-working time, 4) Be
focused on F3-C3/F4-C4 and C3-P3/C4-P4 in AcoA aneurysm, C3-P3/C4-P4 in MCA bifurcation and C3-P3/C4-P4
and P3-O1/P4-O2 in posterior communicating artery.
Results
On bleed day 6, progressive decrement of ADR on the left side (especially more decrease in C3-P3 than F3-C3)
compared to the right was detected using the regular checking-up of the real-time quantitative cEEG. After then,
neurointensivist checked immediately her neurologic status. She developed global aphasia and left hemiparesis
because of vasospasm. Stat chemical angioplasty was performed and she recovered without any significant
neurologic deficit and discharged at home.
Conclusions
Real-time and protocol based cEEG can reduce the detection time of vasospasm in aneurysmal SAH and also
improved clinical outcome.
Financial Support: None
205
ePoster 187
___________________________________________________________________________________
ROLE OF TRANSCRANIAL DOPPLER IN THE MANAGEMENT OF WAR-TIME TRAUMATIC BRAIN INJURY
Alexander Razumovsky1, Teodoro A Tigno2, Efim Kouperberg1, Randy S Bell2, Meryl A Severson2, Scott A
Marshall3, Francis L McVeigh4, Rocco A Armonda5
1
Sentient NeuroCare, Hunt Valley, MD, USA, 2Walter Reed National Military Medical Center, Bethesda, MD, USA,
Uniformed Services University of the Health Sciences, Bethesda, MD, USA, 4Telemedicine&Advanced Technology
Research Center, Fort Detrick, MD, USA, 5Georgetown University Hospital, Washington, DC, USA, 6,
3
Introduction
Cerebral vasospasm (VSP) is a frequent complication after traumatic brain injury (TBI) and carries significant
morbidity and mortality. TBI is associated with the severest casualties from Operation Iraqi Freedom and Operation
Enduring Freedom. The purpose of this study was to evaluate the transcranial Doppler (TCD) determined incidence
of posttraumatic cerebral vasospasm (VSP) and intracranial hypertension (ICH) after wartime TBI patients admitted
to WRNMMC.
Methods
Patients were identified using a computerized registry and a prospective TCD database. TCD recordings of mean
Cerebral Blood Flow Velocities and Pulsatility Indices of the anterior and posterior circulation vessels were
recorded using a 2-MHz transducer (Doppler Box, DWL/Compumedics, Germany). 122 patients were investigated
with daily TCD studies and comprehensive TCD protocol and published diagnostic criteria for VSP and ICH were
applied.
Results
TCD signs of mild, moderate and severe VSP involving anterior circulation vessels were observed in 71%, 42%
and 16% of patients, respectively. TCD signs of mild, moderate and severe VSP involving posterior circulation
vessels were observed in 57%, 32% and 14% of patients, respectively. TCD signs of ICH were recorded in 43%,
eight patients (7%) underwent transluminal angioplasty for post-traumatic symptomatic VSP treatment.
Conclusions
These findings demonstrate that VSP and ICH are frequent complications of combat TBI, therefore daily TCD
monitoring is recommended for their recognition and subsequent management. Acknowledgements: The opinions
and views expressed herein belong solely to those of the authors. They are not nor should they be implied as being
endorsed by the Uniformed Services University of the Health Sciences, Department of the Army, Department of the
Navy, Department of Defense or any other branch of the Federal government of the United States. This paper
supported in part, by the US Army Medical Research and Material Command's Telemedicine and Advanced
Technology Research Center (Fort Detrick, MD, USA).
Financial Support: I am full-time employee for private practice
SUBARACHNOID HEMORRHAGE
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___________________________________________________________________________________
ROUTINE DEPRESSION SCREENING IS FEASIBLE IN SUBARACHNOID HEMORRHAGE PATIENTS
Nasim Rezanejad1, Suhas S Bajgur1,2, Kim Yen Thi Vu3, Ranier G. Reyes1, Rahul R Karamchandani2, Janete
Sheiner3, Christine Glendening3, Nancy J Edwards1,2, Tiffany R Chang1,2, Kiwon Lee1,2, Nicole Harrison3, Sean I
Savitz2, H. Alex Choi1,2
1
University of Texas Health Science Center /Department of Neurosurgery, Houston, TX, USA, 2University of Texas
Health Science Center/Department of Neurology, Houston, TX, USA, 3Mischer Neuroscience Institute, Houston,
TX, USA
Introduction
Depressive symptoms may contribute to quality of life after subarachnoid hemorrhage (SAH). The joint commission
has emphasized the importance of screening for depression in the acute setting after SAH. The prevalence and
risk factors for depressive symptoms acutely after SAH have not been well described. In this study, we assessed
the feasibility of routine depression screening in SAH patients.
Methods
This is a retrospective study of patients admitted with SAH between February 2013 and December 2013 at a
tertiary academic institution. Eligible patients were screened by social workers for depression using the modified
Patient Health Questionnaire-9 (PHQ-9) 24-48 hours before discharge. We defined a score of >4 as having
significant depressive symptoms. In patients who had depressive symptoms, patient education about depression
was performed.
Results
Out of the 134 patients admitted during the time period, 113(84%) were eligible to be screened. 21 patients were
not screened because of death, comfort care measures only or intubated on discharge. Out of those eligible, 75
patients (66%) were screened for depression. Of patients those who were screened, 32 (46.67%) were positive for
depressive symptoms. The median (IQR) on the mPHQ-9 was 4 (2-8, range 0-20). Age, Hunt-Hess, sex, ethnicity,
fisher scale were not significantly associated with depressive symptoms. Screening positive for depression trended
towards an association with ICU length of stay more than 8 days (OR 2.375, P= 0.09). mPHQ-9 scores correlated
with hospital length of stay (r= 0.250, p = 0.03). Screening positive for depression was not significantly associated
with functional status at discharge.
Conclusions
It is feasible to perform routine depression screening in patients with SAH in the acute setting. Depressive
symptoms are common and may be associated with length of stay in the hospital. Further studies examining the
impact of early depressive symptoms on long term clinical outcomes after SAH should be performed.
Financial Support: None
207
ePoster 189
___________________________________________________________________________________
PERFORMANCE OF CONTINUOUS ELECTROENCEPHALOGRAPHY (CEEG) ISCHEMIA MONITORING IN
CLINICAL PRACTICE FOR THE PROSPECTIVE DETECTION OF NEUROLOGIC DECLINE FOLLOWING
SUBARACHNOID HEMORRHAGE (SAH)
Eric S. Rosenthal, Kathryn L. O'Connor, Sahar F Zafar, Siddharth Biswal, M. Brandon Westover
Massachusetts General Hospital, Boston, MA, USA
Introduction
A variety of cEEG features have demonstrated retrospective accuracy for detecting post-SAH delayed ischemic
neurologic decline (DIND) or delayed cerebral infarction (DCI). We evaluated the performance of a clinical
neurophysiologist reporting cEEG prospectively as part of a SAH clinical practice guideline at our institution.
Methods
Nontraumatic Hunt-Hess Grade 4-5 or Fisher Group 3 SAH patients met inclusion criteria for the clinical cEEG
ischemia monitoring guideline. cEEG was scored in the clinical neurophysiology report for the prospective
determination of the following features prior to DIND/DCI: 1) new percent alpha variability decline, 2) new alphadelta ratio decrement or asymmetry, 3) new focal slowing, 4) new epileptiform discharges, or 5) a new subjective
impression of focal electrographic worsening. DIND and DCI events were prospectively recorded by a research
coordinator interviewing the neurocritical care team with subsequent adjudication and secondary review of the
electronic medical record for DIND/DCI events occurring after the first day of cEEG monitoring and before cEEG
discontinuation. The maximal peak systolic velocity (PSV) measured during daily clinical transcranial Doppler
ultrasonography (TCD) was also recorded.
Results
52 patients underwent cEEG ischemia monitoring over 12 months; 25% (13) developed DCI/DIND. Worsening in
any cEEG feature was 76% sensitive for predicting DCI/DIND; upon logistic regression, no single feature
contributed to the majority of detections. PSV>200 cm/s, criteria for sonographic vasospasm within our vascular
laboratory, provided similarly high sensitivity (69%); however, cEEG or TCD alone provided a low positive
predictive value for DCI/DIND (PPV, respectively 34% and 26%). A combined criteria maintained sensitivity (69%)
for DIND/DCI while improving PPV (71%).
Conclusions
Prospective clinical cEEG ischemia monitoring and reporting affords sensitive detection of DCI and DIND.
Concordant findings of cEEG worsening during sonographic vasospasm increase the confidence that DCI or DIND
will ensue. These electrophysiologic criteria for SAH ischemia detection may provide useful selection criteria for
clinical trials of early interventions.
Financial Support: Dr. Rosenthal's research was supported by the Andrew David Heitman Foundation for
Neuroendovascular Research. Dr. Westover was supported by a grant from the American Brain Foundation.
SUBARACHNOID HEMORRHAGE
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ePoster 190
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SAH PATIENTS WITH FOCAL PROCESSES LEADING TO ELEVATED INTRACRANIAL PRESSURE
RESPONDS BETTER TO HYPERTONIC SALINE THAN THOSE WITH GLOBAL PROCESSES
Sureerat Suwatcharangkoon1, Jens Witsch2, J. Michael Schmidt2, Sachin Agarwal2, Stephan A. Mayer3, Jan
Claassen2
1
Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, 2Neurocritical Care,
Department of Neurology, Columbia University Medical Center, New York, NY, USA, 3Institute for Critical Care
Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Introduction
Hypertonic saline (HTS) is widely used to treat elevated intracranial pressure (ICP) but duration and extent of the
intervention are poorly understood.
Methods
We studied 23 consecutive subarachnoid hemorrhage (SAH) patients that underwent multimodality monitoring and
had ICP data available while receiving HTS. We compared the effect of 23.4% or 14.6% HTS on ICP in those with
global cerebral edema (GCE) and midline shift. Patients were treated with 23.4% vs 14.6% based on pharmacy
availability and not due to medical reasons. We used generalised estimating equations to assess relationships
among variables over time.
Results
We identified 81 episodes of ICP crisis leading to administration of HTS (49 with 23.4% and 32 with 14.6%). Mean
age was 47+12 years, median admission Glasgow Coma Scale score was 5 [3-14] and median recorded time was
465 [147-1310] hours. Following HTS administration, mean ICP reduced from 26 mmHg at treatment to 13 mmHg
and 8 mmHg within 30 and 60 minutes, respectively. When GCE was present (72 events [89%]), ICP reduced
significantly less (P=0.001) in the 90 minutes following HTS administration. Within 15 minutes of treatment mean
ICP in GCE patients decreased to 19 mmHg compared to 13 mmHg and 9 mmHg compared to 6 mmHg after an
hour respectively. In contrast patients with midline shift (50%: 3 mm, 25%-75%: 0.1-10.2mm) did not significantly
affect the effectiveness of HTS administration to lower ICP. No differences in ICP reduction were observed
between 23.4% and 14.6% sodium chloride administration.
Conclusions
Hypertonic saline effectively reduced ICP within 60 minutes. SAH patients without GCE tended to respond better to
HTS therapy than those with GCE.
Financial Support: None
209
ePoster 191
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SPONTANEOUS HYPERVENTILATION IS COMMON IN SUBARACHNOID HEMORRHAGE AND ASSOCIATED
WITH DELAYED CEREBRAL ISCHEMIA AND POOR FUNCTIONAL OUTCOME
Craig Williamson1, Kyle Sheehan1, Renuka Tipirneni2,3, Jeff Fletcher1, Venkatakrishna Rajajee1
1
University of Michigan Department of Neurosurgery, Ann Arbor, MI, USA, 2University of Michigan Robert Wood
Johnson Clinical Scholars Program, Ann Arbor, MI, USA, 3University of Michigan Department of Internal Medicine,
Division of General Medicine, Ann Arbor, MI, USA
Introduction
Spontaneous hyperventilation (SH) can occur in acute brain injury, but the incidence of SH following subarachnoid
hemorrhage (SAH) is unknown. Hyperventilation decreases cerebral blood flow and therefore may worsen delayed
cerebral ischemia (DCI). This study was conducted to determine the incidence of SH in SAH and its association
with DCI and functional outcome.
Methods
Consecutive subjects (1/2010-3/2014) were identified from a prospective registry of spontaneous SAH patients and
assessed for the presence of SH. SH was defined as pCO2< 35mmHg and pH>7.45 in the presence of normal pO2
(>70mmHg) while breathing spontaneously or overbreathing the ventilator. Bivariate logistic regression was
conducted to determine clinical characteristics that are significantly associated with SH. Multivariable logistic
regression analyses were performed to determine the association of SH with DCI and poor functional outcome,
which was defined as discharge modified Rankin scale (mRS)>3.
Results
Of 317 subjects, 207 with arterial blood gas analyses obtained while breathing spontaneously or overbreathing the
ventilator were included in the study. Of these, 113 (55%) had SH, 66 (32%) experienced DCI and 112 (54%) had
poor discharge outcome. The following characteristics were significantly associated with SH in bivariate analysis
(odds ratio, [95% confidence interval]): pneumonia 3.5 (1.8-7.0); neurogenic myocardial injury 2.2 (1.2-4.1);
perimesencephalic SAH etiology 0.2 (0.1-0.7); WFNS 1.4 (1.1-1.7); Hunt-Hess 1.6 (1.2-2.1); DCI 3.5 (1.8-6.6); poor
discharge mRS 3.0 (1.7-5.4). In a multivariable logistic regression analysis adjusting for age, gender, WFNS,
Hjidra, and SAH etiology, SH was significantly associated with DCI (3.4, 1.7-6.8). SH was additionally associated
with poor discharge outcome, after adjusting for age, gender, pneumonia, neurogenic myocardial injury, WFNS,
Hjidra and DCI (2.5, 1.1-5.8).
Conclusions
Spontaneous hyperventilation is common following SAH and is associated with DCI and poor discharge outcome.
Further study is needed to determine the pathophysiology underlying this association
Financial Support: None
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SEVERE CEREBRAL VASOSPASM IN A PATIENT WITH A TRAUMATIC SUBARACHNOID HEMORRHAGE
Briana Witherspoon, Justin Calabrace
Vanderbilt University Medical Center Department of Critical Care Anesthesia, Nashville, TN, USA
Introduction
Angiographic evidence of severe cerebral vasospasm along with focal neurological deficits in nonaneurysmal
subarachnoid hemorrhage patients is a rare occurrence. Despite trauma being the most common cause of
subarachnoid hemorrhage, there is minimal information available on vasospasm in this particular population. This
case presents a unique clinical situation where a patient suffered from unrelenting vasospasm ultimately resulting
in a right frontal infarct.
Methods
A 52-year-old female underwent an elective surgery for removal of nasal polyps at an outside facility. While in
recovery, the patient complained of severe headache that was accompanied by nausea and vomiting. The patient
was discharged home the same day, and over the course of the next week continued to have severe persistent
headaches. Four days after surgery she presented to a local ED where her head CT revealed bilateral
subarachnoid hemorrhage. She was then transferred to the neuro intensive care unit at our tertiary care center.
Upon arrival the patient was noted to have left sided weakness and facial droop. She was taken emergently for an
angiogram where severe bilateral ACA spasm and right MCA emboli were noted, so intra-arterial tPa, abciximab
and verapamil were subsequently administered. Her post-operative course was complicated by right frontal
ischemic stroke, continued bilateral ACA and MCA vasospasm requiring a second angiogram with intra-arterial
verapamil, placement of a central line, and induced hypertension requiring a norepinephrine infusion.
Results
After a prolonged hospital course, the patient was discharged with minimal functional deficits.
Conclusions
Critical care providers must remember vasospasm in this patient population is characterized by a different onset
and duration, and possible pathogenesis when compared to aneurysmal subarachnoid hemorrhage patients.
Financial Support: None
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SIMVASTATIN VERSUS PRAVASTATIN FOR THE PREVENTION OF VASOSPASM AFTER ANEURYSMAL
SUBARACHNOID HEMORRHAGE
Matthew Logan Wright, PharmD, BCPS1, Jennifer Bushwitz, PharmD, BC1, Spiros Blackburn, MD2
1
UF Health Shands Hospital/Dept of Pharmacy, Gainesville, FL, USA, 2UF Heath Shands Hospital/Dept of
Neurosurgery, Gainesville, FL, USA
Introduction
Small clinical trials have demonstrated benefit with both simvastatin and pravastatin for the prevention of
vasospasm after aneurysmal subarachnoid hemorrhage (aSAH). Simvastatin was the agent of choice at our
institution, but concerns related to high dose simvastatin use caused a shift in practice to pravastatin in 2011. No
clinical trials to date have compared the efficacy of these agents for vasospasm prevention. Our aim was to
evaluate the comparative efficacy of simvastatin and pravastatin for vasospasm prevention.
Methods
Retrospective cohort study of patients admitted with Fisher grade 3 aSAH from August 2010 to August 2012. Daily
transcranial doppler (TCD) velocities were obtained in all patients. TCD vasospasm was defined using previously
published velocity cutoff values and Linegrad ratios. Radiographic vasospasm was defined as vasospasm on CT or
cerebral angiogram. Angiographic vasospasm was defined as vasospasm on cerebral angiogram only.
Results
Fifty-eight (60.4%) of 69 patients included experienced TCD vasospasm in any cerebral artery. Thirty-one (54.5%)
patients were in the pravastatin cohort vs 27 (61.4%) in the simvastatin cohort (P = 0.86). No difference in the
incidence of middle cerebral artery (MCA) vasospasm among the pravastatin and simvastatin cohorts was found
(46.2% vs 43.2%; P = 0.77), although the median left MCA velocity was statistically higher in the simvastatin cohort
(102 vs 87; P = 0.001). No statistically significant differences were found between the two groups as it relates to
radiographic vasospasm, angiographic vasospasm, time to any vasospasm, hospital length of stay, ICU length of
stay, or in-hospital mortality.
Conclusions
No clinically significant differences were observed between simvastatin and pravastatin. There was a statistically
higher median left MCA velocity in the simvastatin cohort, but it did not correlate with a higher incidence of MCA
vasospasm. Further randomized, controlled clinical trials are needed to establish the comparative efficacy of
available agents.
Financial Support: None
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VOLUMETRIC ANALYSIS OF GLOBAL CEREBRAL EDEMA AFTER ANEURYSMAL SUBARACHNOID
HEMORRHAGE: CORRELATIONS WITH INFLAMMATORY MARKERS AND IMPACT ON OUTCOME
Suhas S Bajgur1,2, Kaushik N Parsha2, Nasim Rezanejad1, Sang-Bae Ko3, Georgene W Hergenroeder1, Ranier G
Reyes1, Dong H Kim1, Tiffany R Chang1,2, Nancy J Edwards1,2, Kiwon Lee1,2, Sean I Savitz2, H Alex Choi1,2
1
University of Texas Health Science Center at Houston/Department of Neurosurgery, Houston, TX, USA,
University of Texas Health Science Center at Houston/Department of Neurology, Houston, TX, USA, 3Seoul
National University/Department of Neurology, Seoul, South Korea
2
Introduction
Early brain injury (EBI) after subarachnoid hemorrhage (SAH) is the most important determinant of clinical
outcome. Global cerebral edema (GCE) is a manifestation of EBI after SAH and is an independent risk factor for
poor outcome. The inability to quantify GCE has limited further investigations into pathomechanisms of GCE after
SAH.
Methods
Patients with SAH were enrolled into a prospective observational database. Initial CT scans were graded for the
presence or absence of GCE in a qualitative manner using established criteria. Volumetric analysis of sulcal space
and cisternal blood volume was performed using MIPAV (Medical Image Processing, Analysis and Visualization
Ver 7.0.1). Selective sulcal volume (SSV) was defined as total mL of sulcal volumes on axial CT slices from above
the most cranial section of the lateral ventricles to the last visible section. Automated contour selection tool in
MIPAV was used to measure areas of sulci and cisternal blood. Venous blood was collected within 48 hours of
admission. Cytokines levels were measured by a multiplexed bead array assay.
Results
A total of 97 patients with volumetric and cytokine analysis were included in this study. Mean age was 51(±14
years), 69/97(68%) were female. 83% were Fisher 3 with a median HH score of 3. 23/97(24%) had GCE. Mean
sulcal volumes differed between patients with GCE and without GCE (5.5ml v 24ml; p< 0.01). SSV correlated
negatively with serum IL-6 (r=-0.41;p=0.01). Volume of total intracranial blood (r= 0.45; p< 0.01) and cisternal blood
(r=0.27, p=0.03) significantly correlated with serum IL-6. Lower SSV was an independent predictor of poor mRS
outcome at discharge (p=0.02) while controlling for age, gender, initial Hunt-Hess Grade and aneurysm size.
Conclusions
GCE can be objectively quantified using volumetric analysis of selective sulcal volume measurements. SSV was
negatively associated with serum IL-6 levels. Lower SSV was associated with worse outcomes after SAH.
Financial Support: None
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ePoster 198
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ULTRA-EARLY COGNITIVE REHABILITATION IN PATIENTS WITH HEMORRHAGIC STROKE USING AN
ONLINE COGNITIVE TRAINING PROGRAM: A FEASIBILITY PILOT
Neha S. Dangayach1, Emma Meyers1, Eric Wei1, Angela Velazquez1, Aoife Macmohan1, Leila Musavi1, Michael
Schmidt1, Christina Falo1, Agarwal Sachin1, Jan Claassen1
1
Columbia University Medical Center/Neurology, New York, NY, USA, 2Columbia University Medical
Center/Neurology, New York, NY, USA, 3Columbia University Medical Center/Neurology, New York, NY, USA,
4
Columbia University Medical Center/Neurology, New York, NY, USA, 5Columbia University Medical
Center/Neurology, New York, NY, USA, 6Columbia University Medical Center/Neurology, New York, NY, USA,
7
Columbia University Medical Center/Neurology, New York, NY, USA, 8Columbia University Medical
Center/Neurology, New York, NY, USA, 9Columbia University Medical Center/Neurology, New York, NY, USA,
10
Columbia University Medical Center/Neurology, New York, NY, USA
Introduction
Cognitive and behavioral problems continue to be important contributors to morbidity after SAH and ICH even in
patients with good neurological outcomes. Accumulating evidence demonstrates that early physical and cognitive
rehabilitation improve functional outcomes in stroke. Based upon their physiological stability patients may or may
not be able to participate in physical or occupational rehabilitation. We hypothesize that patients might be able to
participate in cognitive rehabilitation even in a bed-bound state while they are in the ICU.
Methods
After obtaining IRB approval, we started enrollment in April, 2014. Demographic, clinical, radiological, outcomes
data which are already being collected as part of two large prospective databases at our center; Subarachnoid
Hemorrhage Outcomes Project (SHOP) and Intracerebral hemorrhage Outcomes Project (ICHOP) will be utilized
for data collection. Only English speaking patients >=18 are currently eligible for enrollment. For online cognitive
training modules we are collaborating with Lumos labs. No patient information will be shared with Lumos labs.
Patients are screened every day for their ability to participate in a 20 minute training session till the time of their
discharge and are provided with login information at the time of discharge. Patients will be contacted via telephone
at 1, 3, 12 months post discharge to follow-up regarding their compliance
Results
We have enrolled 8 patients so far; five patients with SAH and three with primary ICH. 5/8 patients have been
successfully able to `participate in one or more sessions of ultra-early online cognitive training. 2/8 patients were
not able to participate due to seizures and sedation. One patient with SAH was not able to participate due to
refractory headaches
Conclusions
This is an on-going pilot study. Although there are some anticipated clinical challenges in implementing an ultraearly cognitive rehabilitation program in the ICU settings, our enrollment thus far suggests feasibility.
