Cerebral Venous Thrombosis and Subdural Collection in a Comatose Patient: Do Not Forget Intracranial Hypotension. A Case Report.

BACKGROUND: The typical sign of intracranial hypotension (IH) is postural headache. However, IH can be associated with a large diversity of clinical or radiological signs leading to difficult diagnosis especially in case of coma. The association of cerebral venous thrombosis (CVT) and subdural hemorrhage is rare but should suggest the diagnosis of IH. METHODS: Case report. CASE DESCRIPTION: We report here a case of comatose patient due to spontaneous IH complicated by CVT and subdural hemorrhage. The correct diagnosis was delayed due to many confounding factors. IH was suspected after subdural hemorrhage recurrence and confirmed by magnetic resonance imaging (MRI). After 2 epidural patches with colloid, favorable outcome was observed. DISCUSSION: The most common presentation of IH is postural orthostatic headaches. In the present case report, the major clinical signs were worsening of consciousness and coma, which are a rare presentation. Diagnosis of IH is based on the association of clinical history, evocative symptomatology, and cerebral imaging. CVT occurs in 1-2% of IH cases and the association between IH, CVT, and subdural hemorrhage is rare. MRI is probably the key imaging examination. In the present case, epidural patch was performed after confounding factors for coma had been treated. Benefit of anticoagulation had to be balanced in this case with potential hemorrhagic complications, especially within the brain. CONCLUSION: Association of CVT and subdural hemorrhage should lead to suspect IH. Brain imaging can help and find specific signs of IH.

Mass Training In Situ During COVID-19 Pandemic: Enhancing Efficiency and Minimizing Sick Leaves.

INTRODUCTION: Avoiding coronavirus disease 2019 (COVID-19) work-related infection in frontline healthcare workers is a major challenge. A massive training program was launched in our university hospital for anesthesia/intensive care unit and operating room staff, aiming at upskilling 2249 healthcare workers for COVID-19 patients' management. We hypothesized that such a massive training was feasible in a 2-week time frame and efficient in avoiding sick leaves. METHODS: We performed a retrospective observational study. Training focused on personal protective equipment donning/doffing and airway management in a COVID-19 simulated patient. The educational models used were in situ procedural and immersive simulation, peer-teaching, and rapid cycle deliberate practice. Self-learning organization principles were used for trainers' management. Ordinary disease quantity in full-time equivalent in March and April 2020 were compared with the same period in 2017, 2018, and 2019. RESULTS: A total of 1668 healthcare workers were trained (74.2% of the target population) in 99 training sessions over 11 days. The median number of learners per session was 16 (interquartile range = 9-25). In the first 5 days, the median number of people trained per weekday was 311 (interquartile range = 124-385). Sick leaves did not increase in March to April 2020 compared with the same period in the 3 preceding years. CONCLUSIONS: Massive training for COVID-19 patient management in frontline healthcare workers is feasible in a very short time and efficient in limiting the rate of sick leave. This experience could be used in the anticipation of new COVID-19 waves or for rapidly preparing hospital staff for an unexpected major health crisis.

Incidence and predicting factors of perioperative complications during monitored anesthesia care for awake craniotomy.

STUDY OBJECTIVE: To assess incidence and predicting factors of awake craniotomy complications. DESIGN: Retrospective cohort study. SETTING: Operating room and Post Anesthesia Care unit. PATIENTS: 162 patients who underwent 188 awake craniotomy procedures for brain tumor, ASA I to III, with monitored anesthesia care. MEASUREMENTS: We classified procedures in 3 groups: major event group, minor event group, and no event group. Major events were defined as respiratory failure requiring face mask or invasive ventilation; hemodynamic instability treated by vasoactive drugs, or bradycardia treated by atropine, bleeding >500 ml, transfusion, gaseous embolism, cardiac arrest; seizure, cerebral edema, or any events leading to stopping of the cerebral mapping. Minor event was defined as any complication not classified as major. Multivariate logistic regression was used to determine predicting factors of major complication, adjusted for age and ASA score. MAIN RESULTS: 45 procedures (24%) were classified in major event group, 126 (67%) in minor event group, and 17 (9%) in no event group. Seizure was the main complication (n = 13). Asthma (odds ratio: 10.85 [1.34; 235.6]), Remifentanil infusion (odds ratio: 2.97 [1.08; 9.85]) and length of the operation after the brain mapping (odds ratio per supplementary minute: 1.01 [1.01; 1.03]) were associated with major events. CONCLUSIONS: Previous medical history of asthma, remifentanil infusion and a long duration of neurosurgery after cortical mapping appear to be risk factors for major complications during AC.

Diagnostic accuracy of a revised computed tomography angiography score for brain death confirmation, combining supra-tentorial arteries and infra-tentorial veins.

