Perioperative Means to Prevent Surgical Site Infections following Elective Craniotomies: A Single-Center Experience.

Background Postoperative surgical site infections are a recognized complication following craniotomies with an associated increase in morbidity and mortality. Several studies have attempted to identify bundles of care to reduce the incidence of infections. Our study aims to clarify which perioperative measures play a role in reducing surgical infection rates further. Methods This study is a retrospective audit of all elective craniotomies in years 2018 to 2019. The primary endpoint was the surgical site infection rate at 30 days and 4 months after the procedure. Univariate analysis was used to identify factors predictive of postoperative infection. Results 344 patients were included in this study. Postoperative infections were observed in 5.2% of our cohort. No postoperative infections occurred within 4 months in patients receiving perioperative hair wash and intrawound vancomycin powder. In univariate analysis, craniotomy size (Fisher's exact test, p = 0.05), lack of perioperative hair wash, and vancomycin powder use (Fisher's exact test, p = 0.01) were predictive of postoperative infection. No complications relative to the use of intrawound vancomycin were observed. Conclusion Our study demonstrates that simple measures such as perioperative hair wash combined with intrawound vancomycin powder in addition to standard practice can help reducing infection rates with negligible risks and acceptable costs. Our results should be validated further in future prospective studies.

What are the predictors of delayed cerebral ischaemia (DCI) after aneurysmal subarachnoid haemorrhage? An up-to-date systematic review.

PURPOSE: Delayed Cerebral Ischaemia (DCI) remains an important preventable driver of poor outcome in aneurysmal subarachnoid haemorrhage (aSAH). Our ability to predict DCI is based on historical patient cohorts, which use inconsistent definitions for DCI. In 2010, a definition of DCI was agreed upon and published by a group of aSAH experts. The aim of this study was to identify predictors using this agreed definition of DCI. METHODS: We conducted a literature search of Medline (PubMed) to identify articles published since the publication of the 2010 consensus definition. Risk factors and prediction models for DCI were included if they: (1) adjusted for confounding factors or were derived from randomised trials, (2) were derived from prospectively collected data and (3) included adults with aSAH. The strength of studies was assessed based on quality, risk of bias and applicability of studies using PROBAST. RESULTS: Eight studies totalling 4,542 patients were included from 105 relevant articles from 4,982 records. The most common reason for not including studies was failure to use the consensus definition of DCI (75%). No prediction models were identified in the eligible studies. Significant risk factors for DCI included the presence of onsite neuro-interventional services, high Neuropeptide Y, admission leucocytosis, neutrophil:lymphocyte >5.9 and Fisher Grade > 2. All studies had a high or unclear risk of bias. CONCLUSIONS: Only a few studies with high risk of bias have investigated the predictors using consensus-defined DCI. Further studies are warranted to clarify risk factors of DCI in the modern era.

Radiological follow-up of endovascularly treated intracranial aneurysms: a survey of current practice in the UK and Ireland.

PURPOSE: Due to the risk of intracranial aneurysm (IA) recurrence and the potential requirement for re-treatment following endovascular treatment (EVT), radiological follow-up of these aneurysms is necessary. There is little evidence to guide the duration and frequency of this follow-up. The aim of this study was to establish the current practice in neurosurgical units in the UK and Ireland. METHODS: A survey was designed with input from interventional neuroradiologists and neurosurgeons. Neurovascular consultants in each of the 30 neurosurgical units providing a neurovascular service in the UK and Ireland were contacted and asked to respond to questions regarding the follow-up practice for IA treated with EVT in their department. RESULTS: Responses were obtained from 28/30 (94%) of departments. There was evidence of wide variations in the duration and frequency of follow-up, with a minimum follow-up duration for ruptured IA that varied from 18 months in 5/28 (18%) units to 5 years in 11/28 (39%) of units. Young patient age, previous subarachnoid haemorrhage and incomplete IA occlusion were cited as factors that would prompt more intensive surveillance, although larger and broad-necked IA were not followed-up more closely in the majority of departments. CONCLUSIONS: There is a wide variation in the radiological follow-up of IA treated with EVT in the UK and Ireland. Further standardisation of this aspect of patient care is likely to be beneficial, but further evidence on the behaviour of IA following EVT is required in order to inform this process.