Financial Support: None
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THE MOTOR COMPONENT OF GLASGOW COMA SCALE PREDICTS POOR OUTCOME AFTER
SUBARACHNOID HEMORRHAGE
Airton Leonardo de Oliveira Manoel1,2, David Turkel-Parrella1,2, Ekaterina Kouzmina1, Alberto Goffi2,3, Tom
Marotta1,2, Menno Germans1,2
1
St. Michael's Hospital/Neuroscience Research Program, Toronto, ON, Canada, 2University of Toronto, Toronto,
ON, Canada, 3Toronto Western Hospital, Toronto, ON, Canada
Introduction
Poor-grade subarachnoid hemorrhage (SAH) is associated with high rates of disability and mortality. This study
addressed the value of the motor component of Glasgow Coma Scale (mGCS) to predict long-term functional
outcomes.
Methods
A consecutive cohort of poor-grade SAH patients (WFNS 4 and 5), admitted to a high-volume SAH center between
January 2009 and June 2013, were retrospectively assessed. Only patients who survived the first 24 hours after
admission were included. GCS was recorded at admission, after external ventricular drain (EVD) insertion and
hourly while the patient was in the intensive care unit. Functional outcome by the modified Rankin score
(mRS) was assessed at least 3 months after the hemorrhage.
Results
130 poor-grade SAH patients survived 24h, 50 had poor (mRS 3-6) and 80 had favorable outcome (mRS 0-2). The
poor outcome group had lower mean GCS (5 ±2.3 vs. 8 ±2.2, p< 0.01) and mean mGCS (2 ±1.5 vs. 4 ±1.3, p<
0.01) on admission. The mean mGCS after EVD insertion was lower in the poor outcome group (5 ±1.3 vs. 6 ±0.3,
p< 0.01). 98% of favorable outcome group achieved mGCS 5 within 72 hours. No patients with mGCS 3 at 24,
48 or 72h recovered to achieve a favorable outcome, therefore motor GCS < 4 yielded 100% specificity and 100%
positive predictive values for poor functional outcome. In the regression model, mGCS 4 at 72h was independent
associated with poor functional outcome (OR 25.2; 2.5-626.0 CI, p< 0.05).
Conclusions
Motor GCS < 4 after 24h of hemorrhage is highly specific for poor long-term outcome after SAH. Poor-grade SAH
patients who did not achieve a mGCS of 4 or greater after 24h of hemorrhage went on to have a poor outcome
despite aggressive treatment. This information could prove useful in prognosticating outcomes for individual
patients.
Financial Support: None
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ePoster 201
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STATIN EFFECTS ON OUTCOMES AFTER ANEURYSMAL SUBARACHNOID HEMORRHAGE
Shaun P. Keegan
University of Cincinnati Medical Center Department of Pharmacy Services, Cincinnati, OH, USA
Introduction
Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high rates of morbidity and mortality. Most
morbidity is attributed to cerebral ischemia occurring in up to 30% of patients mostly between days 4 and 10.
Multiple therapies have attempted to prevent or reverse ishcemia after aSAH. 3-hydroxyl-3-methylglutaryl
coenzyme a reductase inhibitors (statins) have had mixed results preventing cerebral ischemia. This study
compares patients exposed and not exposed to statins during hospital admission and effect on outcomes.
Methods
This was an IRB approved single center retrospective cohort study of aSAH patients greater than 18 years old that
received statins during admission (statin group) compared to those that did not (no statin group). The primary
outcome was incidence of new infarct on CT scan. Secondary outcomes included incidence of vasospasm by TCD
or angiography and Glasgow Outcome Score at follow up.
Results
33 patients were in the statin group and 83 were in the no statin group. The admission median GCS and median
WFNS scores were similar between groups (14 vs 14 p=0.53; 2 vs 2 p=0.47). There was a trend toward the statin
group spending more days in the hospital (14.4 vs 12.9 p=0.29). Rates of infarct on CT scan were similar between
groups (45% vs 35% p=0.4). Evidence of narrowing by TCD was similar between groups (58% vs 46% p=0.38).
Angiographic vasospasm was not different between groups (24% vs 22% p=0.96) Glasgow Outcome Score (n=96)
was also not different between groups.
Conclusions
This small retrospective study was unable to detect differences in outcomes between aSAH patients who did or did
not receive statins during hospital admission. The results of large randomized clinical trials are needed to
determine effects of statin therapy on outcomes in this patient population.
Financial Support: None
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TISSUE OXYGEN IS NOT A MONITOR OF CEREBRAL BLOOD FLOW
Howard Yonas, Mark Krasberg, Huy Tran, Omar Chohan, Pedro Ramirez, Andrew Carlson
University of New Mexico, Department of Neurosurgery, Albuquerque, NM, USA
Introduction
The state of both CBF and O2 reduction that results from a reduction of cerebral perfusion is associated with a
severe compromise of vascular reserve. It has been reported that there is a significant correlation between CBF
and tissue oxygenation, despite the fact that many variables can alter tissue oxygen. This study will examine the
premise that tissue oxygen values or changes can provide an insight into CBF values or changes.
Methods
In 68 patients post SAH, CBF (Hemedex) and tissue oxygen (Licox) were monitored concurrently. Both probes
were inserted in a fixed relationship and distance into the white matter via a duo Hummingbird bolt (Innerspace). All
data were collected and stored through a CNS monitor (Moberg Research). Analysis included a comparison of
paired values obtained simultaneously for every 2 seconds over a monitoring period that ranged from 3-8 days. A
second analysis examined the changes of CBF that correlated with changes of tissue oxygen.
Results
An examination of heat maps of all paired datasets for each patient revealed that while in a few patients a
relationship is evident, in the vast majority there was no relationship. When examining the variance of CBF for each
PbO2 value, the sigma of the relationship was much larger than the change of tissue O2.
Conclusions
Utilizing the absolute value of tissue oxygen or the changes of tissue oxygen, one can make no predictably useful
conclusion about CBF.
Financial Support: Yes, presenting author has minor stock position in Innerspace
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TRENDS IN HOSPITALIZATIONS AMONG ADULTS WITH ACUTE HERPES SIMPLEX ENCEPHALITIS IN THE
UNITED STATES (2001-2010)
Anthony Asemota1, Benjamin Waterhouse1, Eric Schneider2, Romergryko Geocadin1,3, Arun Venkatesan1
1
Johns Hopkins Encephalitis Center, Department of Neurology, Baltimore, MD, USA, 2Johns Hopkins Center for
Surgical Trials and Outcomes, Department of Surgery, Baltimore, MD, USA, 3Johns Hopkins Departments of
Anesthesia-Critical Care and Neurosurgery, Baltimore, MD, USA
Introduction
Herpes Simplex Virus Encephalitis (HSVE) imposes a significant disease burden across the United States. Here
we describe hospitalization trends in adults with HSVE diagnosis, examining demographic and hospitalization
characteristics, with particular emphasis on how these have changed over time.
Methods
Data from hospital discharges from 2001-2010 in the Nationwide Inpatient Sample were analyzed retrospectively.
Patients aged 18 years and older with a principal diagnosis of HSVE (ICD-9-CM code 054.3) were included.
Results
On average, approximately 1,665 patients with primary HSVE were admitted each year. Median patient age was 62
years (IQR 47-75), 48.0% were male, and most patients had Medicare or private healthcare insurance coverage
(47.5% and 37.0% respectively). Most hospitalizations occurred in teaching hospitals (51.3%), urban areas
(90.3%), and the South (38.0%), with no seasonal variation observed. Median length of stay was 9 days (IQR 615). A total of 17.7% of patients required mechanical ventilation, with more than half ventilated longer than 96
hours. Overall inpatient mortality was 7.7% (p>0.05) and survivors were most frequently discharged to home/selfcare (31.9%), followed by short- or long-term hospitals (27.5%), hospice care (18.2%), rehabilitation (6.1%), and
unknown destinations (8.5%). Total charges for all patients admitted with primary HSVE in 2010 amounted to
$152,870,405. The median individual HSVE-related hospital charge increased from $20,568 in 2001 to $52,875 in
2010 [all 2010 dollars] (p< 0.05), representing a 157% increase, while the consumer price index for hospital
inpatient service rose 40% across the period. Older patients were more likely to be hospitalized and to accrue
higher charges (p< 0.05). However, overall hospitalization incidence, length of stay, and mortality did not vary
across time.
Conclusions
Charges for inpatient care in HSVE have more than doubled in the past decade despite relatively constant rates of
hospitalization and mortality. Further research is warranted to better understand these trends.
Financial Support: None
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VALPROIC ACID AS A TRIGGERING FACTOR FOR PROPOFOL INFUSION SYNDROME IN CRITICALLY ILL
PATIENTS
Kathleen A Bledsoe1, J. Nate Hedrick1, Nathan P Charlton2, Stephanie Mallow Corbett1
1
University of Virginia Health System, Department of Pharmacy Services, Charlottesville, VA, USA, 2University of
Virginia Health System, Department of Emergency Medicine and Pediatrics, Charlottesville, VA, USA
Introduction
Theories regarding the pathophysiology of propofol infusion syndrome (PRIS) implicate mitochondrial toxicity and
changes in fatty acid metabolism as potential mechanisms for syndrome development. Valproic acid (VPA) has
also demonstrated an effect on mitochondrial electron transport and ȕ-oxidation, and may contribute to the
development of PRIS when administered concomitantly. This study was designed to describe the development of
symptoms of PRIS in patients treated with propofol and VPA.
Methods
Patients received propofol for > 24 hours, and at least 1 dose of VPA within 96 hours prior to, or within the first 72
hours of the infusion. Data were collected from the time propofol was initiated to 24 hours following its
discontinuation, or for a maximum of 96 hours, whichever was shorter. For each 24 hour period, patients were
evaluated for symptoms of PRIS, including rhabdomyolysis, hypotension, hepatic transaminitis, metabolic acidosis,
hypoxia, hyperthermia, hypertriglyceridemia, cardiac dysfunction, and renal failure. Additional data were collected
regarding propofol and VPA exposure.
Results
Of 25 included patients, 24 (96%) developed at least one symptom of PRIS. The most commonly observed
symptoms were hypotension, renal failure, hyperthermia, and hypoxia. One patient (4%) developed the
constellation of symptoms satisfying the definition for PRIS. The degree of propofol or valproic acid exposure did
not strongly predict symptom development. Eight patients (32%) expired during the evaluated hospital admission,
including the patient with PRIS. The incidence of PRIS and mortality in this study were greater than previously
reported in a large study of patients exposed to propofol alone.
Conclusions
Development of individual symptoms of PRIS was common in this small cohort of patients. One patient developed
PRIS with lower propofol exposure than previously identified in the literature as a risk factor, suggesting valproic
acid may act as a triggering factor for PRIS and warrants continued evaluation.
Financial Support: None
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PULMONARY GLIAL CELLS: NOVEL MEDIATORS OF INFLAMMATION FOLLOWING ACUTE LUNG INJURY
Marion S. Buckwalter, Loren D. Sacks, Gabriela Suarez-Mier, Nancy Fathali
Departments of Neurology and Neurosurgery, Stanford Medical School, Stanford, CA, USA
Introduction
Sympathetically-mediated immunosuppression after stroke and TBI may be beneficial in preventing autoimmune
responses against brain tissue, but also contributes to infections such as pneumonia. We hypothesized that, due to
their physical relationship with sympathetic and parasympathetic nerves, pulmonary glial cells (PGCs) mediate this
immunosuppression locally in lung tissue. We characterized these understudied cells and tested whether cellspecific inhibition of the immune regulator TGFbeta would affect pulmonary immune responses.
Methods
Immunohistochemisty was used to characterize PGCs. Two complementary mouse lines were developed to
specifically inhibit PGC responses to TGFbeta. In Tbr2fl/fl mice the TGFbeta type II receptor is selectively deleted,
and in dominant negative (DN) mice a mutant TGFbeta receptor is overexpressed. Intratracheal (IT) LPS was
administered at 12 mg/kg to model acute lung injury in Tbr2fl/fl mice. For mortality experiments, Tbr2fl/fl mice
received 15 mg/kg LPS IT and DN mice received 2.5x107 colony-forming units (CFU) of IT E.coli. Appropriate
littermate controls (WT) were routinely used.
Results
PGCs express the glial markers GFAP and S100beta and closely associate with autonomic nerves. After LPS,
Tbr2fl/fl mice exhibited twice as much neutrophil MPO at 5 and 24 hour timepoints. Lung IL-6 levels were also 30%
higher than in WT 5 hours after LPS (p=0.0073). A multiplex Luminex assay demonstrated significant elevations in
five other chemokines and cytokines that stimulate neutrophil responses, at 5 and 24 hours after LPS. Mortality
was 80% in Tbr2fl/fl mice vs. 33% in WT (p=0.0012). In DN mice exposed to E.coli, mortality was higher at 24 hours
(p=0.0084) and neutrophil infiltration around the airways was significantly increased at 5 hours (p=0.0055).
Conclusions
TGFbeta signaling in PGCs is critical for limiting the pulmonary immune response. This is the first evidence that
PGCs play a key role in pulmonary inflammation and thus may provide a target to locally modify sympatheticallymediated immunosuppression at infection sites.
Financial Support: R01 NS067132 from NIH/NINDS.
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SYMPATHETIC EXCESS DRIVES SYSTEMIC RESPONSE SYNDROME AFTER BRAIN INJURY
Ko-Eun Choi1, Tae Sim1, Karen Berger2, Shouri Lahiri1, Taehoon Lee1, Bomi Park1, Shwetha Chiluveru1, Axel
Rosengart1
1
Departments of Neurology, Neuroscience and Neurosurgery Weill Cornell Medical College-New York Presbyterian
Hospital, New York, NY, USA, 2Department of Pharmacy New York Presbyterian Hospital, New York, NY, USA
Introduction
The systemic-inflammatory-response-syndrome (SIRS) presents as a cluster of clinical findings including
tachycardia, tachypnea, leukocytosis/leucopenia and hyper-/hypothermia seen in patients with infectious or noninfectious causes. We propose a brain-induced-response-syndrome that is different from SIRS and results from an
immediate sympathetic excess that leads to systemic derangement fulfilling SIRS criteria and multiorgan
dysfunction (MOD).
Methods
Case report from a tertiary referral center.
Results
A 66-year-old man with suprasella arachnoid cyst underwent transsphenoidal cyst fenestration and emerged
normally. Seven hours post-surgery he deteriorated to stupor with mydriasis and bilateral flexion posturing followed
by hypertension, tachycardia, tachypnea, desaturation, and hyperthermia. CT showed extensive tension
pneumocephalus and central downward herniation. Findings/CXR identified ARDS; TTE delineated new
hypokinesia; decreased urine output; labs remarkable for brisk leukocytosis, hyperglycemia, hypoalbuminemia, and
elevated creatinine and troponin. Negative blood/CSF cultures. After stabilization and skull defect closure, full
recovery and resolution of imaging/laboratory abnormalities occurred within 40 hours.
Conclusions
The patient's sudden deterioration fulfilled all criteria for SIRS and subsequent MOD, syndromes known to be
initiated by systemic hyperinflammation caused by inflammatory cytokines (InflCy). However, InflCy production
follows a predictable time pattern with first systemic release 6-24 hours after the inciting event. In contrast, our
patient developed progressive, systemic deterioration minutes after brain injury onset due to excess sympathetic
drive. Extracerebral organ dysfunction, commonly neurogenic pulmonary edema (NPE) and myocardial stunning,
are known to occur after brain injury; however, this patient illustrates that a) systemic multiorgan dysfunction can
occur immediately after severe brain injury, b) involves organs/systems beyond NPE and cardiac stunning, c) is
initiated by sympathetic excess and not InflCy release, and d) differs from classic SIRS. Differentiating a braininduced-response-syndrome (BIRS) from SIRS shifts focus to immediate CNS stabilization as the primary
treatment and to different treatment options such central/peripheral sympatholytics to protect systemic organs from
excessive sympathetic discharge.
Financial Support: None
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THE EFFECT OF INHALED PULMONARY VASODILATORS ON INTRACRANIAL HEMODYNAMICS
Christopher Hopkins, MD1, Michael Erdman, PharmD, BCPS2, Stuart Glassner, DO3
1
University of Florida, Department of Emergency Medicine, Jacksonville, FL, USA, 2University of Florida,
Department of Pharmacy, Jacksonville, FL, USA, 3University of Florida, Department of Neurology, Jacksonville, FL,
USA
Introduction
Inhaled pulmonary vasodilators are commonly used as rescue agents in critically ill patients with refractory hypoxia.
We sought to describe the effect of inhaled epoprostanol and nitric oxide on cerebral hemodynamics in patients
with severe brain injury and fulminant respiratory failure.͒͒
Methods
We reviewed data for all patients in our intensive care unit who received inhaled nitric oxide or epoprostenol with
concurrent intracranial pressure monitoring from January 2012 to March 2014. All intracranial pressure
measurements were obtained from external ventricular drains except for one patient with a fiberoptic
intraparenchymal device. All patients suffered from severe traumatic brain injury.
Results
Inhaled pulmonary vasodilators were initiated 8 times in 4 patients during the study period. Mean intracranial
pressure decreased from 21 mmHg to 18 mmHg after initiation of an inhaled vasodilator (p=0.18, 95% CI=-6.17 to
1.42). Mean cerebral perfusion pressure increased from 64 mmHg to 67 mmHg (p= 0.19, 95% CI=-1.90 to 8.15).
Mean PaO2 increased from 60 mmHg to 82 mmHg (p=0.01 CI=6.7 to 38.8) and median PaCO2 decreased from 46
mmHg to 42 mmHg (p= 0.08). Median PaO2 to FiO2 ratio increased from 60 to 93 (p= 0.017).
Conclusions
Our preliminary data show that inhaled pulmonary vasodilators have no effect on intracranial hemodynamics
despite a significant increase in arterial oxygenation.͒͒
Financial Support: None
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ZEBRAS THAT WALK AMONGST US: A CHALLENGING CASE OF DURAL VENOUS SINUS THROMBOSIS
WITH HEPARIN RESISTANCE.
Avinash Kumar1, Adam King1, Anne O'Duffy2
1
Dept of Anesthesia & Critical Care, vanderbilt University, Nashville, TN, USA, 2Dept of Neurology, Vanderbilt
University, Nashville, TN, USA
Introduction
We report a challenging case of dural venous sinus thrombosis with a complex etiology and heparin resistance
secondary to Anti thrombin III deficiency (AT).
Methods
A 20-year-old previously healthy and currently 8-weeks pregnant female presented with worsening headaches,
nausea, decreasing GCS and acute respiratory failure. Imaging showed extensive clots in multiple dural venous
sinuses including the superior sagittal sinus, transverse, sigmoid, jugular veins, and straight sinus. She was started
on systemic anticoagulation and had an endovascular thrombolysis with mechanical clot removal with limited
success. A comprehensive hypercoagulable workup was intiated. Complicating the ICU care was the development
of ARDS and heparin resistance with an inability to reach the target PTT of 60-80s. At her peak heparin dose she
was receiving > 35000u/24hrs and her PTT was < 50s. AT III deficiency was suspected as a possible etiology of
her heparin resistance. Fresh frozen plasma was administered for AT repletion. The first therapeutic PTT was
achieved after almost 36 hours after starting the heparin infusion. Given her high thrombogenic risk and challenges
with conventional anticoagulation regimens, we transitioned to Argatroban for systemic anticoagulation. She
currently meets anticoagulation goals.
Results
Discussion: Heparin produces its major anticoagulant effect by inactivating thrombin and inctivated factor X through
an antithrombin (AT)-dependent mechanism. For inhibition of thrombin, heparin must bind to both the coagulation
enzyme and AT. A deficiency of antithrombin leads to a hypercoagulable state and decreased efficacy of heparin
that places patients at high risk for thromboembolism
Conclusions
Heparin resistance, especially in the setting of critical illness should raise the index of suspicion for AT deficiency.
Argatroban is an alternate agent for systemic anticoagulation in the setting of heparin resistance.
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USE OF CLEVIDIPINE (CLEVIPREXÒ) TO CONTROL BLOOD PRESSURE (BP) IN PATIENTS WITH
INTRACEREBRAL HEMORRHAGE (ICH) AND SUBARACHNOID HEMORRHAGE(SAH).
Kees H Polderman1, Danielle Bajus1, Joseph Varon2
1
University of Pittsburgh Medical Center, Pittsburgh, PA, USA, 2The University of Texas Health Science Center at
Houston, Houston, TX, USA
Introduction
Rapid BP control is a key initial goal in hemorrhagic stroke. In ICH this decreases hematoma expansion risk; in
SAH, re-bleed risk before securing the aneurysm. However, excessive BP reduction was linked to adverse
outcome in a national registry of neurocritical patients.1 Moreover, hypertension can become a goal in SAH if
vasospasms occur. Clevidipine is a new IV calcium channel antagonist with rapid onset (90 seconds) and offset (510 minutes), making BP control titrateable. This prospective intervention study used clevidipine to manage BP in
hemorrhagic stroke.
Methods
The study is ongoing, with 34 ICH and 24 SAH patients enrolled so far. BP was measured continuously via arterial
line. Patients received clevidipine (starting dose 4-8 mg, increased every 90 seconds as needed until target was
achieved), with BP targets set by the treatment team. Outcomes included median time to target, % patients
achieving target, and time within target range as % of total time on clevidipine. Safety parameters included
"overshoot" and time to recovery above the BP floor. When targets were modified (e.g. after coiling/clipping a
ruptured aneurysm) the new targets were used from the time first achieved.
Results
Target BP was achieved in 58/58 patients (100%). Median time to target was 6 (average 4.9±6.8) minutes.
Average dose required to achieve target was 19.6 mg/hr. Time within target range until discontinuation was 98%. 3
patients (5%) had an overshoot (mean 9, range 5-14 mmHg; average duration 4.3 minutes).
Conclusions
Clevidipine was highly effective in controlling BP in hemorrhagic stroke, with excellent safety profile. Additional
advantages included low infusion volumes (often a problem with nicardipine). Doses to achieve BP targets were
higher than previously reported in cardiothoracic surgery patients, possibly reflecting the hyperadrenergic state
associated with acute brain injury. Reference. 1. Mayer SA et al. Crit Care Med 2011;39:2330-36
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USE OF TOLVAPTAN TO TREAT SIADH-INDUCED HYPONATREMIA IN SELECTED PATIENTS WITH ACUTE
NEUROLOGICAL INJURIES.
Kees H Polderman1, Danielle Bajus1, Joseph Varon2, Joseph B Durkin1
1
1Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA, 2The
University of Texas Health Science Center at Houston, Houston, TX, USA
Introduction
Hyponatremia occurs frequently in patients with acute brain injury and may contribute to adverse outcome. In
addition, it can aggravate neurologic dysfunction, complicate neurological assessments, and contribute
to symptoms such as gait dysfunction that can impair efforts at mobilization and rehabilitation. Various studies have
shown that SIADH is the most frequent cause of hyponatremia in patients with acute neurological injuries.
However, standard therapies for SIADH such as fluid restriction are often impractical, counterindicated or
impossible in neurocritical patients (e.g. patients with SAH). Thus many patients are treated with hypertonic saline,
which is usually effective but at the price of inducing hypervolemia with possible (worsening of) cardiac dysfunction,
and will often require central venous access and ICU monitoring. We tested tolvaptan (SamscaR), a novel oral ADH
antagonist that promotes aquaresis, as an agent to treat neurologically and hemodynamically stable patients with
acute neurological injuries and suspected SIADH.
Methods
So far 37 patients with acute neurological injury (29 SAH, 4 ICH, 2 AIS, 2 post-brain tumor surgery) who had no
counterindications (e.g. liver dysfunction) were treated with tolvaptan according to a predefined protocol. Most
(n=31) had previously received hypertonic saline and had experienced recurrence of hyponatremia when this was
discontinued. All underwent extensive workup for causes of hyponatremia before treatment was initiated. Of note,
liberal fluid intake was ordered in all patients.
Results
Average sodium levels were 129.4 meq before treatment. 34 patients responded to the initial dose (15 mg) of
tolvaptan, 3 required a dose of 30 mg. Sodium levels increased to 135.8 meq within 48 hours. Median treatment
duration was 5 days (average 4.3 days). No significant side effects were noted.
Conclusions
Tolvaptan may be useful in selected patients with acute neurological injuries who develop SIADH, in the more
stable phases of their injury. It should not be used in severe symptomatic hyponatremia.