PURPOSE: The 4-point score is the corner stone of brain death (BD) confirmation using computed tomography angiography (CTA). We hypothesized that considering the superior petrosal veins (SPVs) may improve CTA diagnosis performance in BD setting. We aimed at comparing the diagnosis performance of three revised CTA scores including SPVs and the 4-point score in the confirmation of BD. METHODS: In this retrospective study, 69 consecutive adult-patients admitted in a French University Hospital meeting clinical brain death criteria and receiving at least one CTA were included. CTA images were reviewed by two blinded neuroradiologists. A first analysis compared the 4-point score, considered as the reference and three non-opacification scores: a "Toulouse score" including SPVs and middle cerebral arteries, a "venous score" including SPVs and internal cerebral veins and a "7-score" including all these vessels and the basilar artery. Psychometric tools, observer agreement and misclassification rates were assessed. A second analysis considered clinical examination as the reference. RESULTS: Brain death was confirmed by the 4-score in 59 cases (89.4 %). When compared to the 4-score, the Toulouse score displayed a 100 % positive predictive value, a substantial observer agreement (0.77 [0.53; 1]) and the least misclassification rate (3.03 %). Results were similar in the craniectomy subgroup. The Toulouse score was the only revised test that combined a sensitivity close to that of the 4-score (86.4 % [75.7; 93.6] and 89.4 % [79.4; 95.6], p-value < 0.001, respectively) and a substantial observer agreement. CONCLUSIONS: A score including SPVs and middle cerebral arteries is a valid method for BD confirmation using CTA even in patients receiving craniectomy.

The optimal time between clinical brain death diagnosis and confirmation using CT angiography: a retrospective study.

BACKGROUND: In several countries, a computed tomography angiography (CTA) is used to confirm brain death (BD). A six­hour interval is recommended between clinical diagnosis and CTA acquisition despite the lack of strong evidence to support this interval. The aim of this study was to determine the optimal timing for CTA in the confirmation of BD. METHODS: This retrospective observational study enrolled all adult patients admitted between January 2009 and December 2013 to the intensive care units of a French university hospital with clinically diagnosed BD and at least one CTA performed as a confirmatory test. The CTAs were identified as conclusive (e.g. yielding confirmation of BD) or inconclusive (e.g. showing persistent brain circulation). RESULTS: One hundred and four patients (sex ratio M/F 1.8; age 55 years [41­64]) underwent 117 CTAs. CTAs confirmed cerebral circulatory arrest in 94 cases yielding a sensitivity of 80%. Inconclusive CTAs were performed earlier than conclusive ones (2 hours [1­3] vs. 4 hours [2­9], P=0.03) and were associated with decompressive craniectomy (5 cases [23%] vs. 6 cases [7%], P=0.05) and the failure to complete full neurological examination (5 cases [23%] vs. 4 cases [5%], P=0.02). Six hours after BD clinical diagnosis, the proportion of conclusive CTA was only 51%, with progressive increase overtime with more than 80% of conclusive CTA after 12 hours. CONCLUSIONS: A 12­hour interval might be appropriate in order to limit the risk of inconclusive CTAs.

The progestin etonogestrel enhances the respiratory response to metabolic acidosis in newborn rats. Evidence for a mechanism involving supramedullary structures.

Central congenital hypoventilation syndrome is a neuro-respiratory disease characterized by the dysfunction of the CO2/H(+) chemosensitive neurons of the retrotrapezoid nucleus/parafacial respiratory group. A recovery of CO2/H(+) chemosensitivity has been observed in some central congenital hypoventilation syndrome patients coincidental with contraceptive treatment by a potent progestin, desogestrel (Straus et al., 2010). The mechanisms of this progestin effect remain unknown, although structures of medulla oblongata, midbrain or diencephalon are known to be targets for progesterone. In the present study, on ex vivo preparations of central nervous system of newborn rats, we show that acute exposure to etonogestrel (active metabolite of desogestrel) enhanced the increased respiratory frequency induced by metabolic acidosis via a mechanism involving supramedullary structures located in pontine, mesencephalic or diencephalic regions.

Is platelet transfusion efficient to restore platelet reactivity in patients who are responders to aspirin and/or clopidogrel before emergency surgery?

PURPOSE: The aim of this study was to confirm that emergency platelet transfusion effectively restores platelet function to patients receiving antiplatelet therapy (APT) with aspirin and/or clopidogrel. PATIENTS AND METHODS: This was a prospective observational case report series conducted between January 1, 2009, and January 1, 2012. All responder patients according to the Verify Now device requiring emergency platelet transfusion because of a potentially life-threatening hemorrhage or before emergency neurosurgery were included. Aspirin or P2Y12-specific tests were used as appropriate for patients under aspirin or clopidogrel. Patients who were responders to aspirin had an aspirin reaction unit of less than 550, and patients who were responders to clopidogrel had an inhibition percentage of more than 20%. The Verify Now test was performed again after platelet transfusion. Pretransfusion and posttransfusion test results were compared. RESULTS: During the 36-month period, 25 patients met the inclusion criteria. Of these patients, 4 were receiving dual APT, 8 were receiving clopidogrel only, and 13 were receiving aspirin only. The average platelet transfusion dose was 0.12 UI/kg (range, 0.10-0.14 UI/kg). For patients under clopidogrel, the inhibition percentage lowered significantly after transfusion (median 54 [range, 31-69] before and 25 [range, 18-50] after transfusion; p < 0.005) but remained above the 20% threshold. Our patients were still responsive to clopidogrel after platelet transfusion. This result is conflicting with the existing literature. The median aspirin reaction unit of aspirin users before and after transfusion were 420 (range, 400-470) and 630 (range, 610-640), respectively (p = 0.001). The efficacy of platelet transfusion to restore aspirin-mediated disaggregation is confirmed by our case series. CONCLUSION: Platelet transfusion does not restore platelet function in patients under clopidogrel, but it is efficient for patients under aspirin. This sheds new light on previous large-scale studies that have been unable to show any effectiveness of emergency platelet transfusion in patients under APT. Emergency platelet transfusion may only be indicated in aspirin users who are responders and not in all patients under APT as is actually recommended.