Scale-up of ABC care bundle for intracerebral haemorrhage across two hyperacute stroke units in one region in England: a mixed methods evaluation of a quality improvement project.

BACKGROUND: Intracerebral haemorrhage (ICH) accounts for 10%-15% of strokes in the UK, but is responsible for half of all annual global stroke deaths. The ABC bundle for ICH was developed and implemented at Salford Royal Hospital, and was associated with a 44% reduction in 30-day case fatality. Implementation of the bundle was scaled out to the other hyperacute stroke units (HASUs) in the region from April 2017. A mixed methods evaluation was conducted alongside to investigate factors influencing implementation of the bundle across new settings, in order to provide lessons for future spread. METHODS: A harmonised quality improvement registry at each HASU captured consecutive patients with spontaneous ICH from October 2016 to March 2018 to capture process and outcome measures for preimplementation (October 2016 to March 2017) and implementation (April 2017 to March 2018) time periods. Statistical analyses were performed to determine differences in process measures and outcomes before and during implementation. Multiple qualitative methods (interviews, non-participant observation and project document analysis) captured how the bundle was implemented across the HASUs. RESULTS: HASU1 significantly reduced median anticoagulant reversal door-to-needle time from 132 min (IQR: 117-342) preimplementation to 76 min (64-113.5) after implementation and intensive blood pressure lowering door to target time from 345 min (204-866) preimplementation to 84 min (60-117) after implementation. No statistically significant improvements in process targets were observed at HASU2. No significant change was seen in 30-day mortality at either HASU. Qualitative evaluation identified the importance of facilitation during implementation and identified how contextual changes over time impacted on implementation. This identified the need for continued implementation support. CONCLUSION: The findings show how the ABC bundle can be successfully implemented into new settings and how challenges can impede implementation. Findings have been used to develop an implementation strategy to support future roll out of the bundle outside the region.

Simple endovascular coiling: An effective long-term solution for wide-necked ruptured middle cerebral artery aneurysms? A 10-years retrospective study.

BACKGROUND: Endovascular coiling is usually the first line treatment modality for most ruptured intracranial aneurysms. However, there is still some debate as to whether microsurgical clipping or coiling is the treatment of choice for complex wide-necked ruptured middle cerebral artery (MCA) aneurysms. Our aim was to assess the efficacy, safety and longevity of simple endovascular coiling for ruptured MCA aneurysms. METHODS: This was a single-centre 10 years retrospective study (2008-2019) of all endovascularly treated patients with ruptured MCA aneurysms (n = 148). Patients were treated with simple coiling (n = 111), balloon-assisted coiling (n = 13), dual micro-catheter coiling (n = 19), balloon-assisted and dual micro-catheter coiling (n = 4) and woven endobridge (WEB) device (n = 1). The standard follow-up protocol consisted of Magnetic Resonance angiography at 6, 12 and 24 months. Our primary endpoints were mortality at 2, 12 and 24 months and dependency at discharge. Secondary endpoints included aneurysm occlusion, complications, re-canalisation, rebleeding and retreatment rates. RESULTS: All-cause mortality at 2, 12 and 24 months was 4.7% (n = 7), 8.1% (n = 12) and 10.8% (n = 16), respectively. 81.3% of patients remained independent in activities of daily livings (ADLs) at the point of discharge. Over a mean follow-up period of 19.7 months, we demonstrated re-bleeding and re-treatment rates of 2.7% (n = 4) and 4.1% (n = 6) respectively. Complete occlusion was achieved in 54% (n = 79) of aneurysms, with recanalisation observed in 18.2% (n = 27) of the patients. CONCLUSIONS: Our results demonstrate that simple endovascular coiling techniques offer a safe and effective solution in the management of ruptured MCA aneurysms without the requirement for re-treatment either surgically or endovascularly using endoluminal stents or other devices.