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THINK FAST: EEG AS AN ADJUNCTIVE MONITOR TO GUIDE HYPEROSMOLAR THERAPY IN
INTRACRANIAL HYPERTENSION?
Zachary Threlkeld, Mohan Kottapally, Aimee Aysenne, Nerissa Ko
University of California San Francisco, San Francisco, CA, USA
Introduction
Intracranial pressure (ICP) monitoring is an important tool for the neurointensivist when faced with potential brain
herniation in the setting of a poor neurological exam. However, patients at risk of bleeding may not be suitable
candidates for invasive ICP monitoring. Here we report the case of an 18-year-old female with diffuse intracranial
venous thromboses, known to already be on full dose anticoagulation, in which EEG monitoring was utilized to
assess response to hyperosmolar therapies for elevated ICP.
Methods
Case report
Results
We present the case of an 18-year-old female with superior sagittal, bilateral transverse and straight sinus
thromboses with a clinical exam indicative of increased intracranial pressure. Invasive ICP monitoring could not be
utilized because she was on full-dose anticoagulation. EEG was performed to help evaluate response to
hyperosmolar therapy. Her initial clinical presentation was concerning for poor GCS < 8 with flexor posturing, and
lumbar puncture prior to anticoagulation revealed opening pressure of 55 cm H2O. Initial EEG showed diffuse
background slowing and disorganization with intermittent bursts of monomorphic 2 Hz delta activity suggestive of
FIRDA. After initiation of hyperosmolar therapy with mannitol and 23.4% hypertonic saline, the patient's
neurological exam improved significantly. Continued EEG during this phase showed improvement in background
organization and complexity, as well as improvement in the admixture of frequencies with greater differentiation
and reactivity.
Conclusions
EEG is a helpful bedside tool with potential as a non-invasive adjunctive monitor for elevated intracranial pressure
in selected patients in which invasive ICP monitoring cannot be obtained.
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PREVALENCE OF PENTOBARBITAL ASSOCIATED HYPOXIA IN THE NEUROSCIENCE INTENSIVE CARE
UNIT
Michelle L. Zacchetti1,2, Sheri Tokumaru1,2, Kara Izumi2, Kazuma Nakagawa2,3
1
University of Hawai'i at Hilo, The Daniel K. Inouye College of Pharmacy, Honolulu, HI, USA, 2The Queen's Medical
Center, Honolulu, HI, USA, 3University of Hawai'i, John A. Burns School of Medicine, Honolulu, HI, USA
Introduction
Animal studies suggest that pentobarbital may impair pulmonary vascular autoregulation that would lead to
excessive hypoxia. However, the effect of pentobarbital-associated hypoxia has not been adequately studied in
neurocritical care patients. Therefore, we sought to assess the prevalence of pentobarbital-associated hypoxia in
the neuroscience intensive care unit and determine the associated clinical factors.
Methods
A retrospective review of all patients requiring pentobarbital intravenous continuous infusion who were admitted to
the neuroscience intensive care unit (NSICU) from 1/1/2006 to 12/31/2013 was conducted. Inclusion criteria were
1) age 18 years, 2) administration of pentobarbital intravenous continuous infusion, 3) pentobarbital infusion for a
minimum of two days within five days of admission, and 4) mechanical ventilation. Exclusion criteria were 1)
pentobarbital infusion < 2 days and/or > 5 days after date of admission, or 2) development of new hypoxia prior to
pentobarbital administration. The prevalence of acute hypoxia, defined by PaO2/FiO2 (P:F) ratio < 300 mmHg within
48 hours of pentobarbital infusion was assessed. Multivariable analysis using logistic regression was used to
determine the predictors of acute hypoxia after pentobarbital infusion.
Results
Among the 160 screened patients who received pentobarbital, 50 patients (41 TBI, 5 status epilepticus, 4 others)
met the inclusion and exclusion criteria. Overall, 28 patients (56%, 95% CI 15-41%) developed acute hypoxia
within 48 hours of pentobarbital infusion. Among those who developed hypoxia, 7 (25%) patients had a mildly
abnormal chest X-ray (CXR) and 4 (14%) had a normal CXR on the day hypoxia developed. In the logistic
regression model, none of the factors independently predicted pentobarbital-associated hypoxia.
Conclusions
A considerable number of patients developed new hypoxia after pentobarbital infusion, despite normal or mildly
abnormal chest X-ray findings. A large prospective study is needed to further characterize the clinical factors that
may increase the risk of its incidence.
Financial Support: None
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SEVERE NEUROGENIC MYOCARDIAL STUNNING FROM COLLOID CYST - AN ALTERNATIVE MECHANISM
FOR SUDDEN DEATH
Shouri Lahiri, Christopher Zammit, Fawaz Al-Mufti, Halinder S. Mangat, Hooman Kamel, Mark Souweidane, Axel
Rosengart, Alan Segal
New York Presbyterian/Columbia and Cornell Medical Center, New York, NY, USA
Introduction
Symptomatic third ventricular colloid cysts (CC) may present with headaches, obstructive hydrocephalus, and
rarely sudden death. Sudden death has traditionally been attributed to herniation and brainstem compression. We
present a case of CC complicated by severe neurogenic stunned myocardium (NSM), offering an alternative
mechanism for sudden death.
Methods
Case report from an urban tertiary referral center.
Results
A previously healthy 30-year-old woman presented to the emergency department with progressive headache and
mild confusion. Non-contrast brain computed tomography showed hydrocephalus in bilateral lateral ventricles.
Magnetic resonance imaging (MRI) revealed a 1x0.9cm CC in the anterior third ventricle. Upon returning from MRI,
she developed supraventricular tachycardia (SVT) and then became hypotensive and cyanotic. Her mental status
deteriorated necessitating intubation. After resuscitation, bedside transthoracic echocardiogram showed ejection
fraction 10% with apical sparing. Milrinone and vasopressin were started resulting in improved hemodynamic and
echocardiographic parameters. An external ventricular drain (EVD) was placed. Follow up cerebral imaging
showed acute infarctions in bilateral posterior cerebral artery territories. Over the next 7 days, her cardiac function
improved (EF 40%) and vasopressors were discontinued. She underwent uneventful endoscopic fenestration of the
colloid cyst on day 10.
Conclusions
NSM has rarely been reported in association with CC. Prior reports have been confounded by generalized seizurelike activity or preceding cardiac arrest, which may independently cause NSM and/or cardiomyopathy. In our case,
a significant increase in intracranial pressure may have occurred while the patient was supine in MRI leading to a
sympathetic surge and subsequent myocardial stunning. Alternatively, there could have been direct stimulation of
the nearby hypothalamus by the third ventricular CC, resulting in SVT. This case suggests that sudden death
associated with CC may be due to acute cardiac failure from NSM rather than brain herniation as previously
thought.
Financial Support: None
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WHERE TO TARGET CATHETER ASSOCIATED URINARY TRACT INFECTION PREVENTION IN THE
NEUROCRITICAL CARE UNIT
Elizabeth K Zink1, Haley G Gibbs2, Donna Fellerman3, Gail O Biba1, Wendy C Ziai4
1
The Johns Hopkins Hospital, Department of Neuroscience Nursing, Baltimore, MD, USA, 2The Johns Hopkins
Hospital, Department of Pharmacy, Baltimore, MD, USA, 3The Johns Hopkins Hospital, Department of
Epidemiology and Infection Control, Baltimore, MD, USA, 4The Johns Hopkins University, School of Medicine,
Departments of Neurology, Neurosurgery and Anesthesia Critical Care Medicine, Baltimore, MD, USA
Introduction
NeuroCritical Care Units (NCCU) possess a high incidence of catheter associated urinary tract infections (CAUTIs)
among all ICUs. Our NCCU exceeded benchmarks for 10 of 11 quarters from 2011-2014. We sought to identify
major sources of CAUTI to improve prevention measures.
Methods
Retrospective cohort study of patients with CAUTI meeting Centers for Disease Control (CDC) criteria identified by
an infection preventionist over a 16 month period (2013-2014). The highest prevalence diagnostic groups
[intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH)], representing 54% of CAUTI cases were
compared to patients with ICH/SAH without CAUTI during the same time period. Risk factors were identified
through multivariate logistic regression.
Results
Of 37 CAUTI cases, 68% occurred in females and 100% of patients had stool incontinence. Of 165 patients with
ICH/SAH, 128 had a foley. Median age was 62[IQR 26], 55% were female, admission GCS was 11[7], 30% had a
fecal management system (FMS, surrogate for severe diarrhea) and ICU length of stay (LOS) was 10[13] days.
Median number of foley days was 11[16]. CAUTI developed in 20/128 patients (15%) at median catheter day 10.5
[9.5]. Patients with CAUTI had lower admission GCS (p< 0.0007), higher number of foley catheter insertions (p <
0.0004), more foley days (p< 0.0001) and were more likely to have a FMS (p< 0.0004). They also had longer ICU
and hospital LOS (p< 0.0006 and < 0.004). The only independent predictor of CAUTI was number of foley days
[OR 1.13,CI 95% 1.01-1.26].
Conclusions
CAUTI in ICH and SAH occurs predominantly in patients with lower GCS and in those with severe diarrhea despite
use of FMS, but is independently associated only with increased foley days. Targeting CAUTI prevention to
vulnerable patients should include novel strategies for mitigating contamination of the genitourinary tract and
alternatives for urinary output measurement in long-term management of ICH/SAH patients.
Financial Support: None
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NEUROCRITICAL CARE OF ADULTS WITH FONTAN REPAIR OF COMPLEX CONGENITAL HEART
DISEASE: IDENTIFYING MECHANISMS FOR NEUROLOGIC MORBIDITY IN THE ICU
Eileen Broomall1,3, Alexandra Shaw1, Mary McBride2, Michael Monge4, Andrew De Freitas2, Mark S. Wainwright1,3
1
Department of Pediatrics, Division of Neurology, Chicago, IL, USA, 2Department of Pediatrics, Division of
Cardiology, Chicago, IL, USA, 3Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Chicago, IL, USA,
4
Department of Cardiovascular Thoracic Surgery, Chic, IL, USA
Introduction
Children with functionally univentricular congenital heart disease commonly undergo the Fontan procedure to
increase systemic oxygenation and reduce ventricular overload. Multistaged Fontan repair may involve takedown
of the subclavian arteries. The systemic complications of Fontan physiology include protein losing enteropathy,
hepatic fibrosis, pleural effusions, and thromboembolism. Adult survivors with Fontan physiology may develop
heart failure or arrhythmias, requiring further surgical revisions. The potential acute post-operative neurologic
complications following revision have not been reported.
Methods
We performed a retrospective chart review of the post-operative course of adults with repaired single ventricle
congenital heart disease who underwent Fontan revision and were evaluated by the neurocritical care service at
our institution.
Results
Three patients were identified, ages 34 (male), 35 (female) and 42 (female), seen in the Cardiac ICU or in
neurocritical care clinic. All patients had the Fontan procedure in childhood, and subsequently underwent either
Fontan conversion or heart transplantation. Patient 1experienced an episode of relative hypotension and
decreased cerebral perfusion three days after Fontan conversion, and suffered an ischemic brainstem stroke
resulting in transient locked-in syndrome. Patients 2 and 3 were evaluated by the neurocritical care service preoperatively, had higher target blood pressures peri-operatively and suffered no neurologic injury. Patients 1 and 2
underwent neuroimaging. Both of these studies were abnormal, one with atrophic vertebral arteries with nonvisualized proximal vessels; the other patient had an occluded left vertebral artery.
Conclusions
Adults with complex congenital heart disease have well-recognized systemic pulmonary, kidney and hepatic
complications of their cardiac disease. However, the potential for post-operative neurologic complications is high
due to the high central venous pressures associated with hepatic fibrosis, and the aberrant posterior circulation due
to loss of a vertebral artery. These patients need careful management of fluids and blood pressure to optimize
cerebral perfusion and reduce the risk for vertebrobasilar ischemia.
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OPTIMAL CPP MANAGEMENT AT BEDSIDE: MEDICAL AND NURSING COMPLIANCE TO CPP TARGET
BASED ON CONTINUOUS EVALUATION OF AUTOREGULATION
Celeste Dias1, Maria João Silva2, Eduarda Pereira1, Elisabete Monteiro1, Isabel Maia1, Silvina Barbosa1, Sofia
Silva1, Teresa Honrado1, Antonio Cerejo3, Marcel Aries4, Peter Smielewski5, José-Artur Paiva1, Marek Czosnyka5
1
Intensive Care Department, Neurocritical Care Unit, Hospital Sao Joao, Porto, Portugal, 2Centre of Mathematics of
the University of Porto, Department of Mathematics, Faculty of Sciences, University of Porto, Porto, Portugal,
3
Neurosurgery Department, Hospital Sao Joao, Porto, Portugal, 4Department of Critical Care, University Medical
Center Groningen, University of Groningen, Groningen, Netherlands, 5Division of Neurosurgery, Department of
Clinical Neurosciences, Addenbrooke's Hospital, Cambridge, United Kingdom
Introduction
Guidelines recommend cerebral perfusion pressure (CPP) of 50-70mmHg and intracranial pressure lower than
20mmHg for the management of traumatic brain injury (TBI). However, adequate individual targets persist
controversial, since patients have different perfusion. Bedside assessment of cerebral autoregulation (CAR) may
help to customize CPP-guided treatment. The main objective was to assess staff compliance and outcome impact
to a new method of CAR-guided treatment based on continuous evaluation of cerebrovascular pressure reactivity
(PRx).
Methods
Prospective study of severe TBI adult patients managed with multimodal brain monitoring in a Neurocritical Care
Unit. CPPopt was automatically defined as CPP with the most negative PRx using recent published method.
Patients were managed using CPPopt targets whenever possible and otherwise CPP was managed following
guidelines. In addition, other CPPopt estimates were calculated using cerebral oximetry (cox-CPPopt), brain tissue
oxygenation (orxs-CPPopt) and cerebral blood flow (cbf-CPPopt).
Results
Eighteen patients with a total multimodal brain monitoring time of 5520h were enrolled. For the all-time period of
monitoring 61% of patients had a U-shaped curve for CPPopt, 28% had either ascending or descending curves and
11% had no fitted curve. CPP correlated with CPPopt (r=0.83, p< 0.0001) with a bias of -2.2±4.2mmHg.
Comparison between other estimates of optimal CPP and CPPopt revealed similar limits of precision but the lowest
bias (-0.1mmHg) was obtained with cox-CPPopt. Patients with overall CAR (PRx< 0.25) spent less time with
impaired autoregulation compared to patients without autoregulation (p=0.007). Preserved CAR was associated to
higher Glasgow coma score on admission (p=0.01) and better Glasgow outcome score (GOS) (p=0.01). Patients
with GOS< 3 had a nearly significant higher fraction of time with impaired autoregulation (p=0.055). CPP was
significantly lower than CPPopt on patients with GOS< 3 (p=0.04).
Conclusions
CAR evaluation with CPPopt management at bedside is feasible and seems to be associated to better outcome.
The cox-CPPopt methodology using noninvasive cerebral oximetry warrants further evaluation.
Financial Support: None
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OUTCOME OF SIMULTANEOUS TRACHEOSTOMY AND PERCUTANEOUS ENDOSCOPIC GASTROSTOMY
TUBE PLACEMENT IN THE NEUROCRITICAL CARE UNIT
CHRISTA V. SAN LUIS MD1,3, VINCIYA PANDIAN PhD, RN, ACN2, RAVIRASMI JASTI4, DAVID H. WU4, MAREK
MIRSKI MD, PhD2,3, ROMERGRYKO GEOCADIN MD1,3
1
Johns Hopkins University Division of Neurosciences and Critical Care, Baltimore, MD, USA, 2Percutaneous
Tracheostomy Service Johns Hopkins Hospital, Baltimore, MD, USA, 3Johns Hopkins University Department of
Anesthesia and Critical Care Medicine, Baltimore, MD, USA, 4Johns Hopkins University School of Medicine,
Baltimore, MD, USA
Introduction
The practice of simultaneous tracheostomy and percutaneous endoscopic gastrostomy (PEG) placement has not
been well studied in patients in the neurocritical care unit (NCCU). Our study compared patient characteristics and
outcomes associated with simultaneous (STPEG) and non-simultaneous (NSTPEG) tracheostomy and PEG
placement in the neurocritically-ill.
Methods
We performed a retrospective cohort study on 398 patients admitted in our NCCU from April 2008 to July 2013 who
underwent tracheostomy placement. Of the 120 charts reviewed 91 were included for analysis. Primary outcome
include NCCU and hospital length of stay (LOS). Secondary outcomes include pre-discharge prealbumin, time-towean from the ventilator (hours) and PEG-related complications. Descriptive analyses were performed using ttests, Fisher-exact tests and Wilcoxon rank-sum tests as applicable.
Results
Of the 91 patients included in the study (mean age 55±18, 54% females), 76 (84%) patients underwent STPEG.
The most common etiologies for admission were ICH, SAH and TBI in STPEG and ICH, elective postoperative and
ischemic strokes in NSTPEG. The most common reason for PEG placement was need for chronic nutrition.
STPEG compared to NSTPEG group had similar Severity of Illness Scores (STPEG:8±2 vs NSTPEG:6±4, p=.076).
The NCCU [21(IQR 16,31) vs 28(IQR 14,37), p=.341] and hospital [29.5(IQR 24,46) vs 35(IQR 25,43), p=.752]
LOS were also similar. Furthermore, prealbumin levels pre-discharge [15(IQR 7,18) vs 10(IQR 1,13), p=.275] and
PEG complication rate (22%vs20%, p=.926) were comparable between groups. However, the time to wean from
the ventilator after tracheostomy was longer in STPEG than NSTPEG [27(IQR 20,115) vs 17(IQR 6,16), p=.001]
but VAP rates of both groups were not statistically different.
Conclusions
Our data to date demonstrated that although STPEG method is safe and well tolerated in neurocritically ill patients,
they get weaned from the ventilator post-tracheostomy longer. This knowledge may play a role in the
neurointensivist's decision making of tracheostomy and PEG placement in the NCCU.
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MULTIDISCIPLINARY QUALITY ROUNDS REDUCE CAUTI RATES IN THE NSICU
Fozia Steinkuller1, Janete Sheiner1, Nancy J. Edwards1,2, Tiffany R. Chang1,2, Enedra Allen-McBride 1, Nicole
Harrison 1, Allison M. Murphy 1, Natalie A. Blum1, Kiwon Lee1,2, H Alex Choi 1,2
1
Memorial Hermann Hospital, Houston, TX, USA, 2The University of Texas Health Science Center at Houston,
Houston, TX, USA
Introduction
Urinary tract infection is the most common nosocomial infection accounting for greater than 30 percent of
nationally reported infections. Specifically 80% of these infections are associated with an indwelling catheter.
Complications related to CAUTIs have been correlated with increased mortality, hospital cost, length of stay, and
decreased patient satisfaction. Reducing catheter associated urinary tract infections is a national patient safety
priority.
Methods
This was a quality improvement initiative conducted at a tertiary academic neurocritical care unit from March 2013March 2014. Multidisciplinary quality rounds (MQR) in the afternoon were started in March 2013 to assess Foley
care. MQR focused on necessity of Foley, orders for discontinuation, and active detection of UTI's on presentation.
MQR was rolled out in 2 phases. Phase 1: MQR team consisted of the nurse manager, infection preventionist, and
dedicated quality nurse. Phase 2 was the addition of an attending physician. CAUTIs were defined using National
Health Safety Network definition with third party validation by a hospital epidemiologist. Rates of CAUTI during
period of intervention were compared to standard of care treatment in the preceding two years Feb 2011-Feb 2013.
Results
There was no difference between number of patients before and after intervention (243+/-29 vs 250 +/- 15 p=0.15),
Foley days (544+/-94 v 557 +/-88 p=0.68) and Utilization ratio (.68 v 0.65 p=0.4). There was an increase in patient
days (800+/-73 v 852 +/-64 p=0.04). Standardized infection ratio (SIR) decreased from a quarterly average of
1.47+/-0.3 SD to 0.88+/-0.3 SD (p=0.03). Average monthly rate of 6.8 CAUTI's a month decreased by 38% to 4.2
(p=0.02).
Conclusions
The implementation of multidisciplinary quality rounds in the NSICU significantly decreased the rates of CAUTIs by
38% and decreased SIR to under 1. The addition of a physician enhances the effectiveness of multidisciplinary
quality rounds.
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EFFECT OF KCENTRA® (PROTHROMBIN COMPLEX CONCENTRATE, PCC) ON HEMATOMA EXPANSION
IN INTRACRANIAL HEMORRHAGE
Christine L Ahrens1, Farrukh Chaudhry2, Dani Dhimant2, Joao Gomes2
1
Cleveland Clinic Department of Pharmacy, Cleveland, OH, USA, 2Cleveland Clinic Cerebrovascular Center,
Cleveland, OH, USA
Introduction
Warfarin anticoagulation is known to worsen outcomes following ICH, partly due to an increased risk of hematoma
expansion. The use of a 4-factor PCC (4fPCCC) for reversal of warfarin in ICH has not been well described. We
report our single-center experience.
Methods
Retrospective review of adult patients admitted between October 2013 and March 2014 to an academic medical
center with warfarin-related intracranial hemorrhage and elevated INR (i.e. 1.4) treated with a 4fPCC. Descriptive
statistics, matched-pair t test, and Wilcoxon matched-pairs test were employed.
Results
Thirteen patients (ICH 84%, SAH 8%, SDH 8%) were included. Mean age was 77.1 ± 9.7 years and 70% were
females. GCS on admission was 13 (11.5-15). Median baseline INR 2.3 (1.7-2.55) significantly decreased
compared to the 30-minute follow-up INR 1.3 (1.15-1.4, p=0.001). Goal INR of < 1.4 was met in 70% of patients at
30 minutes and zero patients experienced a rebound INR of > 1.4 within 24 hours of 4fPCC administration. Median
dose of 4fPCC was 1520 (1052-2500) units. Hematoma expansion (defined as >33% growth) did not occur in a
single patient within this cohort: baseline ICH volume 17.8 ml (4.3-39.5) vs ICH volume at 6 hours 11.1 ml (4.0539.74, p=0.1). A drop in platelet count was observed from baseline 217 k/ul (181.5-248.5) compared to the nadir
count at 48 hours 179 k/ul (129.5-269.5, p=0.1). One NSTEMI (7.7% patients) was observed within 24 hours of
4fPCC administration. Survival at discharge was 77%.
Conclusions
In this small cohort of patients, preliminary results demonstrated no instances of hematoma expansion with 4fPCC
treatment, as compared to historical rates of 54% in similar patients. In addition, a drop in platelet count was
observed in the majority of subjects. Documented rate of adverse effects was similar to that previously reported in
other patient populations.
Financial Support: Primary author previously served on advisory board for CSL Behring. No active affiliations with
the company.
INTRACEREBRAL HEMORRHAGE
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DIFFUSION-WEIGHTED IMAGING (DWI) AFTER SPONTANEOUS INTRACEREBRAL HEMORRHAGE:
CLINICAL AND TREATMENT CORRELATIONS.
Luiz Dalfior Junior1,2, Thatiana F. N. Affonso3, Andreia M. H. Vaccari3, Renata C. A. N. Miranda3, Gisele S. Silva3,4
1
Hospital Israelita Albert Einstein/ Intensive Care Unit, São Paulo, Brazil, 2Universidade Federal de São Paulo/
Intensive Care Unit, São Paulo, Brazil, 3Hospital Israelita Albert Einstein/ Programa Integrado de Neurologia do
Hospital Israelita Albert Einstein, São Paulo, Brazil, 4Universidade Federal de São Paulo/ Departamento de
Neurologia e Neurocirurgia da Universidade Federal de São Paulo, São Paulo, Brazil
Introduction
Secondary ischemic lesions detected by DWI recently described in patients with intracerebral hemorrhage (ICH)
raise a concern regarding the safety of aggressive blood pressure (BP) lowering in such patients. Our aim was to
evaluate the prevalence of acute brain infarcts in patients with spontaneous ICH and to examine associations of
DWI lesions and clinical and treatment features, specifically the use of sodium nitroprusside, one of the most
frequently used drugs for BP lowering in ICH in Brazil.
Methods
We evaluated consecutive patients admitted with spontaneous ICH from January/2009 to January/2014 to a tertiary
hospital in whom DWI was performed within 15 days of admission. We compared patients with and without DWI
abnormalities. Univariable analyses were conducted using chi-square, Mann-Whitney and Student-t tests as
appropriate. Multivariable logistic regression was not performed due to insufficient number of outcomes.
Results
Among 41 ICH patients (mean age 63.3 +/- 14.1 yo, 53.7% male) who underwent magnetic resonance imaging,
DWI abnormalities were observed in 24.4%. Patients with and without DWI lesions were similar in age, history of
previous stroke, hypertension and diabetes. Patients with DWI lesions had a trend to have more atrial fibrillation
(20% versus 3.2%, p=0.07) and heart failure (10% versus 0%, p=0.07). The median percentage of mean arterial
pressure (MAP) lowering was 35% [26-45]. Patients with DWI lesions had higher maximal MAP in the first 48 hours
of admission (131.8+/-23.1mmHG versus 114.6+/-13.8 mmHG, p=0.01) and a trend towards more MAP lowering in
the first 48 hours (55.5+/-26.4mmHg versus 40.18+/-17.4mmHg, p=0.08). Patients treated with sodium
nitroprussiate had a trend towards a higher frequency of DWI lesions (33.3% versus 12.5%, p= 0.13).
Conclusions
Acute brain infarction was common after spontaneous ICH. Patients with atrial fribrillation, those with more MAP
lowering and those treated with sodium nitroprussiate had a trend towards a higher frequency of ischemic lesions.
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MEASUREMENT OF EXTERNAL-VENTRICULAR DRAIN TRACT HEMORRHAGE IN THE CLEAR-III TRIAL: A
COMPARISON OF SEMI-QUANTITATIVE VS. COMPUTERIZED QUANTITATIVE MEASUREMENTS.
William D Freeman1, Tamra Ranasinghe2, Prabin Thapa3, Natalie Ullman4, Daniel Jackson5, Sothear Luke6, Vivek
Gupta7, Daniel F. Hanley8
1
Departments of Neurology, Neurosurgery, and Critical Care. Mayo Clinic Florida., Jacksonville, FL, USA,
Neuroscience Research Associate, Mayo Clinic, Jacksonville, FL, USA, 3Biostatistics Division, Mayo Clinic,
Rochester, MN, USA, 4Brain Injury OutcomeS (BIOS) Division, The Johns Hopkins University, Baltimore, MD, USA,
5
Pharmacy Dept, Mayo Clinic, Jacksonville, FL, USA, 6Neuroscience Research, Coordinator, Jacksonville, FL,
USA, 7Neuroradiology Dept, Mayo Clinic, Jacksonville, FL, USA, 8Harriett Legum Professor, Brain Injury OutcomeS
(BIOS) Division, The Johns Hopkins University, Baltimore, MD, USA
2
Introduction
External ventricular catheter (EVD) placement is the standard intervention in patients with intraventricular
hemorrhage (IVH) to divert cerebrospinal fluid and reduce intracranial pressure. We hypothesized that a semiquantitative method of EVD tract hemorrhage (EVD-TH) would correlate with a computerized quantitative
measurement of EVD-TH to gauge intracranial hemorrhage (ICH) severity, and that ICH severity would correlate
with EVD placement accuracy.
Methods
CLEAR-III is a multicenter trial of subjects with symptomatic IVH who are randomized to either tissue plasminogen
activator (TPA) or saline (placebo) injections via EVD. All CT scans were analyzed for quantitative EVD -TH
volumetrics at Johns Hopkins neuroimaging laboratory. A semi-quantitative (Jackson) method was utilized which
graded bleeding at superficial (< 2cm calvarium), middle, and deep EVD tract locations using a categorical scale
(0-3, with 0 = no TH, 1=trace, 2=TH, and 3 = TH with mass effect). EVD placement accuracy was graded via
modified Karkala scale. ICH without adjacent EVD were not analyzed.
Results
We reviewed 173 noncontrast head CTs (NCHCT) of the first 100 patients enrolled in the trial. There was no
significant association between EVD placement accuracy and the EVD-TH semiquantitative method (p =0.44)
which suggests that initial placement may not be factor on worsening EVD-TH. A significant relationship between
semi quantitative and quantitative data (p
Conclusions
The data demonstrate a positive correlation between semi-quantitative and the quantitative EVD-TH methods.
However, EVD placement accuracy did not correlate with worsening ICH volume, but exposure to TPA-treated
patients cannot be analyzed until trial completion. The data suggest relative safety of standard EVD placement by
neurosurgeons in the trial and data safety monitoring within the trial before injections occur into the EVD.
Financial Support: Dr Hanley is principal investigator of the CLEAR III trial and receives funding from the
NIH/NINDS and Genentech supporting the trial.
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EXTRACORPOREAL MEMBRANE OXYGENATION AND THE BRAIN: FINDINGS ON INTRACRANIAL
IMAGING
Vikas Grover, Andy J Michaels, Sandra M Wanek
Legacy Emanuel Medical Center, Portland, OR, USA
Introduction
CNS hemorrhage is the one of leading causes of death in adults treated with ECMO for refractory hypoxic ARDS
but incidence and effect on outcome is unknown. We present a review of intracranial imaging findings from our
center.
Methods
All ECMO patients underwent CT head just after cannulation per center protocol. Patients received heparin 100
units/kg bolus and were maintained on heparin or bivalirudin infusion with monitoring of factor Xa activity and ACT
and PTT respectively. Cerebral monitoring was done with serial exams, serial pupillometry and continuous cerebral
oximetry. Repeat scans were performed on as-needed basis.
Results
43 patients received ECMO between Jan 2013 and April 2014 (36 veno-venous, 7 veno-arterial). One patient had
pre-existing traumatic SAH before cannulation. Initial scan revealed intracranial hemorrhage in 4 (9%) patients - all
intraparenchymal and subarachnoid hemorrhages. No extra-axial bleed was identified. Serial CT scans were
performed until stability, anticoagulation was held for 48-72 hours and aminocaproic acid infusion was used for 72
hours. No patient developed massive ICH. One patient had concomitant hypoxic ischemic injury due to recent
cardiac arrest. Pupillary change led to emergent neuroimaging in 2 additional patients. Intra-parenchymal,
subarachnoid and intra-ventricular bleeds and hydrocephalus was identified. One patient received a
ventriculostomy. Both patients had support withdrawn. Survival to discharge was 33 (76%) with one still on ECMO.
Conclusions
In our series, two-thirds of patients with intracranial hemorrhage did not progress to massive bleed or need
withdrawal of ECMO. Intracranial hemorrhage at initiation of ECMO appears to be tolerated in setting of prudent
anticoagulation regimen and use of antifibrinolytics. Clinically detectable ICH on ECMO was catastrophic. Early
detection of CNS bleeding with routine imaging and aggressive monitoring may provide an opportunity to reduce
mortality.
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FEVER AND ICU ACQUIRED INFECTIONS ARE ASSOCIATED WITH PROLONGED MECHANICAL
VENTILATION AND TRACHEOSTOMY
Laurie F. McWilliams, MD1, Errol Gordon, MD2, Jennifer A Frontera, MD1
1
Cleveland Clinic/Cerebrovascular Center, Cleveland, OH, USA, 2Mount Sinai/Neurosurgery and Neurology, New
York, NY, USA
Introduction
Joint Commission patient safety measures have placed increased focus on infectious outcomes in ICU patients.
We hypothesized infectious complications were related to increased mechanical ventilation (MV) days and
tracheostomy rates in patients with intracerebral hemorrhage (ICH).
Methods
A prospective, observational study was conducted of ICH patients who underwent MV between 7/2008-10/2011.
Patients who underwent withdrawal of life-sustaining treatment were excluded. Admission demographics, clinical
status, past medical history, radiographic features, and medical complications were compared between patients
with and without prolonged MV days and patients with and without tracheostomy using chi-squared and MannWhitney U tests. Multivariable logistic regression models were constructed to identify factors associated with
prolonged MV days and tracheostomy.
Results
Of 126 ICH patients, 70 (56%) received MV and 17 underwent withdrawal, leaving 53 patients for analysis. The
median MV days was 10 (range 1-69) and 25/53 (47.2%) underwent tracheostomy. Both prolonged MV days and
tracheostomy were associated with tracheobronchitis, fever, meningitis/ventriculitis, sepsis, use of a cooling device,
IV sedation, hydrocephalus and ICH evacuation (all P< 0.05). MV days were also significantly longer in
tracheostomy patients (21 vs 4; P< 0.0001). In multivariable logistic regression analysis, after adjusting for
admission GCS, independent factors associated with tracheostomy included: fever (aOR 67.7, 95% CI 4.4-1037,
P=0.002), sepsis (aOR 13.6, 95% CI 1.2-152, P=0.034) and ICH evacuation (aOR 70.8 (95% CI 2.8-596, P=0.007).
Fever, sepsis and ICH evacuation also predicted prolonged MV days in multivariable analysis (all P< 0.05).
Admission GCS, NIHSS, ICH volume, ICH score, past medical history and mechanism of ICH were not associated
with tracheostomy or prolonged MV days.
Conclusions
Infectious complications, particularly fever and sepsis are associated with tracheostomy and prolonged MV days in
intubated patients with ICH, irrespective of admission clinical status or size of ICH. Aggressive infection and fever
control may be critical to improving ventilator liberation rates.
Financial Support: None
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IN-HOSPITAL OUTCOMES AND RESOURCE UTILIZATION AFTER INTRAVENTRICULAR THROMBOLYSIS
IN INTRACEREBRAL HEMORRHAGE REQUIRING VENTRICULOSTOMY: A DECADE-LONG REAL-WORLD
EXPERIENCE
Yogesh Moradiya1, Santosh B Murthy1, David E Newman-Toker2, Daniel F Hanley3, Wendy C Ziai1
1
Johns Hopkins University School of Medicine/Division of Neurosciences Critical Care, Baltimore, MD, USA, 2Johns
Hopkins University School of Medicine/Department of Neurology, Baltimore, MD, USA, 3Johns Hopkins University
School of Medicine/Division of Brain Injury Outcomes, Baltimore, MD, USA
Introduction
Intraventricular thrombolysis (IVT) may improve outcomes after intraventricular hemorrhage by facilitating
ventricular clot resolution. We examined in-hospital outcomes and resource utilization after thrombolysis in patients
with intracerebral hemorrhage requiring ventriculostomy in a 'real-world' setting.
Methods
Retrospective cohort. We identified adults with primary diagnosis of non-traumatic intracerebral hemorrhage (ICD-9
code 431) requiring ventriculostomy from the Nationwide Inpatient Sample (NIS) from 2002-2011. NIS is a 20%
stratified random sample of all admissions to non-federal hospitals in the United States. The primary outcome was
inpatient mortality and the secondary outcomes were favorable discharge (composite of discharge to home or
rehabilitation), and unfavorable discharge (skilled nursing facility, hospice or death). Safety outcomes studied were
bacterial meningitis and permanent ventricular shunting. Population estimates were extrapolated using standard
NIS weighting algorithms.
Results
34,044 patients were included, of whom 1,133 (3.3%) received IVT. The thrombolysis group had lower unadjusted
inpatient mortality (32.4% vs 41.6%, P=0.001). Inpatient mortality (adjusted OR: 0.670; 95% CI: 0.520-0.865,
P=0.002) and the unfavorable discharge rate were lower (adjusted OR: 0.670; 95% CI: 0.502-0.894, P=0.007) in
the IVT group after controlling for baseline demographics, hospital characteristics, comorbidity, case severity and
withdrawal of care status. There was a trend toward favorable discharge (home or rehabilitation) among the
thrombolysis cohort (adjusted OR: 1.335; 95% CI: 0.983-1.812, P=0.064). The adjusted rates of bacterial
meningitis and ventricular shunt placement were similar between groups. The thrombolysis group had longer length
of hospital stay (LOS) (median [interquartile range]: 18 [10-26] vs 14 [6-25] days, P< 0.001) and higher inflation
adjusted cost of care (58,770 [33,379-88,434] vs 42,052 [21,757-71,481] USD, P< 0.001), but cost of care per day
LOS was similar in both groups (P=0.285).
Conclusions
IVT for intracerebral hemorrhage requiring ventriculostomy resulted in lower inpatient mortality and a trend toward
favorable discharge outcome with similar rates of inpatient complications compared to the non-IVT group.
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PALLIATIVE CARE UTILIZATION IN NON-TRAUMATIC INTRACEREBRAL HEMORRHAGE IN THE UNITED
STATES
Santosh B Murthy, Yogesh Moradiya, Daniel F Hanley, Wendy C Ziai
Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
Introduction
Palliative care utilization following intracerebral hemorrhage (ICH) has been studied in small populations, with poor
generalizability. We aimed to explore the utilization of palliative care in ICH at a population level using a large
national database.
Methods
Intracerebral hemorrhage patients with and without palliative care were identified from the 2002- 2011 Nationwide
Inpatient Sample by using ICD-9 codes. Demographics, comorbidities and surgical procedures were compared
between palliative and non-palliative patients. The primary outcome was in-hospital mortality, while the resource
utilization measures were discharge total hospital charges and length of stay.
Results
Of the 321,277 ICH patients, 39,325 (12.2%) had palliative care. Palliative care use increased from 6.9% in 2002 to
18.9% in 2011 (trend p< 0.001). In-hospital mortality rate was 73.5% in the palliative group vs. 22.9% in the nonpalliative group. There was no difference in Charlson's comorbidity scores (p=0.480) or disease severity (p=0.320).
Average total charges in palliative group were $11,438 (IQR: 6371 - 22904) versus $5,889 (IQR: 3068 - 13511, p<
0.001) in the non-palliative group. Palliative care patients also had a much shorter length of stay (3 vs. 5 days, p<
0.001). Independent predictors of palliative care use were older age (OR: 5.54, 95% CI: 4.93-6.22, p< 0.001),
female sex (OR: 1.18, 95% CI: 1.13-1.24, p< 0.001), Caucasian race (p< 0.001), and Medicare coverage (p<
0.001). Palliative care utilization was also significantly lower in hospitals with large bed number (OR: 0.63, 95% CI:
0.54- 0.74, p< 0.001) and high ICH case volume (OR: 0.63, 95% CI: 0.52- 0.77, p< 0.001).
Conclusions
Palliative care utilization has been on the uptrend over the last decade. Gender and racial differences, and hospital
characteristics appear to influence palliative care use in the United States. While resource utilization measures are
lower in these patients, there is an inherent bias of self-fulfilling prophecy of poor outcome.
Financial Support: None
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PRESENCE OF HAPTOGLOBIN ALLELE-2 IS ASSOCIATED WITH WORSE FUNCTIONAL OUTCOMES
FOLLOWING SPONTANEOUS INTRACEREBRAL HEMORRHAGE
Santosh B. Murthy1, Andrew Levy2, Joshua Duckworth1, Eric Schneider1, Hadar Shalom1, Daniel F. Hanley1, Rafael
Tamargo3, Paul A. Nyquist1
1
Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA, 2Medicine,
Technion Institute of Technology, Haifa, Israel, 3Neurological Surgery, Johns Hopkins University, Baltimore, MD,
USA
Introduction
The Haptoglobin (Hp) phenotype has been shown to be a predictor of clinical outcomes in cerebrovascular
disorders. We sought to determine if the Hp phenotype was predictive of functional outcomes after spontaneous
intracerebral hemorrhage (ICH).
Methods
Patients admitted with a diagnosis of ICH were divided into three groups based on their genetically determined Hp
phenotype: 1-1, 2-1, and 2-2. Outcome measures included in-hospital mortality and modified Rankin score (mRS)
at 30 days. Pearson's Chi Square and Wilcoxon-Mann-Whitney tests were used for categorical and continuous
variables respectively. Logistic regression was used to assess association between Hp genotype and ICH
outcomes.
Results
A total of 94 patients were included in the study. The distribution of Hp phenotype in the 94 ICH patients was- Hp 11: 12 (13%), Hp 2-1: 46 (49%), Hp 2-2: 36 (38%). The three Hp subgroups did not differ in terms of demographic
variables, comorbidities or ICH characteristics. Favorable functional outcomes were noted among 4 patients
(33.4%) in Hp 1-1, 2 (4.3%) in Hp 2-1 and 4 (11.1%) in Hp 2-2. In the univariate analysis, Hp 2-1/2-2 phenotypes
were less likely to have mRS 0-2 at 30 days (OR: 0.16, CI: 0.04-0.68, p=0.013). There was a non-significant trend
towards increased mortality in Hp 2-1/2-2 compared to Hp 1-1, with mortality being 8% in Hp 1-1, 17% in Hp 2-1
and 25% in Hp 2-2, p=0.328). In the regression model adjusted for confounders, Hp 2-1/2-2 phenotypes had
significantly lower odds of having favorable outcome (mRS 0-2) compared to Hp 1-1 (p=0.018). Hp 2-1 (OR: 0.05,
95% CI: 0.01-0.47, p< 0.001) and 2-2 (OR: 0.14, 95% CI: 0.02-0.86, p=0.045) each had poor functional outcomes.
Conclusions
Following ICH, individuals with Hp allele 2 (2-1,2-2) had worse functional outcomes than individuals with the Hp 11. There was no association between Hp phenotype and mortality.
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HEMATOMA LOCATIONS PREDICTING DELIRIUM SYMPTOMS AFTER INTRACEREBRAL HEMORRHAGE
Andrew M Naidech, Kelly L Brandstattt, Michael Berman, Joel L Voss
Northwestern Medicine, Chicago, IL, USA
Introduction
Delirium symptoms following acute brain injury include altered consciousness and disorganized thinking. They are
associated with later worse functional outcomes in patients with acute ischemic stroke and intracerebral
hemorrhage, and worse health-related quality of life in patients with intracerebral hemorrhage. There is no known
neurologic basis for delirium symptoms in patients with intracerebral hemorrhage. We tested the hypothesis that
hematoma location is predictive of delirium symptoms.
Methods
We prospectively identified 90 patients with intracerebral hemorrhage who underwent routine twice-daily screening
for delirium symptoms with a validated examination. Voxel-based lesion-symptom mapping with acute computed
tomography was used to identify hematoma locations associated with delirium symptoms.
Results
Acute delirium symptoms were predicted by hematoma of right-hemisphere subcortical white matter (superior
longitudinal fasciculus) and parahippocampal gyrus using a whole-brain-corrected P< 0.05 threshold. Hematoma
including these locations increased relative risk for delirium by 6.8 (95% CI 2.7-17.0; Z=4.1, P< 0.0001). Disruption
of long-range cortical networks that normally support attention and conscious awareness was thus associated with
delirium symptoms acutely. Furthermore, we found that acute delirium symptoms were associated with poorer
health-related quality of life measured up to 1-year follow-up, specifically in the domain of reported executive
cognitive function.
Conclusions
Hematoma location predicts subsequent symptoms of delirium, which is in turn predictive of later worse healthrelated quality of life. Future research might determine which cognitive impairments underlie reduced health-related
quality of life, subtype delirium by its attributes, and determine whether focal injury is associated with delirium
symptoms in other populations.
Financial Support: None
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GUIDELINE ADHERENCE AND OUTCOMES IN SPONTANEOUS INTRACEREBRAL HEMORRHAGE
Emily J Owen1, Brian Anger1, John Chibnall2, Pavan Tummala2, Abhay Kumar2
1
Saint Louis University Hospital, Saint Louis, MO, USA, 2Department of Neurology and Psychiatry, Saint Louis
University School of Medicine, Saint Louis, MO, USA
Introduction
Clinical practice guidelines assist in evidence-based care and improve outcomes. Variability in practice patterns
affects adherence with guidelines. This study describes adherence to the American Stroke Association's (ASA)
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage (sICH) at a primary stroke centercertified academic medical center and determines association between guideline adherence and outcomes in
patients with sICH.
Methods
Patients admitted with a diagnosis of sICH were identified using electronic health records and data related to
demographics and care received were retrospectively collected. A non-adherence score (NAS) was created using
the clinical parameters relating to 18 selected guideline recommendations from ASA. Co-primary endpoints
included rate of full adherence and percentage of overall adherence to the sICH guidelines. The effects of guideline
adherence on in-hospital mortality, length of stay (LOS), discharge location, and mRS were investigated. Data were
analyzed using descriptive statistics and multivariate logistic regression.
Results
Of 202 patients, 131 were included in the analysis. Full guideline adherence was observed in 10 patients (7.6%),
with a mean adherence rate of 88% overall. Guideline adherence was not achieved in 58% of patients for blood
pressure control during first 24 hours and improved only marginally at the time of discharge (48%). Guideline
adherence was lacking in other areas: blood glucose control (21%), no prophylactic antiepileptic drug use (19%),
and pharmacologic venous thromboembolism prophylaxis (22%). Total adherence was higher for class I
recommendations (94.2%) than with class II recommendations (75.8%). NAS did not predict in-hospital mortality,
LOS, discharge location, or mRS.
Conclusions
There was disparity between the rate of complete and overall guideline adherence, probably affected by the
adherence rates stratified by recommendation class. Adherence may be improved by targeting a few key
recommendations. However, recommendations themselves need to be more robust to further study if guideline
adherence affects patient outcomes.
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INR REVERSAL MORE FREQUENTLY ACHIEVED IN PATIENTS RECEIVING PCC-4 VS PCC-3 FOR THE
TREATMENT OF WARFARIN RELATED HEMORRHAGES
Iwona Rybak, Omar Al Majzoub, David Reardon, Patricia Krause
Brigham and Women's Hospital/Pharmacy, Boston, MA, USA
Introduction
Warfarin remains the most commonly used oral anticoagulant. For the treatment of warfarin reversal in addition to
intravenous vitamin K, our institution switched to recently FDA-approved 4-factor prothrombin complex (PCC-4),
replacing previously used 3-factor prothrombin complex concentrate (PCC-3) with fresh frozen plasma. Our
objective was to retrospectively compare PCC-3 to PCC-4 in reversing warfarin in patients who were actively
bleeding.
Methods
We conducted a single-center, retrospective cohort analysis of adult patients on warfarin who received PCC-3 or
PCC-4 for INR reversal. We evaluated PCC-3 between August 2012 and January 2013 and PCC-4 between
August 2013 and January 2014. We excluded patients not actively bleeding. The main outcome was the
percentage of patients who achieved warfarin reversal defined as INR < or = 1.3 at first INR check post factor
administration. We recorded baseline demographics including PCC dose, location of bleed, pre- and post-treatment
INR and time to INR reversal.
Results
We included 35 patients in the PCC-3 group and 18 patients in the PCC-4 group. Intracranial hemorrhage was the
most common site of bleeding [26 (70%) in PCC-3 vs. 12 (66%) in PCC-4]. Patients in the PCC-3 arm received a
mean dose of 26 units/Kg compared to 28 units/Kg in the PCC-4 arm. The mean pre-treatment INR was 2.3 in the
PCC-3 group compared to 2.9 in the PCC-4 group (p=0.03) with post-treatment INR recorded as 1.4 vs 1.2,
respectively (p< 0.01). Warfarin reversal was achieved in 15 (43%) patients who received PCC-3 and 15 (83%)
patients who received PCC-4 (p< 0.01). Faster time to INR reversal was noted in the PCC-4 group vs PCC-3 (220
vs 300 minutes, p=0.48).
Conclusions
INR reversal was more frequently achieved in patients receiving PCC-4 vs. PCC-3 treatment for warfarin reversal.
A larger study is necessary to confirm our results.
Financial Support: None
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OUTCOMES OF ELDERLY PATIENTS WITH SYMPTOMATIC SUBDURAL HEMATOMA FOLLOWING
SURGICAL EVACUATION OR CONSERVATIVE TREATMENT
Michael Su, Ana Beesen, Kimberly Alva, Asma Moheet, Wengui Yu
Cedars Sinai Medical Center Departments of Neurology and Neurosurgery, Los Angeles, CA, USA
Introduction
Management of patients with symptomatic subdural hematoma includes conservative treatment and surgical
evacuation. However, it is unclear whether surgical evacuation results in better functional outcome in elderly
patients. Therefore, we sought to determine if patients over age 80 fare better following craniotomy for subdural
hematoma evacuation than conservative treatment.