Radiologically defined acute hydrocephalus in aneurysmal subarachnoid haemorrhage.

BACKGROUND: Ventriculomegaly is common in aneurysmal subarachnoid haemorrhage (aSAH). An imaging measure to predict the need for cerebrospinal fluid (CSF) diversion may be useful. The bicaudate index (BCI) has been previously applied to aSAH. Our aim was to derive and test a threshold BCI above which CSF diversion may be required. METHODS: Review of prospective registry. The derivation group (2009-2015) included WFNS grade 1-2 aSAH patients who deteriorated clinically, had a repeat CT brain and underwent CSF diversion. BCI was measured on post-deterioration CTs and the lower limit of the 95% confidence interval (95%CI) was the hydrocephalus threshold. In a separate test group (2016), in WFNS ≥ 2 patients, we compared BCI on diagnostic CTs with CSF diversion within 24 hours. RESULTS: The derivation group (n = 62) received an external ventricular (n = 57, 92%) or lumbar drain (n = 5, 8%). Mean post-deterioration BCI was 0.19 (95%CI 0.17-0.22) for age ≤49 years, 0.22 (95%CI 0.20-0.23) for age 50-64 years and 0.24 (95%CI 0.22-0.27) for age ≥65 years. Hydrocephalus thresholds were therefore 0.17, 0.20 and 0.22, respectively. In the test group (n = 105), there was no significant difference in BCI on the diagnostic CT between good and poor grade patients aged ≤49 years (p = 0.31) and ≥65 years (p = 0.96). 30/66 WFNS ≥ 2 patients underwent CSF diversion, although only 15/30 (50%) exceeded BCI thresholds for hydrocephalus. CONCLUSION: A significant proportion of aSAH patients may undergo CSF diversion without objective evidence of hydrocephalus. Our threshold values require further testing but may provide an objective measure to aid clinical decision making in aSAH.

The Immune System's Role in the Consequences of Mild Traumatic Brain Injury (Concussion).

Mild traumatic brain injury (mild TBI), often referred to as concussion, is the most common form of TBI and affects millions of people each year. A history of mild TBI increases the risk of developing emotional and neurocognitive disorders later in life that can impact on day to day living. These include anxiety and depression, as well as neurodegenerative conditions such as chronic traumatic encephalopathy (CTE) and Alzheimer's disease (AD). Actions of brain resident or peripherally recruited immune cells are proposed to be key regulators across these diseases and mood disorders. Here, we will assess the impact of mild TBI on brain and patient health, and evaluate the recent evidence for immune cell involvement in its pathogenesis.

Are do-not-resuscitate orders associated with limitations of care beyond their intended purpose in patients with acute intracerebral haemorrhage? Analysis of the ABC-ICH study.

Implementation of an acute bundle of care for intracerebral haemorrhage (ICH) was associated with a marked improvement in survival at our centre, mediated by a reduction in early (<24 hours) do-not-resuscitate (DNR) orders. The aim of this study was to identify possible mechanisms for this mediation. We retrospectively extracted additional data on resuscitation attempts and supportive care. This observational study utilised existing data collected for the Acute Bundle of Care for ICH (ABC-ICH) quality improvement project between from 2013 to 2017. The primary outcome was whether a patient received an early (<24 hours) DNR order. We used multivariable logistic regression to estimate the adjusted association between clinically meaningful factors, including an indicator for a change in treatment on the introduction of the ABC care bundle. Early DNR orders were associated with a reduced odds of escalation to critical care (OR: 0.07, 95% CI: 0.03 to 0.17, p<0.001). Commencement of palliative care within 72 hours was far more likely (OR: 8.76, 95% CI: 4.74 to 16.61, p<0.001) if an early DNR was in place. The cardiac arrest team were not called for an ICH patient before implementation but were called on five occasions overall during and after implementation. Further qualitative evaluation revealed that on only one occasion was there a cardiac or respiratory arrest with cardiopulmonary resuscitation performed. We found no significant increase in resuscitation attempts after bundle implementation but early DNR orders were associated with less admission to critical care and more early palliation. Early DNR orders are associated with less aggressive supportive care and should be judiciously used in acute ICH.