Methods
We performed a retrospective study of patients aged 80 years or above who were treated for symptomatic subdural
hematoma at our institution from November 2012 to April 2014. Baseline demographics, antiplatelet or
anticoagulant use, and coagulopathy reversal data were collected. Primary outcome was estimated Modified
Rankin Score (mRS) at hospital discharge. Secondary outcomes included ICU and hospital length of stay. A good
outcome was defined as mRS 3, whereas a poor outcome was defined as 4. Independent samples t- test was
used to look for differences.
Results
71 patients met inclusion criteria. Their mean age was 87.04 years old. 26 (36.6%) patients underwent craniotomy
and 45 (63.4%) were managed conservatively. Craniotomy patients had poorer outcomes (88% with mRS 4)
compared to conservative management (64% with mRS 4) (p = < 0.001), and longer ICU (p = 0.002) and hospital
length of stays (p = 0.011).
Conclusions
In elderly patients with subdural hematoma, craniotomy may lead to worse functional outcome compared to
conservative management. Further investigations, including randomized controlled trials, are warranted.
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CLINICAL OUTCOMES OF METASTATIC INTRA-CEREBRAL HEMORRHAGE AND ROLE OF ACUTE
RADIOTHERAPY
Umair Afzal1, Michael Mendoza1, Mijung Lee2, Seung Hahn3, Julius G Latorre1
1
Neurocritical Care Unit, Department of Neurology, SUNY Upstate Medical University, Syracuse, NY, USA,
Hematology and Oncology, Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, NY,
USA, 3Department of Radiation Oncology, SUNY Upstate Medical University, Syracuse, NY, USA
2
Introduction
Tumor related intracerebral hemorrhage (ICH) represents 0.8-4.4% of all spontaneous ICH. Causes of tumor
related ICH include intratumoral bleeding, cerebral metastases, coagulation disorders and complication of
chemoradiotherapy. Specific guidelines for critical care management of metastatic ICH are lacking and studies on
outcomes have been sparse. We describe seven patients with metastatic ICH and followed their clinical course.
Methods
We reviewed clinical records of 7 patients with discharge diagnoses of metastatic ICH with known primary
malignancy by tissue biopsy admitted to the neuro-critical care unit between 2010-2014.
Results
Out of 7 patients, five were males. Mean age was 64 years. Acute to subacute motor symptoms were seen in five
(71%) patients. Melanoma and Small Cell Lung Cancer were the common primary malignancies. On presentation,
mean systolic blood pressure was 145 mm Hg and mean platelet count was 197,000/uL. Supratentorial hematoma
was seen in 5 patients (71 %). Mass effect was seen in all cases. Midline shift seen in 3 cases (43 %). Five
patients (71.4 %) received corticosteroid therapy. Four patients (57%) received prophylactic anti-epileptic
medication. Two patients (28%) received continuous hypertonic saline as osmotherapy. Four patients (57%)
received radiotherapy. Time of initiation of radiotherapy was variable ranging from 1-20 days from presentation.
Emergent radiotherapy was performed in 1 patient with infratentorial ICH. Recurrence of hematoma was seen in
three patients (43%). Out of these three patients, two patients never recieved radiotherapy and one patient had
recurrence prior to initiation of radiotherapy. Delayed initiation of radiotherapy results commonly to increased
recurrence of metastatic ICH.
Conclusions
Early recognition of metastatic disease as the etiology of ICH is important, particularly when it is the presenting
manifestation. Despite the overall poor prognosis of metastatic cancer, early radiotherapy may increase survival
and offer quality of life in selected group of patients. A larger case series is needed
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DELAYED INTRACEREBRAL HEMORRHAGE AFTER IRRADIATION OF ARTERIOVENOUS MALFORMATION
IN A PATIENT WITH ATRIAL FIBRILLATION ON RIVAROXABAN
Farrukh S Chaudhry, Peter A Rasmussen, Laurie McWilliams-Dunnigan
Cleveland Clinic Foundation, Cerebrovascular Center, Cleveland, OH, USA
Introduction
Delayed intracerebral hemorrhage (ICH) due to radionecrosis is a rare complication after radiotherapy of brain for
arteriovenous malformation (AVM). The risk can be theoretically higher in patients on chronic anticoagulation for
other systemic disease. There are no current case reports of such delayed complication in patients who are being
treated with novel oral anticoagulants like Rivaroxaban for atrial fibrillation.
Methods
Case report with review of literature
Results
We report a case of a 64-year-old right handed Caucasian man with past medical history of hypertension,
congestive heart failure, rheumatoid arthritis, pulmonary fibrosis and ruptured left parietal AVM treated with gamma
knife radiosurgery in 2009. A follow up MRI brain in 2011 showed changes in left parietal lobe consistent with
radiation necrosis. Catheter cerebral angiography in 2012 showed complete obliteration of the AVM. He developed
non-valvular atrial fibrillation in 2013, and treatment was initiated with Rivaroxaban. He was admitted in 2014 with
new onset confusion and altered sensorium. CT head showed a 50 cc left pariet-o-occipital hematoma with
surrounding edema, and transfalcine herniation. Oral anticoagulation was discontinued, despite a CHADS2 score
of 4 (8.5% risk of ischemic events). There was no comparative data for future risk ICH if chronic anticoagulation is
resumed, particulalry in context of radiation necrosis. He was discharged from the hospital two weeks later and was
referred to cardiology for a left atrial appendicular occlusion procedure.
Conclusions
This case presents a unique dilemma of whether to continue oral anticoagulants to prevent further cardioembolic
strokes in a patient with spontaneous ICH after radiation necrosis. As in our patient we opted for surgical treatment
for atrial fibrillation, as the risk of restarting anticoagulation was theoratically higher.
Financial Support: None
247
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COMPARISON OF ICH VOLUME ESTIMATION TECHNIQUES IN SPONTANEOUS SUPRATENTORIAL
INTRACEREBRAL HEMORRHAGE OF VARYING SHAPES AND SITES
Lucia Rivera-Lara, MD, Saman Nekoovaght-Tak, BS, Joshua F. Betz, Daniel F. Hanley, MD, Wendy Ziai, MD, MPH
Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine,
Baltimore, MD, USA
Introduction
The ABC/2 formula overestimates intracerebral hemorrhage (ICH) volume with increasing error for larger
hematomas. We previously showed that using a denominator of 2.4 is a simple, objective way to improve rapid ICH
assessment for both large and small hematomas. Our objective was to validate the ABC/2.4 method based on
analysis of hematoma shape and location.
Methods
Two independent readers assessed diagnostic computed tomography (CT) scans of 364 patients enrolled in the
MISTIE II(N=100) and CLEAR III(N=264) clinical trials. Location was divided into deep and lobar hemorrhages. ICH
shape was designated as: (I)round to ellipsoid, (II)irregular with frayed margins, and (III)multinodular to separated.
We compared averaged ABC/2, 2.4, and 3 with planimetry volumetric calculations using median percentage
deviation with regard to hematoma site and shape.
Results
Median hematoma volume was 13.75[iqr 20.27]cm3(ABC/2), vs. 11.44[16.9](ABC/2.4), vs. 9.16[13.52](ABC/3) vs.
11.99 [18.33]cm3 (planimetry). Hemorrhage location was deep in 88.5%, lobar in 11.5%. Distribution of hematoma
shapes were (1-55%), (II-29%) and (III-16%). Polychoric correlation for 2 raters for shape was 0.69 (p< 0.0001,
95%CI 0.61-0.78). Using consensus determination, ABC/2 significantly overestimated volume by 9.5%(round),
15.9%(irregular) and 19.7%(separated). Degree of overestimation differed across shape categories)(p0.0001).
ABC/2.4 underestimated volume by 8.8%(round), 3.5%(irregular) and 0.3%(separated), but deviations were not
significantly different (p=0.31). ABC/3 underestimated volume by 27.1%(round), 22.8%(irregular) and
20.2%(separated)(p=0.23). Deviations in volumes from planimetry in deep vs. lobar hematomas were smallest
using ABC/2.4, but did not differ significantly within each method.
Conclusions
ABC/2 consistently over-estimates ICH volumes. Median difference between planimetry and ABC/2 increases with
greater departures from elliptical lesions suggesting that ABC/2 is a biased estimate of ICH volume. Using a
denominator of 2.4 is a simple, objective way to improve rapid ICH assessment with the existing measurement
paradigm, which is consistent in both non-elliptical shaped lesions, and for deep and lobar ICH.
Financial Support: None
INTRACEREBRAL HEMORRHAGE
Neurocrit Care
INTRACEREBRAL HEMORRHAGE
248
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DIFFUSE CEREBRAL MICROHEMORRHAGES IN A PATIENT WITH ADULT ONSET POMPE'S DISEASE: A
CASE REPORT
Divyajot S Sandhu, Adam Rizvi, Mustapha Ezzeddine, Rwoof Reshi
University of Minnesota, Minneapolis, MN, USA
Introduction
Pompe's Disease is glycogen storage disease that manifests as vasculopathy, progressive neuropathy and
myopathy. There are a few reports of vasculopathy in this disease, thought to be from small and medium vessel
arteriopathy. We present a case of late-onset Pompe's disease with microhemorrhages and review of the pertinent
literature.
Methods
We describe a case of microhemorrhages in a patient with known late onset Pompe disease.
Results
Our patient was noted to have numerous microhemorrhages concentrated in posterior circulation distribution in
what can best be described as central microhemorrhages, distinct from amyloid angiopathy pattern. Previous
autopsy studies have found vacuoles in the vessel wall resulting in small aneurysms as a part of the Pompe
syndrome.
Conclusions
There is an accumulating body of evidence that suggests cerebral vasculopathy as one of the primary
manifestations of adult onset Pompe's disease. This is manifested as dolichoectasia of basilar artery, aneurysms
and microhemorrhages that are central in distribution. The primary pathology is thought to be glycogen deposition
in small and medium size intracranial vessels. Controlling blood pressure aggressively and screening intracranial
vascular imaging is recommended. Further definition of the syndrome is continuing from phenotypic and genotypic
dimensions.
Financial Support: None
249
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DECOMPRESSIVE HEMICRANIECTOMY IN PRIMARY INTRACEREBRAL HEMORRHAGE
Syed O Shah, Lauren Ng, James Peoples, Michelle Ghobrial, Karen Hoerst, Moshe Mizrahi, Muhammad Athar,
Jacqueline Urtecho, Jack Jallo, Rodney Bell, Matthew Vibbert, Fred Rincon, Barak Bar
Thomas Jefferson University Hospital, Philadelphia, PA, USA
Introduction
Intracerebral Hemorrhage (ICH) remains a devastating type of stroke. Besides blood pressure control, treatment
options including surgery, remain limited. Decompressive hemicraniectomy (DCH) in patients with spontaneous
ICH may be considered a salvage therapy. The purpose of this study was to compare the outcome of patients with
primary ICH who had DCH performed versus expected outcome based on the ICH score.
Methods
A retrospective chart review was conducted between 2011-2014 at our institution of patients with ICH and DCH.
Charts were reviewed for demographics, previous medical history, and serial neurological exams. Glasgow coma
scale (GCS) and computed tomography scans were then reviewed at the time of admission, allowing calculation of
ICH scores. Functional outcome was assessed over the phone using the Simplified Modified Rankin Scale
Questionnaire (smRSq).
Results
We identified 16 patients in this cohort with a mean age of 53± 15 years and 50% male. The overall mortality in our
patient population was 31%. The median ICH score for our cohort was 2 (IQR 0.75-3.25). The average time to
DCH was 65.1±104 hours and 25% had clot evacuation with their DCH. Preoperative GCS and discharge GCS
were 6 and 12, respectively. The average length of follow-up was 582 days. The median mRS on discharge was 5
(IQR 4.75-5.25), while on follow-up the median mRS was 4 (IQR 2-6). Overall, 64% of the patients had an mRS 4
at last follow-up compared to 55% as predicted based on the ICH score. 50% of patients improved by 1 or more
mRS points during followup.
Conclusions
This case-series suggests that patients with ICH associated with significant cerebral edema may potentially benefit
from DCH. Further research in a larger patient population conducted prospectively is warranted to assess the
potential benefit of DCH in ICH.
Financial Support: None
INTRACEREBRAL HEMORRHAGE
Neurocrit Care
MUSCLE AND NERVE DISORDERS
250
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ePoster 238
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RETREATMENT OF THE GUILLAIN-BARRé SYNDROME
Mark N Rubin1, Sara E Hocker2
1
Mayo Clinic Department of Neurology, Jacksonville, FL, USA, 2Mayo Clinic Department of Neurology, Rochester,
MN, USA
Introduction
Acute inflammatory polyradiculoneuropathy, known as Guillain-Barré syndrome (GBS), can cause severe
neurologic morbidity. Treatment typically involves a course of intravenous immunoglobulin (IVIG) or
plasmapheresis (PLEX). A second course of treatment is sometimes recommended, but no evidence-based
guidelines exist to inform this decision. There may be clinical or laboratory features of GBS that predict retreatment.
Methods
We performed a retrospective chart review of patients diagnosed with GBS admitted to the Mayo Clinic Hospital in
Rochester, MN between 01/01/1996 and 11/01/2012. The inclusion criteria were the diagnosis and treatment of
idiopathic acute inflammatory polyradiculoneuropathy. Descriptive statistics and univariate analysis of clinical
parameters were performed. Severity was graded by the GBS Disability Score (GBSDS).
Results
135 patients were included. The mean age was 54 and the cohort was 41% female. At admission, 49% of the
cohort was bedridden or ventilator dependent (poor GBSDS >3). Mean time from symptom onset to first treatment
was 9.7 days. Retreatment was performed in 29% of the cohort at a mean time of 21.4 days from symptom onset.
There was a significant association between time to first treatment and retreatment (p = 0.045), although time to
poor GBSDS and retreatment were not significantly associated (p = 0.388). Retreatment was also associated with
poor GBSDS at 7 days (p = 0.002) and 14 days (p < 0.0001) from hospital admission. No other clinical variable was
associated with retreatment, including age, GBSDS at admission, Miller-Fisher variant phenotype, method of
treatment (IVIG or PLEX), cerebrospinal fluid protein at admission, or serum sodium at admission.
Conclusions
In a large retrospective referral center cohort, only shorter time from symptom onset to first treatment and duration
of poor GBSDS were associated with retreatment. Further research is needed to establish guidelines for GBS
retreatment.
Financial Support: None
251
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PAINFUL CERVICAL LYMPHADENOPATHY, EOSINOPHILIA, AND HIGH EPSTEIN-BARR VIRAL LOAD: AN
UNUSUAL PRESENTATION OF GUILLAIN-BARRé SYNDROME
Farrukh S Chaudhry, Samer AbuBakr, Laurie mcWilliams-Dunnigan, Susan C Samuel
Cleveland Clinic Foundation, Cerebrovascular Center, Cleveland, OH, USA
Introduction
Guillain-Barré syndrome (GBS) has been rarely reported with recent Epstein-Barr virus (EBV) infection, particularly
in younger patients after initial infection or immune compromised patients. The reactivation of EBV as a cause of
GBS after non myeloablative stem cell transplantation has also been reported. There are no case reports in
literature describing an older immune competent patient with high viral load of EBV, with initial presenting
symptoms of GBS.
Methods
Case report with review of literature
Results
We present an extremely unusual case of a 53-year-old Caucasian woman with past medical history of recurrent
sinusitis and asthma. She presented with two weeks history of painful cervical lymphadenopathy without any
associated night sweats, or weight loss, followed by painful paresthesias in the feet and gait disturbance. Over the
next several days of hospitalization, she developed ascending flaccid quadriparesis with generalized areflexia and
respiratory failure. The diagnosis of GBS was confirmed with clinical examination, cerebrospinal fluid analysis and
electromyography/nerve conduction velocity (EMG/NCV) testing. Initial ancillary data also showed leukocytosis
(17K) with marked eosinophilia (26%). Peripheral smear showed absolute eosinophilia. CT of chest and abdomen
showed diffuse lymphadenopathy. An excisional cervical lymph node biopsy showed follicular and paracortical
hyperplasia with increased EBV positive lymphocytes, consistent with EBV related lymphadenitis. Serologies for
EBV showed >390,000 copies of EBV DNA per milliliter, positive EBV nuclear antigen, positive IgG EBV and
negative IgM EBV. CSF analysis for EBV was negative. Patient was treated with plasmapheresis and required
ventilator support due to poor respiratory effort. In addition, she was treated with intravenous ganciclovir. She had a
protracted recovery and was dicharged to a long term acute care facility.
Conclusions
This is an extremely unusual case of an adult patient, otherwise immune competent, with high viral loads of
EBV (with positive EBV IgG and EBV nuclear antigen but negative EBV IgM) in the setting of diffuse
painful lymphadenopathy and eosinophilia presenting with GBS.
Financial Support: None
MUSCLE AND NERVE DISORDERS
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PEDIATRIC NEUROICU
252
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'ADAPTATION OF APNEA TEST FOR BRAIN DEATH DETERMINATION IN PATIENTS ON
EXTRACORPOREAL MEMBRANE OXYGENATION'
Nathan P Dean1,2, Vinay Kukreti2, Jessica L Carpenter2,3, John T Berger1,4
1
Department of Critical Care,Children's National Medical Center, Washington, DC, USA, 2Division of Neurocritical
care,Children's National Medical Center, Washington, DC, USA, 3Center of Neuroscience and Behaviour,Children's
National Medical Center, Washington, DC, USA, 4Department of Cardiology,Children's National Medical Center,
Washington, DC, USA
Introduction
The apnea test is mandatory to confirm brain death unless a medical contraindication exists; however, it is
considered difficult for the patients receiving extracorporeal membrane oxygenation (ECMO). We report a case
series of 4 pediatric patients who underwent apnea testing on Venous Arterial (VA)-ECMO after development of
clinical signs of brain death. To date, this is the largest case series to describe apnea testing in pediatric patients
with hypoxic-ischemic brain injury supported on VA- ECMO.
Methods
Patients who underwent brain death examination while supported with VA-ECMO between 2005 and 2014 were
identified from a prospective ECMO database. Details of the brain death examination and clinical course were
obtained from a retrospective chart review.
Results
A total of 5 patients were identified in which brain death examination was done while they were supported on VAECMO. The apnea test was not performed on one patient where a nuclear scan was done. In 4 patients, apnea
testing was performed after identifying loss of all brain stem reflexes. One patient was on therapeutic hypothermia
which was discontinued and the neurological evaluation was done after rewarming
Conclusions
Apnea testing is an essential component of the brain death examination, and is not described in patients on VAECMO by current guidelines on the determination of death by neurologic criteria. We have shown it can be
performed in a modified way by decreasing the sweep gas flow through the ECMO membrane to allow for
appropriate rise in arterial carbon dioxide levels.
Financial Support: None
253
ePoster 234
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AGE-DEPENDENT DIFFERENCES IN THE EFFECT OF MICROGLIAL INHIBITION AFTER HYPOXIAISCHEMIA IN THE DEVELOPING BRAIN
Peter Ferrazzano1,2, Vishal Chanana1, Douglas Kintner1, Ulas Cikla1, Pelin Cengiz1,2
1
University of Wisconsin, Waisman Center, Madison, WI, USA, 2University of Wisconsin School of Medicine and
Public Health, Department of Pediatrics, Madison, WI, USA
Introduction
The microglial response plays an important role in injury and recovery after hypoxia-ischemia (HI) in the developing
brain, but age-dependent differences in microglial responses are poorly understood. The aim of the current study
was to assess for differences in the effect of microglial suppression after HI in infant and juvenile mice. We
hypothesized that administration of minocycline after HI would result in suppression of microglial activation in both
age groups, and would improve brain injury after HI in younger mice.
Methods
HI was induced in P9 and P30 mice using the Vannucci method of carotid artery ligation and subsequent exposure
to 10% O2 for 50 minutes. Mice were administered minocycline (45mg/kg ip, 2h and 24h post-HI) or vehicle and
sacrificed for flow cytometry (microglia quantification) and immunostaining (MAP2, neurological injury score) at 2
days and 9 days post-HI.
Results
HI induced a significant increase in activated microglia in ipsilateral vehicle treated hippocampus on day 2 post-HI
and a delayed increase in the cortex and striatum at post-HI day 9. Minocycline treatment resulted in a significant
decrease in microglia activation in the hippocampus at post-HI day 2 in P9 and P30 mice. Interestingly, microglia
responses remained suppressed in P9 mice, while P30 mice demonstrated a rebound increase in microglia
activation. Additionally, minocycline treatment resulted in significant improvement in injury scores in P9 mice but
not P30 mice at day 2 and day 9 post-HI.
Conclusions
Minocycline treatment resulted in a sustained suppression of microglial activation and proliferation in P9 but not
P30 mice. Minocycline treatment decreased neurological injury at day 2 and day 9 post-HI only in P9 mice.
Ongoing experiments will assess for age-dependent differences in baseline expression of microglial genes
associated with M1 phenotype and M2 phenotype, and the effect of minocycline treatment on M1 and M2 microglial
responses after HI.
Financial Support: None
PEDIATRIC NEUROICU
Neurocrit Care
PERI-OPERATIVE MANAGEMENT
254
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ACOUSTO-OPTIC CEREBRAL BLOOD FLOW (CBF) MONITORING DURING INDUCTION OF ANESTHESIA IN
HUMANS
W Andrew Kofke1, Giovanni Rivera1, Mary Hammond1, Limor Barkan2, Zmira Silman2, Kirk Jackson1, Moshe
Kamar2
1
University of Pennsylvania/ Department of Anesthesiology and Critical Care, Philadelphia, PA, USA, 2Ornim
Medical, Kefar Saba, Israel
Introduction
CBF is an important variable in Neurocritical care but a non-invasive monitor of CBF has not been available. A
recently developed approach is based on an opto-acoustic adaptation of near infrared spectroscopy. Our objective
was to determine whether the acousto-optic CBF monitor would detect changes in CBF which are known to occur
with propofol(decrease) and subsequent endotracheal intubation (increase)(1).
Methods
57 patients scheduled for elective non-intracranial surgery were enrolled of which 42 were analyzed. Patients with
intracranial disease were excluded. A Cerox3215F (Ornim, Israel) acousto-optic CBF monitor was used. On arrival
in the operating room, the acousto-optic transducers were applied bifrontally. Baseline values were obtained.
Subsequently changes in CBF from baseline were determined at three points: two minute baseline, the lowest
value over three minutes after propofol injection and the highest value over five minutes after laryngoscopy. SaO2
and mean arterial pressure were determined at the same time points. Data were evaluated by repeated measures
ANOVA.
Results
CBF decreased to 83+14% of baseline after propofol (P< 0.001) and increased to 146+34% of baseline after
endotracheal intubation (P< 0.001). Concurrently SaO2 remained >95% across all measurement times. At each
measurement time MAP was 105 + 15 mmHg (baseline), 84+ 18(propofol) (P< 0.001), and 96 +
22mmHg(laryngoscopy) (P=0.11)
Conclusions
Our data are congruent with TCD observations(1) made under similar conditions and similar experimental
paradigm. This supports the notion that acousto-optic monitoring yields valid real-time measures of changes in
CBF in humans. Further validation research compared against other quantitative measures of CBF would be
appropriate. (1) Kofke WA, etal: Transcranial Doppler ultrasonography with induction of anesthesia for
neurosurgery. J Neurosurg Anesth 6:89-97, 1994.
Financial Support: Research supported by Ornim Medical. CoAuthors Barkan, Silman, and Kamar are employees
of Ornim Medical.
255
ePoster 237
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SAFETY, FEASIBILITY AND CLINICAL OUTCOME OF PATIENTS WHO UNDERWENT ENTERPRISE STENT
ASSISTED REPAIR OF INTRACRANIAL ANEURYSM USING LOADING DOSE OF ASPIRIN AND
CLOPIDOGREL -A SINGLE CENTER EXPERIENCE
Varun V Reddy1,2, Karmel Shehadeh3, Ashok Devasenapathy1,2, A Houran3, Joe Chou3, Yahia M Lodi1,2,3
1
Upstate Medical University/UHS-Wilson Medical University, Binghamton, NY, USA, 2UHS-Wilson Medical
Campus, Johnson City, NY, USA, 3Binghamton University, Binghamton, NY, USA
Introduction
Antiplatelet regimen in stent-assisted treatment of intracranial aneurysm is not universal and varies from center to
center. Objectives: To determine the safety, feasibility and clinical outcome of patients who underwent Enterprise
stent-assisted repair of intracranial aneurysm using acute loading doses of aspirin and clopidogrel.
Methods
Consecutive patients underwent enterprise stent-assisted repair of aneurysm using loading doses of aspirin 324
mg and clopidogrel 300 mg were enrolled.The outcome was measured using national institute of health stroke
scale (NIHSS) and modified Rankin Scale (mRS)
Results
47 patients with mean age of 53 ± 13 underwent 56 stent-assisted procedures to treat 53 (2 ruptured cases)
aneurysms. Stent deployed in (98%) but one who underwent aneurysm coiling. There was no intra-operative
hemorrhagic event. Small left subtrachnoid hemorrhage was observed in one with right middle cerebral artery
aneurysm (MCA). Intra-operative asymptomatic MCA branch occlusion developed in one and MCA was
recanalized using inreaarterial eptifibatide. Coil fractured developed in one, which was corrected by placement of
stents without clinical consequences. Post-operative thromboembolic events was observed in 2 cases (4%); first
event developed day 2 with NIHSS 6 in a 42 years old woman with a giant right ICA giant aneurysm and who
recovered completely (NIHSS 0, mRS 0) in 90days. The second event was visual distortion developed on day 2 in
a 66 years old woman with basilar artery aneurysm. Her symptoms resolved completely. Immediate complete and
near complete obliteration of aneurysm was observed in 66% and subtotal in 34%. There was no mortality or
permanent disability in our series. 90 days mRS 0 and 1 was observed in 96% and mRS 2 in 4%.
Conclusions
Using loading doses of aspirin and clopidogrel in Enterprise stent-assisted repair of intracranial aneurysm is not
only safe and feasible but associated with good clinical outcome. Further studies are required.
Financial Support: None
PERI-OPERATIVE MANAGEMENT
Neurocrit Care
PERI-OPERATIVE MANAGEMENT
256
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ACUTE COMA DURING CESAREAN SECTION AND EPIDURAL ANESTHESIA
Prasad Shirvalkar1, Natalie T. Cheng1, Shouri Lahiri3, Katherine Dwulet2, Ko Eun Choi3, Taehoon Lee3, Axel
Rosengart3
1
Department of Neurology Weill Cornell Medical College-New York Presbyterian Hospital, New York, NY, USA,
2
Department of Nursing New York Presbyterian Hospital, New York, NY, USA, 3Departments of Neurology,
Neuroscience and Neurosurgery Weill Cornell Medical College-New York Presbyterian Hospital, New York, NY,
USA
Introduction
Epidural anesthesia (EA) is a common procedure utilized in women undergoing cesarean section (CS). However,
inadvertent puncture of the thecal sac may lead to injection of anesthetic directly into the subarachnoid space,
often without clinical consequence. We present a case where epidural anesthesia was complicated by transient
onset of coma, apnea, loss of all brainstem reflexes minutes after delivery.
Methods
Case report from a tertiary referral center.
Results
We describe a 23-year-old healthy woman who was 39 weeks pregnant and underwent emergent CS utilizing EA
with lidocaine/epinephrine 1:200,000 and morphine dosed to surgical level. Minutes after delivery she vomited
twice, and rapidly became unresponsive to sternal rub, prompting stroke code activation and intubation.
Neurological examination revealed a comatose patient with flaccid tetraplegia and loss of all brainstem reflexes
with 8mm fixed pupils bilaterally. Emergent head CT identified subarachnoid air in the basilar and suprasellar
cisterns; CTA of head/neck were unremarkable; MRI showed normal DWI. Within 60 minutes she gradually
regained brainstem reflexes, was arousable and following commands; she was then extubated and had a normal
examination except for mild paraparesis secondary to epidural anesthesia.
Conclusions
Serious anesthesia-related EA complications such as high neuraxial block, respiratory arrest, and unrecognized
spinal catheter placement are known (SCORE project). However, deep coma after EA is extremely rare and
thought to be due to rostral migration and accumulation of subarachnoid air directly compressing the brainstem.
However, this case report demonstrates that intoxication of brainstem structures by anesthetic may be causative as
1) both progression (within minutes) and resolution (within 2 hours) of coma followed the pharmacokinetics of
injected drugs, 2) while the volume and location of identifiable subarachnoid air (initial CT during coma and MRI
after improvement) remained unchanged; and 3) the clinical symptomatology resembled progressive loss of
caudocranial function typical for intoxications.
Financial Support: None
257
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TEACHING INSTITUTIONS' IMPACT ON CRANIOTOMY MORTALITY: A NATIONAL ASSESSMENT ON
MEASURES OF HEALTH CARE QUALITY
Gregory R. Stenoien1, Ali Seifi1,2
1
University of Texas School of Medicine at San Antonio/Department of Neurosurgery, San Antonio, TX, USA,
University of Texas School of Medicine at San Antonio/Assistant Professor, Department of Neuro Critical Care,
San Antonio, TX, USA
2
Introduction
Mortality of craniotomies is included as a quality of health care. There are many factors that can affect the mortality
of craniotomies, but the impact of teaching institutions on outcome is missing in medical literature. The study seeks
to assess the impact of teaching institutions on the mortality of craniotomy patients.
Methods
Data was acquired from the national information on measures of health care quality based on the NIS, using the
Agency for Healthcare Research and Quality (AHRQ) Quality Indicators. Mortality of craniotomies across the
United States was compared between teaching and non-teaching institutions between 2000-2011.
Results
During 12 years of study, craniotomy mortality as an inpatient quality indicator was significantly higher in males and
elderly (P-Value < 0.0000). The mortality of craniotomies decreased significantly from 97.9 per 1000 in 2000 to
35.7 in 2011 (P-Value < 0.0000). The mean and median cohort mortality was 71.124 and 73.126 respectively.
When considering the impact of teaching institutions on mortality, it was significantly higher only in 2004 (P-value <
0.0000). The effect of teaching institutions was significantly protective of craniotomy patients in 2000, 2002, 2006,
2008, 2009, 2010, and 2011 (P-value < 0.0000) and was neutral in other years.
Conclusions
Craniotomy mortality has been significantly decreasing from 2000 to 2011. The effect of teaching institutions on
mortality has been variable but, most of the time, protective. Teaching hospitals are often level I trauma centers
with a more complicated patient population, which affects mortality. On the contrary, these hospitals may go to
extra measures to be more thorough in patient care for the sake of education. Furthermore, there may be more
concern with hygiene and infection control practices. Having more healthcare providers with different levels of
experience, including students, residents, and attending physicians, brings more people involved in patient care to
prevent errors.
Financial Support: None
PERI-OPERATIVE MANAGEMENT
Neurocrit Care
DISORDERS OF CONSCIOUSNESS
258
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EVOLUTION AND CLINICAL RELEVANCE OF REACTIVITY AND CONTINUITY OF EEG BACKGROUND IN
CARDIAC ARREST PATIENTS TREATED WITH THERAPEUTIC HYPOTHERMIA
Sachin Agarwal1, Andres Rodriguez1, Brandon Foreman1, Priyank Patel1, Hyunmi Choi1, Stephan A. Mayer2, Jan
Claassen1
1
Columbia University, new york, NY, USA, 2Icahn School of Medicine at Mount Sinai, new york, NY, USA
Introduction
The prognostic significance of reactive and continuous background on EEG during and after therapeutic
hypothermia (TH) is unclear.
Methods
This is a retrospective analysis of consecutive cardiac arrest patients who underwent both TH (goal 33 C), and
continuous EEG monitoring for 72 hours at Columbia University Medical Center from 2008 to 2013. The EEG
reactivity was categorized into (present or absent), and continuity into continuous (< 10%) and discontinuous
(>10% period of suppression). Different groups (Group 1: absent/absent; Group2: present/absent; Group 3:
present/present; Group 4: absent/present) were created based on their pattern on the day of event and postrewarming phase. Rates of poor (CPC>3) outcome was compared in different groups.
Results
A total of 130 patients with mean age (63±17 years), CPC>3 (76%), change of reactivity in group 1, 2, 3, 4 (59%,
7%, 24%, 10%), and continuity (35%, 18%, 42%, 5%) respectively. Group 1 had 100% poor outcome compared to
28% in group 3. Group 2 patients who later lost their reactivity had poor outcome in 87.5%. Group 4 had no
difference in outcomes. For background continuity, group 1 had the lowest incidence of poor outcome (63%)
compared to group 2: (77%), with highest incidence in patients with discontinuous background during and after TH
(group 3: 92%). change of background from discontinuous to continuous after TH mantained higher rates of poor
outcome (group 4: 86%). The group with discontinuous background compared to continuous background on both
days had 6.5-fold higher risk of poor outcome (p=0.002).
Conclusions
There was a higher incidence of patients whose reactivity and continuity whether present or absent did not change
due to TH and these groups have the highest rates of good and poor outcomes respectively, after cardiac Arrest.
Future studies should evaluate the prognostic value of these patterns by prolonged EEG monitoring beyond 72
hours.
Financial Support: None
259
ePoster 245
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EFFECT OF ADVANCED COMA EVALUATION AND CARE FOR MEDICAL EDUCATION: A PROPOSAL OF A
NOVEL TRAINING SYSTEM FOR NEUROLOGICAL EMERGENCIES.
Yasuhiko Ajimi1, Ichiro Kaneko1, Yasuo Takeuchi1, Hisashi Ishikawa1, Hiroshi Okudera2, Tetsuya Sakamoto1
1
Teikyo University/ Emergency Medicine, Tokyo, Japan, 2University of Toyama/Crisis Medicine, Toyama, Japan
Introduction
Japan Resuscitation Council (JRC) released JRC guidelines 2010, in which a concept of neuro-resuscitation (NR)
was proposed ahead of the world. Based on NR, JSEM (Japanese Society for Emergency Medicine) developed a
training system named ACEC (Advanced Coma Evaluation and Care) for learning initial managements of acute
impaired consciousness caused by various pathologies. In this paper, we introduce a simulation training according
to ACEC system and report its effect for medical education.
Methods
ACEC algorithm consists of three steps: (1) primary survey for resuscitation including the assessment and
treatment of Airway, Breathing, Circulation, Disability of the central nervous system, Epilepsy, Fever and Freeze
(abnormal temperature), abnormal level of blood Glucose, Hydrogen (acidosis), and Ions (abnormal levels of blood
electrolytes), (2) secondary survey for emergencies and (3) tertiary survey for connecting specialists of each field.
Thirty-eight fifth-year medical students in our university joined in this training. We used 3G human simulator made
by Laerdal Medical and employed five training scenarios of emergency treatments for patients with acute impaired
consciousness caused by (1) hemorrhagic stroke, (2) status epilepticus, (3) heat stroke, (4) bacterial infection and
(5) diabetic ketoacidosis selected from 21 ACEC scenarios, which were designed on a clinical map possessing a
two-dimensional fashion with a treatment of ACEC algorithm. All the students took a same examination consisting
of 10 multiple choice questions (MCQ) before and after their training. We compared scores of the MCQ between
before and after.
Results
Average scores of the MCQ before and after the training were 4.13 (95%CI: 1.32 í 6.95) and 7.42 (95%CI: 4.98 í
9.86). A significant difference was observed in these two averages (p < 0.05).
Conclusions
The system and the materials of ACEC can be effective for medical students to learn neurological emergencies.
Financial Support: None
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AN ATYPICAL PRESENTATION OF AN ATYPICAL SYNDROME: A NEARLY-FATAL CASE OF HANDL:
SYNDROME OF TRANSIENT HEADACHE AND NEUROLOGIC DEFICITS WITH CEREBROSPINAL FLUID
LYMPHOCYTOSIS: A CASE REPORT
M.Ali Babi M.D1, Waqar Waheed M.D1, Paul Penar M.D2, Christopher Commichau M.D1
1
Fletcher Allen Healthcare and the University of Vermont / Department of Neurosciences, Burlington, VT, USA,
2
Fletcher Allen Healthcare and the University of Vermont / Department of Neurosurgery, Burlington, VT, USA
Introduction
HaNDL is described as a self-limited benign entity and was first described in 1981. Although not entirely
understood, the pathogenesis of HaNDL is thought to involve a post-infectious or inflammatory mechanism in which
auto-antibodies are directed against neuronal or vascular antigens. An aseptic leptomeningeal vasculitic process
results into headache and neurological deficits and secondary injury in the setting of elevated in ICP may also
occur.
Methods
This is a case report with review of previously described cases (Pubmed search). A previously healthy 31-year-old
woman developed rapidly declining mental status and respiratory failure following a course of 10 days of daily
persistent headache. There were no other antecedent triggers identified. The patient's rapidly progressed to coma
(Glascow Coma Scale of 5T) following admission and was emergently resuscitated in an ICU setting.
Results
Extensive imaging and serological diagnostic work-up failed to yield a specific etiology. An emergent lumbar
puncture revealed a lymphocytic pleocytosis with elevated protein and intracranial pressure (ICP) over 55cmH2O.
EEG monitoring did not reveal any features suggestive of seizures. MRI brain with gadolinium revealed subtle but
diffuse leptomeningeal enhancement without any focal lesion. Patient's poor neurological examination was thought
to be secondary to elevation in ICP; in the setting of impaired autoregulation, and cerebral hyperemia (vasogenic
edema) secondary to inflammatory cascade. The patient was aggressively treated with pulmonary support,
hyperosmolar therapy, acetazolamide, and CSF shunting via lumbar drain. The patient made a complete recovery
within 3 weeks with eventual normalization of CSF profile. She had no neurological sequaelae.
Conclusions
HaNDL has previously been characterized as a self-limited headache syndrome with a benign course. This case
illustrates an atypical presentation of a rare syndrome culminating in uncontrolled elevated ICP. Additionally, we
highlight the need for a high index of suspicion when patient present with unusual pattern of headaches
accompanied by non-focal exam suggesting elevated ICP.
Financial Support: None
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ALBUMINOCYTOLOGIC DISSOCIATION IN POSTERIOR REVERSIBLE ENCEPHALOPATHY SYNDROME
Sudhir V Datar, Tarun D Singh, Jennifer E Fugate, Alejandro A Rabinstein, Sara E Hocker
Mayo Clinic, Rochester, MN, USA
Introduction
Patients with posterior reversible encephalopathy syndrome (PRES) present with acute onset of headache,
decreased level of consciousness and often, seizures. The differential diagnosis is extensive and includes
inflammatory and infectious processes. Spinal fluid analysis is sometimes indicated to differentiate among these
possibilities, but can also create diagnostic confusion because expected CSF findings in PRES are not known. The
purpose of this study was to describe CSF patterns in patients with PRES.
Methods
Retrospective review of 73 consecutive adults diagnosed with PRES, based on clinical features (headache, vision
changes, encephalopathy, and seizures) and imaging characteristics with documented reversibility.
Results
Seventy-three patients, mean age 51 years (SD ± 17), were included in the analysis. 50 (69%) were women. The
most common causes were hypertension (85%) and immunosuppression (30%). Renal failure was present in 55%.
Median CSF protein was 58 mg/dL (IQR 44-81). Median CSF protein was significantly higher in patients with
vasogenic edema involving the thalamus (96 vs 53 mg/dL, IQR 76-134, p 0.0007) compared to those without
involvement of thalamus. Median WBC count was 1 cells/uL (IQR 1-2) and with lymphocytic predominance (48%).
Median opening pressure was 230 cm H2O (IQR 180-280) which was however available in only 27 patients.
Median interval between clinical onset of PRES and CSF analysis was 1 day (IQR 0-2).
Conclusions
Albuminocytologic dissociation can also be seen in patients with PRES. Knowledge of this finding is important to
avoid unnecessary tests to evaluate elevated CSF protein. The presence of CSF pleocytosis should prompt
consideration for further diagnostic testing.
Financial Support: None
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DECREASED GROWTH OF ARACHNOID CELLS EXPOSED TO FIBROBLASTS AND BILIRUBIN
Catherine A. Miller1, Eric Hansen2, Cornelius H. Lam1, 2
1
University of Minnesota, Minneapolis, MN, USA, 2Veterans Affairs Medical Center, Minneapolis, MN, USA
Introduction
The pathophysiology of non-obstructive hydrocephalus involves alteration in cerebrospinal fluid (CSF) pathways.
The exact mechanism has yet to be elucidated. As arachnoid CSF egress is a major route of CSF removal,
damage or alteration to the growth of arachnoid cells may influence the rate of CSF absorption. We investigated
the effect of soluble factors secreted by fibroblasts and the presence of bilirubin on arachnoid cell growth.
Methods
4 x 106 arachnoid cells from an immortalized rat cell line were plated in the basal compartment of transwells in
triplicate, while fibroblasts were plated in each apical chamber. Cell counts at day 3, 5, and 7, and growth rates
were obtained using a hemocytometer and compared to controls. Similar experiments were conducted with bilirubin
(1mg/mL concentration), which was added to fibroblasts in the apical chamber. DNA content in the cell cultures
was determined using the DNeasy Blood and Tissue Kit.
Results
The control cell counts for days 3, 5, and 7 were 1.43 x 105, 1.95 x 105, and 2.30 x 105, respectively. Arachnoid
cells in the presence of fibroblasts had cell counts of 9.57 x 104, 1.50 x 105, and 2.14 x 105 on days 3, 5, and 7
respectively, and when exposed to both fibroblasts and bilirubin, the cell counts were 9.65 x 104, 1.35 x 105, and
1.92 x 105 on days 3, 5, and 7. DNA content was reduced at all time points.
Conclusions
Arachnoid cells are closely related to CSF as they form the barrier of the subarachnoid space and arachnoid
granulations. Fibroblasts and bilirubin are encountered in inflammation and/or hemorrhage, and we show that
arachnoid growth decreases in the presence of both fibroblasts and bilirubin. Given its intimate relationship with
CSF, it is possible that this decreased growth may affect absorption and thus the development of hydrocephalus.
Financial Support: None
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INTERRATER RELIABILITY OF PUPILLARY ASSESSMENTS AMONG PHYSICIANS AND NURSES
Daiwai M. Olson, Sonja E. Stutzman, Ciji Saju, Margaret J. Wilson, Venkatesh Aiyagari
The University of Texas Southwestern Medical Center, Dallas, TX, USA
Introduction
Assessment of pupillary size, shape, and reactivity is one of the most fundamental aspects of the neurological
examination. However, interrater reliability of these findings has not been established.
Methods
We examined interrater reliability of bedside pupillary exams as part of a large prospective study comparing
penlight and pupillometer evaluations in a multi-site study of patients admitted to Neurology and Neurosurgery
units. Exams were performed by neurology and neurosurgery attending and resident physicians, staff nurses and
mid-level practitioners. Under identical conditions, two assessors simultaneously evaluated the left (OS) and right
(OD) pupils of consented patients. An interim analysis of the first 200 samples (final N = 1,183) was performed,
evaluating only between-assessor observational data.
Results
Currently, 210 paired observational assessments of OS and OD pupils have been completed. There was
composite agreement in all three parameters (size, shape, reactivity) for 75 (35.7%) OS and 71 (33.8%) OD. Both
assessors scored the pupil size identically in 92 (43.8%) OS and 88 (41.9%) OD assessments; pupil shape was
scored identically in 201 (95.7%) OS and 200 (95.2%) OD assessments; pupil reactivity was scored identically by
both assessors in 165 (78.6%) OS and 152 (72.4%) OD assessments. Complete non-reactivity (fixed pupil) was
scored identically by both assessors in 19/31 (61.3%) OS and in 4/10 (40%) OD assessments.
Conclusions
Preliminary results suggest that there is a surprising degree of disagreement between scores from trained
observers in assessing pupillary findings. Furthermore, in 23 of 41 (44%) of the assessments, there was no
agreement on the absence of pupillary reactivity. Given the importance of pupillary reactivity in patients with
neurological injury, these findings may have significant clinical implications. Final results will be reported at the
2014 Neurocritical Care Society Meeting.
Financial Support: Pupillometers and headrests were lent by NeurOptics Inc. at no cost.
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NON-HERPETIC ACUTE LIMBIC ENCEPHALITIS: A CASE SERIES AND REVIEW
Adam Rizvi, Takamasa Higashimori, Divyajot Sandhu, Rwoof Reshi
University of Minnesota, Minneapolis, MN, USA
Introduction
Background Non-herpetic acute limbic encephalitis (NHALE) is a poorly described entity currently with no known
cause. It was first identified in 1994 in the Kyushu district of Japan and only recently has it been described in more
detail. It is characterized by a clinical presentation similar to HSV encephalitis with MRI imaging findings often
showing bilateral hippocampal and amygdala hyperintensities. Detailed work-up however including HSV PCR,
ELISA, and post-mortem analysis in select cases have been negative for herpes simplex encephalitis. Its clinic
course is notable for altered behavior, fever, and prolonged seizures with cognitive deficits being a common
sequelae. It generally carries a favorable prognosis, however, and is therefore important to recognize. A correlation
has been found between NHALE and autoantibodies against glutamate receptor epsilon2 and delta2. (GluRepsilon2 and GluR-delta2). Here we present a consolidated case series of 24 patients gathered from previously
listed case reports in Japan including 4 patients of our own as well as review the implications of this important
entity.
Methods
Following an extensive literature review, we gathered 24 cases of non herpetic acute limbic encephalitis
predominantly from Japan including 4 of our own and present our findings.
Results
Among the patients we listed there is a common presentation of altered behavior, fever, and prolonged seizures.
Workup is notably negative for HSV encephalitis and inpatient stay is often prolonged to weeks or months. There is
also a correlation with autoantibodies against glutamate receptor which may aid in diagnosis and prognosis is
generally favorable.
Conclusions
NHALE is a known entity with a similar presentation to HSV limbic encephalitis. Given the generally favorable
prognosis and known correlation with glutamate receptor antibodies, it is an important entity to consider in the
critical care setting.
Financial Support: None
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EVENT-RELATED POTENTIALS: COMATOSE PATIENTS AND PREDICTION OF AWAKENING
Starane A. Shepherd1, Brian Arwari2, Kristine H. O'Phelan1
1
Department of Neurology, Jackson Memorial Hospital/University of Miami, Miami, FL, USA, 2Department of
Kinesiology and Sport Sciences, University of Miami, Miami, FL, USA
Introduction
Neurological prognosis in comatose patients is assessed via the clinical exam and clinician's judgment, and is often
subjective. Neurophysiological tests, namely, event related potentials (ERPs), are inexpensive, readily available
and noninvasive tests. ERPs can be used to demonstrate higher level cortical processing in comatose patients and
contribute to the prediction of neurological recovery.
Methods
17 comatose patients, defined by Glasgow Coma Scale (GCS) < 9, underwent electroencephalogram (EEG)
recordings while hearing a series of randomly computer-generated tones (1000Hz standard and 1200Hz deviant),
presented randomly with 90% and 10% probabilities respectively. The EEG was processed offline producing the
ERPs by averaging neuro-electrical signals to the standard and deviant tones. Mismatch negativity (MMN) and the
N100 waveforms were extrapolated and analyzed from this recording. Outcome was assessed at 6 months with the
Glasgow Outcome Scale Extended. Patients were grouped by outcome, awake vs. non-awake, according to
question 1 of the Glasgow Outcome Coma Scale Extended. This was defined as being able to obey simple
commands or speak.