What do neurosurgical trainees think about neuro-interventional training and service provision in the United Kingdom?

BACKGROUND: There is a disparity between the number of interventional neuroradiologists (INRs) in the UK and the number needed to provide a comprehensive 24/7 interventional neurovascular service. It is recognized that trainees from other specialties such as neurosurgery may be able to provide INR services after appropriate training. At present gaining skills in INR is not a mandatory requirement of the neurosurgical training curriculum in the UK. The views on this issue of current neurosurgical trainees are unknown. We aimed to address this knowledge gap. METHODS: We performed an anonymized online survey to gauge the opinion of neurosurgical trainees about their attitudes to INR training and service provision. RESULTS: 90/265 (34%) UK neurosurgical trainees responded to the survey. About 56% of respondents reported they were likely or very likely to pursue interventional training if a curriculum was approved by the general medical council. About 80% thought training should take up to 2 years. About 90% of those very likely or likely to pursue INR wanted a hybrid neurosurgical practice and 92% were willing to provide endovascular services out of hours. CONCLUSION: The responses described suggest that a significant proportion of neurosurgical trainees would pursue INR training and have realistic expectation regarding out of hours commitment and length of training.

Value of dynamic clinical and biomarker data for mortality risk prediction in COVID-19: a multicentre retrospective cohort study.

OBJECTIVES: Being able to predict which patients with COVID-19 are going to deteriorate is important to help identify patients for clinical and research practice. Clinical prediction models play a critical role in this process, but current models are of limited value because they are typically restricted to baseline predictors and do not always use contemporary statistical methods. We sought to explore the benefits of incorporating dynamic changes in routinely measured biomarkers, non-linear effects and applying 'state-of-the-art' statistical methods in the development of a prognostic model to predict death in hospitalised patients with COVID-19. DESIGN: The data were analysed from admissions with COVID-19 to three hospital sites. Exploratory data analysis included a graphical approach to partial correlations. Dynamic biomarkers were considered up to 5 days following admission rather than depending solely on baseline or single time-point data. Marked departures from linear effects of covariates were identified by employing smoothing splines within a generalised additive modelling framework. SETTING: 3 secondary and tertiary level centres in Greater Manchester, the UK. PARTICIPANTS: 392 hospitalised patients with a diagnosis of COVID-19. RESULTS: 392 patients with a COVID-19 diagnosis were identified. Area under the receiver operating characteristic curve increased from 0.73 using admission data alone to 0.75 when also considering results of baseline blood samples and to 0.83 when considering dynamic values of routinely collected markers. There was clear non-linearity in the association of age with patient outcome. CONCLUSIONS: This study shows that clinical prediction models to predict death in hospitalised patients with COVID-19 can be improved by taking into account both non-linear effects in covariates such as age and dynamic changes in values of biomarkers.

When should we measure surgical site infection in patients undergoing a craniotomy? A consideration of the current practice.