Results
Of the 11 follow-ups conducted, 4 patients awoke from coma (36.3%). Of these patients, 2/4 had both the N100
wave form present and a positive MMN. The 2/4 remaining patients who awoke had neither the N100 nor MMN
present. Of the 7 patients who did not awake (63.6%), the N100 waveform was present in 1 only (sensitivity 85.7%,
specificity 50%). Absence of MMN was 71.4% sensitive and 50% specific in predicting non-awakening.
Conclusions
The absence of the N100 waveform is highly sensitive but nonspecific in predicting non-awakening from coma.
MMN is less sensitive than the N100 wave form and nonspecific. Limitations include small sample size, mixed
etiology of coma, and the impact of both aphasia and withdrawal of care on outcome assessment. Further data in a
larger and more homogeneous sample need to be collected for conclusive results.
Financial Support: None
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EEG GAMMA BAND ENERGY AS AN OUTCOME INDICATOR AFTER CARDIAC ARREST IN AN ANIMAL
MODEL
David L. Sherman1, Marin Kheng1, Sharjeel Chaudhary1, Nitish V. Thakor1,2, Romer G. Geocadin2
1
Johns Hopkins University/Biomedical Engineering, Baltimore, MD, USA, 2Johns Hopkins University/Neurology,
Baltimore, MD, USA
Introduction
The electroencephalogram (EEG) has been useful as a predictor of outcome during resuscitation after
experimental cardiac arrest (CA). Previously our group has used different EEG entropy and spectral measures as a
means to forecast outcome after CA. Additionally, we have shown that EEG bursting and burst counts may be a
powerful tool to show that EEG shows a robust recovery. Now we show that EEG gamma band activity from 30-50
Hz often synonymous with bursting is an effective tool for discerning recovery status.
Methods
We subjected rats (N=9) to nine minutes of asphysxic cardiac arrest after gas washout. Rats were then
resuscitated. Animals were subjected to a behavioral neuro-deficit score or NDS assessment testing at 72 hr postreturn of spontaneous circulation (ROSC). An NDS of 60 or greater served as the delineator of favorable outcome.
Two channels of EEG were recorded continuously for entire experiment. EEG was filtered and the filter output was
subjected to an instantaneous, point-by-point energy operator. Data points were averaged in one minute intervals
and then the gamma energy fraction or relative gamma was formed.
Results
Eight 10-minute energy estimates calculated from 90 to 170 minutes post-ROSC were subjected to repeatedmeasures ANOVA statistical testing. Gamma fraction could distinguish the groups with a p-value of less than 0.02.
Individual epoch t-tests showed differences at p< 0.03. Gamma activity in the EEG post-cardiac arrest may provide
critical outcome information.
Conclusions
This buttresses earlier work that suggests that EEG entropy and high frequency activity are candidate markers for
recovery of arousal and cognition. In the awake, aroused state, generalized desynchronization of EEG is
accompanied by dynamic, bi-directional, coherent oscillations between reciprocal thalamocortical and
corticothalamic projections. These oscillations occur in the high frequency range, clustering around 40Hz, the so
called gamma rhythms which are prominent in the reawakening animal.
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STRUCTURAL INJURY AND TIME TO RECOVERY OF CONSCIOUSNESS FOLLOWING HEMORRHAGIC
STROKE
Jan Claassen, Emma Meyers, Angela Velasquez, J Michael Schmidt, Maria Cristina Falo, Fawaz Al-Mufti, Sureerat
Suwatcharangkoon, Jens Witsch, Soojin Park, Sachin Agarwal, E. Sander Connolly
Columbia University, NY, NY, USA
Introduction
Impaired consciousness of varying duration frequently follows hemorrhagic stroke. Structural injury may explain the
inability to regain consciousness but prolonged impairment of consciousness without structural injury is poorly
understood.
Methods
In this prospective observational study of 130 comatose aneurysmal subarachnoid hemorrhage (SAH,N=94) and
intracerebral hemorrhage patients (ICH,N=36), we explored the ability and timing of recovery to follow simple
commands while in the hospital. Based on daily interruption of sedation (except in status epilepticus [N=4] or
refractory intracranial pressure (ICP) crisis [N=10]) we determined the first time that patients were able to follow
simple commands. We compared those with to those without diffuse bi-hemispheric, diencephalic, tegmental and
thalamic structural injury (Plum&Posner,ISBN #978-0-19-532131-9) based on serial CT(N=130) and MRIs(N=66).
Results
Overall, 48% (N=62) of comatose patients (48%[N=45] of SAH and 47%[N=17] of ICH patients) started following
simple commands while in the hospital (median post bleed day 18[IQR 12, 21]). Amongst those with bilateral,
extensive structural injury 93%(13/14) had prolonged impairment of command following (compared to those without
P=0.001;OR 0.1;95%-CI 0.1-0.6). 57%(17/30) and 44%(38/86) of those with partial or no structural injury had
prolonged impairment of consciousness. None of those with diffuse bi-hemispheric (N=9), tegmental (N=3), or
thalamic (N=2) and only one patient with diencephalic injury (N=6) started following commands. Frontal lobe injury
if absent or unilateral was not but if bilateral was associated with failure to recover command following if extensive
and bilateral (14%[3/21] vs 51%[59/109]).
Conclusions
We confirm that structural injury of the brainstem, diencephalon, thalamus, and cortex is associated with prolonged
impairment of consciousness but almost half of those without structural injury have prolonged impairment of
consciousness and only a small fraction of these are medication induced. Structural injury below the resolution of
standard imaging likely accounts for some of this variability but non-structural causes may play a role in some
patients.
Financial Support: None
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STIMULANT USE TO IMPROVE WAKEFULNESS FOLLOWING BRAIN INJURY IN THE NEURO-ICU.
RESULTS OF AN ON-LINE SURVEY THROUGH THE NEUROCRITICAL CARE SOCIETY .
James Peoples, MD1,2,6, Kristopher Feeko, DO3, Lauren Ng, MD1,2,6, Michelle Ghobrial, MD1,2,6, Omar Shah,
MD1,2,6, Matthew Vibbert, MD1,2,5, Jacqueline Urtecho, MD1,2,5, Barak Bar, MD1,2,5, Jack Jallo, MD, PhD2,5, Carissa
Pineda, MD1,6, Diana Tzeng, MD1,6, Rodney Bell, MD1,6, Fred Rincon, MD1,2,5, Kamran Athar, MD2,4,5
1
Thomas Jefferson University, Department of Neurology, Philadelphia, PA, USA, 2Thomas Jefferson University,
Department of Neurosurgery, Philadelphia, PA, USA, 3Thomas Jefferson University, Department of Physical
Medicine & Rehabilitation, Philadelphia, PA, USA, 4Thomas Jefferson University, Department of Medicine,
Philadelphia, PA, USA, 5Division of Critical Care and Neurotrauma, Philadelphia, PA, USA, 6Division of
Cerebrovascular Diseases, Philadelphia, PA, USA
Introduction
Brain injury can have lasting neurologic sequelae. Many patients suffer from disorders of attention and arousal
following brain injury. Most of the therapies offered to these patients are largely supportive. Our goal was to create
a clinical practice survey to evaluate which specific medications are currently being used by neurointensivists in the
management of attention and arousal disorders following brain injury.
Methods
We organized an 8 question unvalidated survey. Our sampling population was primarily made up of
neurointensivists, medical intensivists, neurosurgeons and anesthesiologists. The survey was conducted through
email and was available for participation: November 15, 2013 through November 29, 2013. The survey was sent to
1366 Neurocritical Care Society (NCS) members. We utilized descriptive statistical analysis when reviewing our
percentage data.
Results
We received 122 completed on-line responses. More than half of our respondents were neurointensivists (54.9%).
59.8% of the respondents selected amantadine as their medication of choice to address attention and arousal
issues. 69.4% of the respondents initiated therapy more than a week out from injury. 34.4% of the respondents
treat their patients for more than 2 weeks. 55.7% of respondents reported trying another agent, if the initial
selection did not improve wakefulness. 76.2% selected traumatic brain injury (TBI) as the primary diagnosis of
patients receiving pharmacologic treatment. Overall, 50.4% of the respondents felt that medications were effective
only a quarter of the time. Interestingly, 99.1% of the respondents reported their institution does not follow a clinical
practice guide line when using pharmacologic agents to treat disorders of attention and arousal.
Conclusions
In the survey, amantadine, a dopaminergic agent, is used most frequently. However, there are a variety of
medications and time schedules that are utilized. Our results show that nearly all respondents do not have an
institutional policy directing medication therapy for disorders of attention and arousal following brain injury.
Financial Support: None
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TRANSORBITAL SONOGRAPHIC EVALUATION OF NORMAL OPTIC NERVE SHEATH DIAMETER IN
HEALTHY NEPALESE ADULTS
Gentle S Shrestha
Tribhuvan University Teaching Hospital, Department of Anaesthesiology, Kathmandu, Nepal
Introduction
Sonographic evaluation of optic nerve sheath diameter (ONSD) is increasingly used as a non-invasive technique
for detecting raised intracranial pressure. This study aims to find out the normal ONSD in healthy Nepalese adults.
Methods
In a prospective observational study, ONSD was measured 3 mm behind the globe using 6 to 13 MHz linear probe.
Subjects were examined in supine position with their eyes closed and in neutral position. Tranducer was placed
horizontally and in each eye, an average of three readings were documented.
Results
One hundred healthy subjects above 18 years of age were enrolled in the study. The ONSD ranged from 2.5 - 4.9
mm with a mean of 3.9 mm and standard deviation of 0.5 mm. There was no significant difference in ONSD
measurement between males and females (p=0.064) and between right and left eye (p=0.695). There was no
relationship between ONSD and age (R2=0.014, p=0.243).
Conclusions
The range for normal ONSD in healthy Nepalese subjects is 2.5 - 4.9 mm with no significant relationship with
gender, age and side of the body.
Financial Support: None
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USE OF SANGUINATE IN ENCEPHALOPATHY FROM SEVERE SICKLE CELL DISEASE ANEMIA
Panayiotis N Varelas1, Vassilios Mastorodimos2, Michael Mendez3, Emily Iocco3, Yathreb Alaali3, Mohammed
Rehman1, Abe Abuschowski4, Tamer Abdelhak1
1
Henry Ford Hospital, Division Neurosciences Critical Care, Detroit, MI, USA, 2University of Crete, Department of
Neurology, Heraklion, Crete, Greece, 3Henry Ford Hospital, Division Pulmonary Critical Care, Detroit, MI, USA,
4
Prolong Pharmaceuticals, South Plainfield, NJ, USA
Introduction
Patients with sickle cell anemia (SSC) are at increased risk for stroke. Periodic blood transfusions decrease
velocities < 200cm/s-1 in middle cerebral (MCAs) monitored by Transcranial Doppler (TCD) and prevent strokes.
Sanguinate (PEGylated carboxyhemoglobin bovine) is an intravenously administered product that combines the
beneficial functions of a carbon monoxide releasing molecule in dilating vessels with an oxygen transfer agent.
Methods
A 23-year-old Jehovah witness woman with sickle cell/ȕ°-thalassemia trait was admitted with encephalopathy and
respiratory distress. She had been recently discharged from another hospital after multi-organ failure, including
myocardial infarction secondary to severe anemia, cerebral infarction, and acute kidney injury requiring
hemodialysis. Despite lowest hemoglobin (Hg) 3.1 g/dL she strictly refused transfusion. Patient was managed with
intubation and mechanical ventilation due to hypoxia (PaO2 54.3, sPaO2 88.4%, pH 7.48 and PaCO2 38.2) and
anemia (Hg 4.6 g/dL), antibiotics for pneumonia and hemodialysis for oliguric acute tubular necrosis. She remained
delirious despite these measures. 500ml infusion of 40 mg/mL SANGUINATE was given IV and repeated in 24
hours. After initial extubation failure, two more units of anguinate were provided.TCD was performed serially.
Results
Initial TCD revealed hyperemia with high blood flow velocities. After Sanguinate was administered a gradual
velocity reduction was observed in both MCAs (for example, right MCA baseline 151 ± 3.2 vs 48 hours post last
transfusion 120 ± 3.2 cm/s-1, p < 0.001, ANOVA). A similar trend was noted in the posterior circulation. The
encephalopathy resolved, she improved hemodynamically, was successfully extubated after a second attempt and,
despite Hb of 3.1 g/dL upon extubation, she had resolved dyspnea and left the hospital.
Conclusions
Sanguinate is a promising alternative to human blood transfusion in treating symptomatic SCD patients. It improved
respiratory failure, encephalopathy and cerebral hemodynamics and facilitated extubation in the setting of severe
anemia.
Financial Support: Dr Abe Abuchowski is the CEO/CSO of Prolong Pharmaceuticals, which provided the drug
free for compassionate use in this patient
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A CASE OF PEROXYSMAL SYMPATHETIC HYPERACTIVITY DUE TO BASILAR ARTERY DISSECTION
Hitoshi Kobata, Erina Yoritsune, Akira Sugue, Masayuki Oka
Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan
Introduction
Paroxysmal sympathetic hyperactivity (PSH) is a recently recognized syndrome characterized by episodic fever,
tachycardia, hypertension, tachypnea, diaphoresis, muscle rigidity, and pupillary dilatation. Traumatic brain injury is
the most common etiology leading to PSH followed by hypoxia and subarachnoid hemorrhage. There are few
reports of imaging features of PSH to identify the causative location.
Methods
Case report.
Results
A previously healthy 23-year-old man was found unresponsive with vomit at home. His Glasgow Coma Scale was
11 (E4, V2, M5) on arrival. Initial brain CT scan revealed acute ischemic lesion in the left occipital lobe. CT
angiography showed near occlusion of the distal basilar artery (BA). Emergent DSA demonstrated faint filling of the
distal BA and the right posterior cerebral artery. Perforators around the basilar bifurcation were seen. Despite
antiplatelet treatment, he further deteriorated. MRI taken next day revealed progress of ischemic lesions involving
bilateral thalami, bilateral occipital lobes, right cerebellar hemisphere, and vermis. A crescendo-shaped thrombus
was seen in the distal BA lumen. Based on these radiological findings, the lesion was diagnosed as BA dissection.
Repeated DSA demonstrated tapering occlusion of the BA. He remained stuporous while the 8th day after
admission he presented episodic fever, tachycardia, tachypnea, hypertension, diaphoresis, pupillary dilatation, and
muscular stiffness, which occurred 4 to 5 times a day with duration around 30 minutes. Diagnosis of PSH was
made. His PSH episodes gradually decreased after administration of clonidine, bromocriptine, amantadine, and
gabapentin. He could obey verbal commands when he discharged to rehabilitation hospital 2 months later.
Conclusions
A case of PSH due to BA dissection was presented. BA dissection has not been reported as a cause of PSH. The
present case is noteworthy in localizing the possible responsible lesion of PSH.
Financial Support: None
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RECOVERING CONSCIOUSNESS IN COMATOSE SURVIVORS OF CARDIAC ARREST WITH SEIZURES:
EEG MARKERS REVISITED
Benjamin R. Waterhouse1, Maximilian Mulder2,3, Raoul Sutter5, Peter W. Kaplan2, Romergryko G. Geocadin2,3,4
1
Medical Sciences Division, University of Oxford, Oxford, United Kingdom, 2Department of Neurology, Johns
Hopkins University School of Medicine, Baltimore, MD, USA, 3Department of Anesthesia and Critical Care
Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA, 4Department of Neurosurgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA, 5Department of Neurology and Intensive Care Units,
University Hospital Basel, Basel, Switzerland
Introduction
Seizures and status epilepticus (SE) in comatose patients after cardiac arrest are believed to be associated with
mortality. However, in the comatose population with severe brain injury, the EEG diagnosis of seizures and SE
continue to vary widely among practitioners and institutions.
Methods
We conducted a retrospective study of 36 comatose survivors of cardiac arrest admitted to Johns Hopkins Bayview
Medical Center who were referred for consultation regarding SE. EEGs were reviewed independently of clinical
course and outcome. EEG and clinical characteristics were compared between survivors and non-survivors, and
between those who did and did not regain consciousness during admission.
Results
The mean patient age was 58.2 years, 56% were male, and overall survival was 28% (10/36). Except for a longer
ICU stay in survivors, (43 versus 15 days, p=0.03), no difference was noted between survivors and non-survivors
by SOFA Score; location of arrest; initial cardiac rhythm; and therapeutic hypothermia. 24/36 EEGs exhibited
seizures/epileptiform activity, however, this did not correlate with mortality; 6/24 with seizures on EEG survived and
3/24 regained consciousness by discharge. Specific EEG parameters (e.g. GPED, PLEDS, reactivity) correlated
poorly with outcome, except for generalized versus frontal seizures, which correlated with mortality (p=0.034).
Using a dichotomized (favorable versus unfavorable) composite EEG score comprising reactivity, background
activity, seizure localization, and the absence of GPEDs, significant difference was seen between those who did
and did not regain consciousness (p=0.01).
Conclusions
The clinical or EEG diagnosis of epileptiform activity, seizures or SE did not predict death and should not be used
routinely to guide decisions regarding withdrawal of life sustaining treatment. Preliminarily, we found a simple
dichotomized composite scoring of EEG that predicted the recovery of consciousness in this population. A larger,
prospective study is needed to validate our findings.
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EYE-OPENING MYOCLONUS IS A POOR PROGNOSTIC SIGN AFTER CARDIAC ARREST.
Julia B. Whitlock, MD, William O. Tatum, DO, William D. Freeman, MD
Mayo Clinic, Department of Neurology, Jacksonville, FL, USA
Introduction
Following hypoxic ischemic brain injury (HIBI), suppression-burst (S-B) EEG pattern, status myoclonus (MS), and
elevated neuron specific enolase are poor prognostic indicators. Eye-opening (EO) is a myoclonus variant seen
after HIBI that can be misinterpreted as volitional movement, potentially becoming a source of confusion and
creating false hope for families which can hinder medical decision-making. Correlation of EO with EEG is helpful in
determining an accurate diagnosis and prognosis, as well as educating families and caregivers.
Methods
Retrospective chart review of in-hospital cardiac arrests (CA) who developed EO myoclonus was conducted from a
prospective Mayo Clinic Florida CA database from 2007 to 2013. Clinical, radiographic, and laboratory data were
reviewed; EEG and video were reviewed from segments of continuous video EEG to correlate with EO.
Results
314 CA occurred during the study period; 79 underwent therapeutic hypothermia; 11 developed EO myoclonus (10
CA and 1 non-cardiac cause). All patients were evaluated with EEG within 24 hours of initial injury. Seven (64%)
exhibited S-B pattern on EEG, 1 (9%) had generalized periodic discharges (GPDs), 1 (9%) had suspected GPDs
versus MS, 1 (9%) had intermittent epileptic myoclonus without S-B pattern, 1 (9%) had bitemporal slowing with
mild non-specific encephalopathic changes without true S-B pattern. The latter patient suffered HIBI from noncardiac cause with good outcome and near complete recovery except for mild residual action myoclonus. All
patients (10/11 or 91%) with EEG showing S-B, GPDs, epileptic myoclonus and SM died.
Conclusions
EEG helps define severe patterns such as S-B, GPDs, and MS that predict patient outcome. EO myoclonus
associated with these patterns on EEG appears to portend a poor prognosis after CA. EO myoclonus associated
with non-cardiac etiology may carry a more favorable prognosis than seen post CA. Family education of such
patients is important to understand such eye opening is not volitional.
Financial Support: None
DISORDERS OF CONSCIOUSNESS
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SURVIVING CARDIAC ARREST DESPITE THE PRESENCE OF MALIGNANT EEG PATTERNS: A CASE
SERIES
Edilberto Amorim1, Jon C Rittenberger2, Yangzhong Zhou3, Maria E Baldwin1, Alexandra Popescu1
1
University of Pittsburgh Medical Center, Department of Neurology, Pittsburgh, PA, USA, 2University of Pittsburgh,
Department of Emergency Medicine, Pittsburgh, PA, USA, 3University of Pittsburgh Schoold of Medicine,
Department of Neurology, Pittsburgh, PA, USA
Introduction
Status epilepticus and other malignant EEG patterns (MEP) are prevalent and strongly associated with mortality
and poor outcome in cardiac arrest (CA). Since the advent of induced hypothermia (IH), cases of favorable
outcome despite development of MEP have been reported. We herein describe a case series of patients who
survived despite the development of MEP.
Methods
Review of medical records and cEEG from patients undergoing IH after CA between April/2010 and June/2013.
MEP were defined as myoclonic status epilepticus (MSE), status epilepticus (SE), convulsive seizures, and
generalized periodic discharges (GPD). Only subjects who developed MEP and survived to hospital stay were
included. A Cerebral Performance Category score (CPC) of 1-2 at hospital discharge was considered good
outcome.
Results
Four hundred subjects were screened. One-hundred and nineteen subjects (29.8%) survived to hospital discharge,
and twenty survivors (5%) experienced MEP. Median cEEG duration was five days (IQR 3-7), and ten subjects
(50%) developed MEP within the first 24h of EEG monitoring. Generalized periodic discharges were the most
common MEP (10 cases), followed by SE (5), MSE (4), and convulsive seizure (1). Malignant EEG patterns started
during hypothermia in eight (40%) subjects, and nine (45%) required three or more anti-seizure drugs. Eight (40%)
subjects were discharged home or to an acute rehabilitation facility, and two (10%) had a CPC score of 1-2 at
hospital discharge. Two subjects with MSE were discharged to an acute rehabilitation facility with CPC scores of 3.
The two subjects with good outcome developed EEG background reactivity in the first 24 hours of recording and
did not have signs of anoxic injury on brain MRI.
Conclusions
Post-anoxic malignant EEG patterns are prevalent and associated with poor outcome. Presence of EEG
background reactivity and lack of structural damage on brain MRI may identify patients more likely to survive with
good outcome.
Financial Support: None
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PROPOSAL FOR A PROSPECTIVE, SINGLE CENTER, RANDOMIZED, CONTROLLED, PILOT STUDY TO
EVALUATE THE FEASIBILITY, EFFECTIVENESS AND SAFETY OF CONTINUOUS INTRAVENOUS INSULIN
INFUSION AS ADD-ON STRATEGY TO STANDARD TREATMENT FOR REFRACTORY STATUS
EPILEPTICUS IN ADULTS
Indira De Jesus, Christopher Morrison, Amedeo Merenda
University of Miami/Jackson Memorial Hospital/Neurocritical Care, Miami, FL, USA
Introduction
Refractory Status epilepticus (RSE) carries a dismal prognosis, with mortality rates of 39%, and poorer functional
outcomes than non-refractory SE. Rapid anesthetic coma induction with continuous intravenous (cIV) infusion of
midazolam, propofol or pentobarbital (i.e. refractory therapy) is the recommended approach to this clinical entity,
but course can be prolonged and results variable. The recognition of increasing mortality and morbidity with
increasing duration of RSE and the detrimental effects of prolonged anesthetic coma and mechanical ventilation
points to the necessity of improving the efficiency of therapy for this clinical entity. Purpose: To determine whether
the combination of cIV insulin infusion with the standard therapy for RSE is feasible, acceptably safe, and effective
in achieving rapid resolution of electrographic seizure or EEG-burst suppression, as well as reducing the rate of
breakthrough seizures during the tapering phase of the refractory therapy, compared with standard RSE treatment
alone.
Methods
Prospective, single center, randomized, controlled pilot study in adult patients with non-anoxic RSE. Subjects will
be randomized to standard therapy for RSE plus cIV insulin infusion (with or without concomitant dextrose
infusion), or standard RSE therapy alone.
Results
The primary outcomes will be feasibility and safety of adjuvant cIV insulin infusion. Safety outcome measures will
be mortality, hypoglycemia (BG < 70) and severe hypoglycemia (BG 40). The secondary outcome will be
effectiveness of adjuvant cIV insulin as measured by time to resolution of RSE and rate of breakthrough seizures.
Conclusions
The refractoriness of SE is, in part, underlain by internalization of GABAA receptors with ensuing loss of GABAmediated inhibition in neuronal networks. Insulin has been shown to increase surface membrane expression of
GABAA receptors in central nervous system neurons. This trial expects to determine whether adjuvant cIV insulin
infusion has a role for the treatment of RSE.
Financial Support: None
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SEIZURES AND EPILEPTIFORM DISCHARGES IN HEPATIC DYSFUNCTION
James C Guth, Matthew B Maas, Irena I Garic, Elizabeth E Gerard, Eric M Liotta, Andrew M Naidech, Stephan U
Schuele
Northwestern University/Neurology, Chicago, IL, USA
Introduction
Seizures are commonly seen in patients with hepatic dysfunction. It is unclear if seizures in patients with hepatic
dysfunction are associated with worse outcome, and what clinical features identify patients at increased risk of
developing seizures in this population. The objectives of this study are to evaluate if seizures or epileptiform
discharges (SED) found on electroencephalography (EEG) in patients with hepatic dysfunction are associated with
higher in-hospital mortality, and to identify clinical features associated with finding SED on EEG.
Methods
Patients undergoing EEG were enrolled into a prospective registry between January 2007 and November 2013.
EEGs were performed at the discretion of the primary team and were interpreted by board-certified epileptologists.
Electronic medical records were reviewed for clinical variables and to identify patients with hepatic dysfunction.
Binary logistic regression models with backward conditional variable selection were developed to test whether the
occurrence of seizures was independently associated with in-hospital mortality, and to identify clinical markers
associated with SED.
Results
82 patients were studied. Of these patients, 28 (34%) had SED on EEG. SED were associated with in-hospital
mortality (odds ratio 4.83, [95% CI 1.25-18.87], p=.023). Other associated variables identified on regression
modeling were the use of immunosuppression medication and encephalopathy grade. Independent predictors of
SED found on multivariate analysis were encephalopathy grade, alkaline phosphatase level and aspartate
aminotransferase levels.
Conclusions
SED are associated with in-hospital mortality in patients with hepatic dysfunction. Predictors of SED include
encephalopathy grade, alkaline phosphatase and aspartate aminotransferase levels.
Financial Support: None
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SHOULD A KETOGENIC DIET BE CONSIDERED EARLIER IN THE TREATMENT COURSE OF
ADULTS WITH SUPER-REFRACTORY STATUS EPILEPTICUS?
Ryan Hakimi, Marguerite A Butchee, Jaclyn D Duvall, Emmaculate M Fields, Andrea S Hakimi
Univ. of Oklahoma Department of Neurology, Oklahoma City, OK, USA
Introduction
Super-refractory status epilepticus (SRSE) is defined as refractory status epilepticus that persist for 24 hours or
more despite appropriate anesthetic therapy. The ketogenic diet (KD) is an established antiepileptic treatment in
some children with epilepsy. However, there is limited evidence for its use in adults with SRSE.
Methods
We present a case of Creutzfeldt-Jakob disease (CJD) presenting as SRSE in a 44-year-old woman with a history
of depression who was involved in a minor motor vehicle collision due to witnessed seizures. Initial EEG revealed
complex partial status epilepticus. Diagnostic studies were unremarkable including five contrast-enhanced brain
MRIs, four lumbar punctures, paraneoplastic, autoimmune and infectious studies. Intractable clinical and subclinical
seizures continued as captured on continuous video EEG despite treatment with lorazepam, levetiracetam,
lacosamide, valproic acid, fosphenytoin, clobazam, midazolam and propofol. Burst suppression was achieved with
pentobarbital, however seizures returned upon weaning. Further treatment included therapeutic hypothermia for a
total of 120 hours, intravenous steroids, intravenous immune globulin and later on plasmapheresis for possible
autoimmune encephalitis with mild improvement in seizure frequency. Once SRSE persisted enteral KD was
started on day 27.
Results
Marked clinical improvement and resolution of SRSE was noted five days after KD initiation. Results later returned
supporting the diagnosis of CJD with positive CSF 14-3-3, Tau protein and real-time quaking-induced conversion.
Family declined biopsy given patient had considerable clinical improvement. She was discharged to inpatient
rehabilitation on a modified Atkins diet (MAD). At three-month follow-up, she remained on MAD and seizure burden
was reduced to once daily on clobazam, valproic acid, lacosamide, phenobarbital, levetiracetam and clonazepam
with tapering plans.
Conclusions
This case suggests the potential value of KD in patients with SRSE. Future studies evaluating the role of KD earlier
in the treatment of SRSE in the adult population should be pursued.
Financial Support: None
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RACE, ANOXIC BRAIN DAMAGE, HYPOTHERMIA AND METABOLIC ABNORMALITIES ARE ASSOCIATED
WITH STATUS EPILEPTICUS IN PATIENTS POST CARDIAC ARREST: FINDINGS FROM THE NATIONWIDE
INPATIENT SAMPLE (NIS) 2011 DATABASE
Neville M Jadeja, Peter Mabie, Lenore Ocava
Jacobi Medical Center,Albert Einstein College of Medicine/Departments of Medicine & Neurology, New York, NY,
USA
Introduction
Cardiac arrest is the most common cause of death in the Unites States with over 350,000 deaths per year.
Seizures in these patients are associated with poor outcomes. We investigate the association of cardiovascular,
neurological and metabolic factors with status epilepticus in hospitalized patients with cardiac arrest from a large
nationwide registry.
Methods
All hospitalized patients included in the nationwide inpatient sample (NIS) 2011 database with a confirmed
discharge diagnosis of Cardiac arrest, as per the ICD-9-CM code 427.5 were identified. NIS is the largest all-payer
inpatient database in the United States. Multivariable logistic models were used to determine the associations of
African American race, anoxic brain damage, hypothermia, acid-base disturbances, hyposmolarity, hypocalcemiamagnesemia and hypoglycemia with status epilepticus amongst these patients.
Results
From the 8,023,590 admissions in the NIS 2011 database, 34,739 patients with cardiac arrest were identified.
Patients had a mean age of 65.69(+18.05) years, 45.3 % (15731) were women. We used weighted analysis to
estimate the national values. 164,109 cardiac arrest patients were thus analyzed with status epilepticus identified in
2350 (1.41%) patients. The model was adjusted for Age, sex, race, income, residence, anoxic brain damage, brain
trauma, hypothermia, myoclonus, stroke, sepsis, cardiac shock, metabolic encephalopathy, acute renal failure,
anuria-oliguria, hypoxemia, hypocalcemia-magnesemia, hypoglycemia, acid-base disorders, osmolality and
phosphate disorders. African American race (OR 1.18), anoxic brain damage (OR 10.81), hypothermia (OR 1.62)
and the metabolic disturbances such as hyposmolarity (OR 1.34), hypocalemia-magnesemia (OR 1.91), acidosis
(OR 1.31), alkalosis (OR 1.41) and hypoglycemia (OR 1.62) were independently associated with risk of status
epilepticus (P< 0.005).
Conclusions
In this large national database African American race, anoxic brain damage, hypothermia and specific metabolic
disturbances were associated with an increased risk of status epilepticus. Further studies are needed to
understand if correcting these factors can improve outcomes.
Financial Support: None
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THE IMPACT OF CONTINUOUS EEG (CEEG) MONITORING ON OUTCOMES IN PATIENTS ADMITTED TO
ICU: A PROSPECTIVE OBSERVATIONAL STUDY
Ayaz M Khawaja1, Guoqiao Wang2, Gary Cutter2, Jerzy P Szaflarski1, 3
1
Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA, 2Department of
Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA, 3Division of Epilepsy, University of
Alabama at Birmingham, Birmingham, AL, USA
Introduction
Limited evidence from retrospective studies suggests that cEEG impacts patient outcomes. This study aimed to
prospectively investigate disposition (home, inpatient rehabilitation [IR], nursing home [NH], death) and discharge
GCS (GCSD) as outcome measures in ICU patients who did (cEEG-group) or did not receive (non-cEEG-group)
cEEG monitoring.
Methods
Data were prospectively collected from 222 patients, divided equally into cEEG-group and non-cEEG-group. Two
sub-cohorts were created based on admission diagnosis. (A) TBI or stroke with hemorrhage (25.8%)/TBI or Stroke
without hemorrhage (14.5%)/other (59.7%) regardless of hemorrhage; (B) TBI (19%)/Stroke (21.3%)/other (59.7%)
. Patients admitted due to seizures only were excluded. Primary outcomes were disposition and GCSD.
Explanatory variables included: demographics, comorbidities, admission GCS (GCSA), and duration of ICU stay.
Ordinal logistic regression and general linear modeling were used to identify factors associated with disposition and
GCSD, respectively.
Results
After controlling for GCSA, there were no significant differences in both outcomes between cEEG-group and noncEEG-group for 1) any diagnosis or 2) diagnosis listed within the sub-cohorts A and B. Differences in disposition
within sub-cohorts A and B were significant (p< 0.0001) regardless of cEEG monitoring. Most common disposition
was IR for TBI-patients (54.76%), NH for stroke-patients (40.43%), and home for patients with other diagnosis
(40.43%). Disposition in cEEG-group was home (13.1%), IR (12.7%), NH (14.5%) and death (10.4%); and in noncEEG-group was home (16.7%), IR (11.3%), NH (12.7%), and death (8.6%). Disposition was significantly impacted
by age (p=0.0016; OR=0.975, 95% CI=0.960-0.990), duration of ICU stay (p=0.0007; OR=0.969, 95% CI=0.9510.987;) and GCSA (p=0.0104; OR=1.088, 95% CI=1.020-1.160). There was no significant difference in either
GCSA between cEEG-group and non-cEEG-group [9.9(4.1) vs 10.9(3.8)] or GCSD [11.5(4.5) vs 11.9 (4.5)],
respectively.
Conclusions
There were no differences in disposition and GCSD of ICU patients who did or did not receive cEEG monitoring.
Other outcome measures (e.g. modified-Rankin scores) need to be investigated.
Financial Support: None
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SUCCESSFUL TREATMENT OF PROLONGED REFRACTORY STATUS EPILEPTICUS WITH PLASMA
EXCHANGE AND RITUXIMAB
Nagendra Madisi1, Jennifer L. Berkeley2
1
Sinai Hospital of Baltimore, Department of Medicine, Baltimore, MD, USA, 2Sinai Hospital of Baltimore,
Department of Neurology, Baltimore, MD, USA
Introduction
Refractory status epilepticus (RSE) is a life-threatening condition characterized by failure to respond to antiepileptic
drugs (AEDs). Here, we present a case of prolonged RSE (> 100 days), which resolved with plasma exchange
(PLEX) followed by rituximab.
Methods
A 23-year-old woman presented with a 4-day history of URI symptoms with fevers and new-onset seizures. Upon
admission, her seizures increased in frequency and duration. She was transferred to the ICU for continuous EEG
monitoring and induction of a barbiturate coma. CSF revealed 18 WBC (91% segs) with normal protein and
glucose. EEG showed both generalized tonic clonic and subclinical seizures. MRI showed restricted diffusion in the
splenium. An extensive work-up revealed only elevated mycoplasma and Coxsackie B antibodies.
Results
She was treated with multiple AEDs, as well as trials of pentobarbital, midazolam, ketamine, magnesium, ketogenic
diet and hypothermia, in various combinations. Methylprednisolone and IVIG were ineffective. PLEX notably
decreased her seizure activity and drip requirements. However, this effect lasted only 2-3 weeks before seizure
activity increased again. Thus, she underwent another course of PLEX followed by rituximab. After a 4-week
rituximab course, her drips were weaned. The patient woke up and began following commands.
Conclusions
Febrile Illness-Related Epilepsy Syndrome (FIRES) and New Onset Refractory Status Epilepticus (NORSE)
describe a severe epileptic encephalopathy in previously healthy individuals. In this case, we exhausted most
treatment options reported in the literature. We suspected a post-infectious autoimmune mechanism given our
patient's preceding febrile illness, and felt this hypothesis was confirmed by the initial response to PLEX. Treatment
with rituximab expanded the gains made with PLEX allowing our patient to begin her recovery. There are several
reports in the literature of rituximab treatment for FIRES, with limited success. Yet, for cases of prolonged RSE, a
course of PLEX followed by rituximab should be considered, as there are few alternatives.
Financial Support: Dr. Berkeley is on the Speaker's Bureau for UCB, makers of lacosamide. This drug is not
specifically discussed in this abstract, but is one of the many AEDs the patient described was given.
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SHORT-ACTING NEUROMUSCULAR BLOCKADE IN PATIENTS WITH POST-ANOXIC MYOCLONUS
IMPROVES CONTINUOUS ELECTROENCEPHALOGRAPH (CEEG) RECORDINGS
Christopher R Newey, Alejandro Hornik, Mezian Guerch, Wilson Cueva, Jeff Frank, Agnieszka Ardelt
University of Chicago, Chicago, IL, USA
Introduction
Myoclonus and generalized periodic discharges (GPDs) are independently associated with poor outcome in coma
patients post cardiac arrest (Bouwes et al 2012, Foreman et al 2012). Determining if myoclonus and other
myogenic artifacts are of cortical origin on cEEG can be difficult secondary to the muscle artifact obscuring the
underlying EEG background. The use of a short-acting neuromuscular blocker in these patients can be useful for
identifying the background cerebral activity.
Methods
Retrospective review of cEEGs in patients who had post-anoxic myoclonus and received cisatracurium while being
monitored.
Results
Nine patients (mean age 60.3 years, range 34-74 years; 6:9 M:F) met inclusion criteria of clinical post-anoxic
myoclonus. The initial cEEG patterns immediately prior to neuromuscular blockade showed myoclonic artifact with
continuous slowing (5/9; 55.6%), burst suppression with myoclonic artifact (3/9; 33.3%), and continuous myogenic
artifact obscuring cEEG (1/9; 22.2%). After intravenous administration of cisatracurium (range 10-100mg), the
cEEG tracings improved in 7/9 (77.8%) revealing previously unrecognized patterns: continuous EEG seizures in
3/7 (42.8%), lateralizing slowing (1/7; 14.3%), burst suppression (1/7, 14.3%), GPDs (1/7, 14.3%), and in the
patient who had an initially uninterpretable cEEG from myogenic artifact, continuous slowing (1/7, 14.3%).
Conclusions
Short-acting neuromuscular blockade is useful in determining background cerebral activity on cEEGs otherwise
partially or completely obscured by muscle artifact in patients with post-anoxic myoclonus. Fully understanding
background cerebral activity is important in prognostication and treatment, particularly when there are underlying
EEG seizures.
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SUBTHERAPEUTIC LEVETIRACETAM CONCENTRATIONS IN TRAUMATIC BRAIN INJURY PATIENTS
REQUIRING POST-TRAUMATIC SEIZURE PROPHYLAXIS
Farid Sadaka1,2, Matthew J Korobey1
1
Mercy Hospital St Louis/Critical Care and Neurocritical Care, St Louis, MO, USA, 2St Louis University, St Louis,
MO, USA
Introduction
Seizures are common after traumatic brain injury (TBI). Phenytoin has traditionally been used for seizure
prophylaxis or treatment in TBI patients, but the adverse-effect profile and need for frequent monitoring lead to
search for safe alternatives. Because of its safety profile and ease of use, Levetiracetam is frequently used for
seizure prophylaxis in TBI patients. Evidence suggests that Levetiracetam systemic clearance may be faster in
neurocritical care patients.
Methods
Six TBI patients received intravenous Levetiracetam at recommended dose (500 mg or 1000 mg every 12 hrs) for
seizure prophylaxis for 7 days post-TBI. After a minimum of 3 doses, blood samples were collected 30 minutes
before the next dose (trough level). Samples were sent to Mayo clinic lab for determination of serum Levetiracetam
concentrations.
Results
Patients' characteristics were as follows: age (31 ± 8 years), BMI (26 ± 6), GCS (7 ± 3), APACHE II score (16 ± 5),
serum creatinine (0.6 ± 0.1 mg/dl), and creatinine clearance (193 ± 64 ml/min). Four patients received
Levetiracetam at a dose of 500 mg every 12 hours and 2 patients received it at a dose of 1000 mg every 12 hours.
All trough levels were significantly subtherapeutic, ranging from < 2.0 to 4.4 mcg/ml (reference range for trough
concentration: 12.0- 46.0 mcg/mL). None of the patients developed clinical seizures.
Conclusions
When given at recommended doses, Levetiracetam therapeutic concentrations were not achieved in TBI patients,
suggesting high systemic clearance rate in this patient population. Higher doses or more frequent doses may be
needed to achieve target trough concentrations. When appropriate Levetiracetam dosing is identified in future
studies, then it can be appropriately studied and compared to other anti-epileptic drugs in the management of
seizures in TBI patients.
Financial Support: None
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THE SIGNIFICANCE OF EQUIVOCAL VERSUS UNEQUIVOCAL EEG PATTERNS IN CARDIAC ARREST
Navid Tabibzadeh, Jocelyn Cheng
Drexel College of Medicine/Neurology, Philadelphia, PA, USA
Introduction
Rhythmic and periodic EEG patterns have been increasingly recognized in critically ill patients. Although criteria
have been proposed to distinguish whether these patterns represent ictal or interictal phenomena, their
significance, and whether they represent nonconvulsive status epilepticus (SE) in comatose individuals without
additional overt signs of seizures, remains unclear. Prior research has been confounded by multiple variables,
including non-uniform patient pathology. In this study, we focused on patients with the same underlying potential
seizure etiology (cardiac arrest, CA) to determine whether survival differed between those with unequivocal
electrographic SE and continuous equivocal EEG patterns.
Methods
This was a retrospective study of CA patients diagnosed with presumed SE who underwent EEG at a university
hospital (1/1/2005-10/31/2012). Status epilepticus was classified as unequivocal (clear electrographic seizures) or
equivocal (rhythmic/periodic EEG pattern). Baseline data included age, gender, CA rhythm and duration,
hypothermia and medical co-morbidities. Outcome was survival. Continuous and categorical data was assessed
using 2-tailed t-testing and Pearson's Chi2, respectively. Logistic regression analysis adjusted for covariates.
Significance was set at p< 0.05.
Results
The cohort consisted of 45 subjects, mean age=60 years (range: 25-92), 18(40%) male. Eleven (24.4%) subjects
survived. The majority of subjects with available cardiac rhythm data exhibited asystole (N=38/43,88%). Mean CA
duration=20 minutes (range:5-80), and 14/45(31%) subjects underwent hypothermia. There was no significant
difference in baseline features. EEG was unequivocally consistent with SE in 29(64.4%) subjects, of whom 2 were
in nonconvulsive SE. Sixteen (35.6%) demonstrated equivocal EEG patterns. In 10/16(62.5%) subjects, equivocal
EEG patterns were clinically correlated to seizure-like activity, while clinical correlate was absent in 6/16(37.5%).
After adjusting for demographic, medical and CA characteristics, survival did not differ between subjects with
equivocal versus unequivocal SE.
Conclusions
In cardiac arrest patients, comatose individuals with continuous equivocal EEG patterns demonstrated equally poor
survival compared to those with unequivocal convulsive and nonconvulsive electrographic status epilepticus.
Financial Support: None
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NONCONVULSIVE SEIZURES IN SUBARACHNOID HEMORRHAGE LINK INFLAMMATION AND OUTCOME
Jan Claassen1,2, David Albers3, J. Michael Schmidt1, Gian Marco De Marchis1, Deborah Pugin1, Christina Maria
Falo1, Stephan A. Mayer1, Serge Cremers4, Sachin Agarwal1, Mitchell SV Elkind5, E. Sander Connolly2, Vanja
Dukic6, George Hripcsak3, Neeraj Badjatia1
1
Division of Critical Care Neurology, Department of Neurology Columbia University, College of Physicians and
Surgeons, New York, NY, USA, 2Department of Neurosurgery Columbia University, College of Physicians and
Surgeons, New York, NY, USA, 3Department of Biomedical Informatics Columbia University, College of Physicians
and Surgeons, New York, NY, USA, 4Biomarkers Core Laboratory of the Irving Institute Columbia University,
College of Physicians and Surgeons, New York, NY, USA, 5Department of Epidemiology, Mailman School of Public
Health Columbia University, College of Physicians and Surgeons, New York, NY, USA, 6Department of Applied
Mathematics, University of Colorado-Boulder, Boulder, CO, USA
Introduction
Nonconvulsive seizures (NCSz) are frequent following acute brain injury and have been implicated as a cause of
secondary brain injury but mechanisms that cause NCSz are controversial. Pro-inflammatory states are common
after many brain injuries and inflammatory mediated changes in blood-brain-barrier permeability have
experimentally been linked to seizures.
Methods
In this prospective observational study of aneurysmal subarachnoid hemorrhage (SAH) patients we explored the
link between the inflammatory response following SAH and in-hospital NCSz studying clinical (systemic
inflammatory response syndrome, SIRS) and laboratory markers of inflammation (tumor necrosis factor receptor
1,TNF-R1; high sensitivity C-reactive protein,hsCRP). Logistic regression, cox proportional hazards regression, and
mediation analyses were performed to investigate temporal and causal relationships.
Results
Among 479 SAH patients, 53(11%) had in-hospital NCSz. Patients with in-hospital NCSz had a more pronounced
SIRS response (OR1.9 per point increase in SIRS; 95%-CI1.3-2.9), inflammatory surges were more likely
immediately preceding NCSz onset, and the negative impact of SIRS on functional outcome at 3 months was
mediated in part through in-hospital NCSz. In a subset with inflammatory serum biomarkers we confirmed these
findings linking higher serum TNF-R1 and hsCRP to in-hospital NCSz (OR1.2 per 20 point hsCRP increase [95%CI1.1-1.4]; OR2.5 per 100 point TNF-R1 increase [95%-CI2.1-2.9]). The association of inflammatory biomarkers
with poor outcome was mediated in part through NCSz.
Conclusions
In-hospital NCSz were independently associated with a pro-inflammatory state following SAH reflected in clinical
symptoms and serum biomarkers of inflammation. Our findings suggest that inflammation following SAH is
associated with poor outcome and this effect is at least in part mediated through in-hospital NCSz.
Financial Support: None
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THE PROGNOSTIC SIGNIFICANCE OF MYOCLONUS AFTER CARDIAC ARREST
Teddy S Youn1, Adithya Sivaraju2, Emily J Gilmore1, Nicolas Gaspard2
1
Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of
Medicine, New Haven, CT, USA, 2Comprehensive Epilepsy Center, Department of Neurology, Yale University
School of Medicine, New Haven, CT, USA
Introduction
Myoclonic status epilepticus (MSE) is still considered predictive of a fatal outcome in cardiac arrest survivors.
However, some patients have had favorable outcomes with MSE. The aim of this study was to identify
determinants of outcome in patients with MSE.
Methods
We retrospectively identified and performed a subgroup analysis of twenty-three patients with myoclonus, that are
part of a cohort of 101 patients treated for anoxic encephalopathy after cardiac arrest in our institution between
May 2011 and May 2014. Myoclonus was defined as any clinical description consistent with jerking movement of
the face, arms and legs. MSE was defined by the presence of a time-locked EEG correlate to the myoclonus. The
onset of myoclonus was defined as either before therapeutic hypothermia (TH), during TH, during rewarming, or
after rewarming (in days). Electrographic patterns of burst suppression and nonconvulsive status epilepticus
electrographic markers were also noted. Outcome was assessed according to the Glasgow-Pittsburgh Cerebral
Performance Categories (CPC), dichotomized as good (CPC1-3) or poor (CPC4-5).
Results
Of the twenty-three patient with myoclonus, only three had a good outcome. Two of them developed myoclonus
before hypothermia that recurred after rewarming. Neither patient presented with a malignant EEG pattern
(suppression-burst, GPDs on a suppressed background or suppression) at any point. They did not receive
anticonvulsants. Both made a good recovery (CPC 2 and 3). One patient developed MSE two days after
rewarming. Myoclonic movements were associated with GPDs, but the underlying EEG background was
continuous and variable. The patient was treated with lorazepam, phenytoin, valproate, levetiracetam, midazolam
and ketamine. She made a good recovery (CPC = 3).
Conclusions
Early myoclonus before TH, and MSE after rewarming are not always associated with a poor outcome. EEG
findings may have a higher prognostic significance than myoclonus. In particular, malignant patterns may invariably
be associated with poor outcome.
Financial Support: None
SEIZURES
ePoster 267
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Alberto Goffi