Introduction: Surgical site infection (SSI) is a common postoperative complication that causes significant morbidity, particularly in patients undergoing cranial neurosurgery. The treatment of SSI can attract a significant cost by way of increasing length of stay, readmission and reoperation in some cases. Cranial neurosurgical cases without implant surgery are recommended by the centre for disease control to be surveyed for SSI for a 30-day period. The number and proportion of SSI cases that present outside of this 30-day period is unknown.Method: All cranial, neurosurgical procedures at Salford Royal Foundation NHS Trust (SRFT) between October 2011 and April 2015 (n = 3513) were identified and followed up prospectively. The number of SSIs detected, the length of time following operation, microbiological organisms cultured and the need for further neurosurgical procedure was recorded. Mean length of time from operation to detection of SSI was calculated and a hazard function analysis was undertaken.Results: Of the 3531 cases (m = 1903, f = 1628) that underwent cranial neurosurgery included in this series 86 cases of SSI were noted. The mean number of days at which SSI was first clinically diagnosed in this series was 53 days. The time period in which 75% of cases were identified to be SSI was 49 days from the date of the surgical procedure, with 32 cases (37%) presenting outside of the 30-day period of surveillance. Over half of cases required some degree of operative intervention to treat SSI.Conclusion: A longer period of surveillance in cranial neurosurgical procedures is likely to detect a truer rate of SSI in addition to the identification of a notable number of cases that require surgical intervention. We recommend a period of at at least 50 days.

The self-reported needs of patients following subarachnoid hemorrhage (SAH).

Background: Despite advances in the acute care of subarachnoid haemorrhage, longer-term services remain under-developed. Clinical measures are commonly used to assess outcome and quality of life, but patient-reported needs and the extent to which they are met have not been measured. This information is essential to plan and develop evidence-based, patient-centred services. The aim of this study was to describe the frequency and type of self-reported met and unmet needs of subarachnoid haemorrhage survivors, explore whether these differ early and late in recovery and the factors associated with whether needs were met.Methods: A census cross-sectional postal survey of 400 subarachnoid haemorrhage survivors discharged from a large neurosurgical unit. The Self-Reported Needs after Stroke Questionnaire was modified and used to measure the self-reported needs of subarachnoid haemorrhage survivors and the extent to which they were met 1-2 years and 3-5 years post haemorrhage.Results: 203 (51%) participants responded: 122/260 (47%) from the early and 81/143 (57%) from the late cohort. 63% were female; mean age was 55 years. 86% of survivors reported one or more need, and 78% reported at least one unmet need (median 6, range 1-19). The most commonly reported need related to fatigue (66%). This and several other health needs were reported as unmet in over 80% of identified cases. We found no consistent factors that were associated with needs remaining unmet.Conclusion: Most subarachnoid haemorrhage survivors in both cohorts had unmet needs. Future research should aim to inform the development of post-discharge services to address the persistent long-term needs identified.Implications for rehabilitationSubarachnoid haemorrhage survivors report a number of needs 1-2 years and 3-5 years post haemorrhage.Needs relating to fatigue, memory, concentration, headache and anxiety were the most commonly reported.A large proportion of needs were described as unmet.The design of rehabilitation services for subarachnoid haemorrhage survivors should consider the self-reported needs described in this study.

Posterior Inferior Cerebellar Artery/Vertebral Artery Subarachnoid Hemorrhage: A Comparison of Saccular vs Dissecting Aneurysms.

BACKGROUND: Two distinct categories of aneurysms are described in relation to the posterior inferior cerebellar artery (PICA) and vertebral artery (VA): saccular (SA) and dissecting (DA) types. This distinction is often unrecognized because abnormalities here are uncommon and most studies are small. OBJECTIVE: To determine if there are any differences in the clinical presentation, in-hospital course, or outcomes in patients with DA vs SA of the PICA or VA. METHODS: Thirty-eight patients with a VA or PICA aneurysm were identified from a departmental subarachnoid hemorrhage database and categorized into DA or SA types. Prospectively collected demographic and outcome data (length of stay, discharge Glasgow Outcome Score) were supplemented by abstracting records for procedural data (extraventricular drain [EVD], ventriculoperitoneal [VP] shunt, tracheostomy, and nasogastric feeding). Univariate, binary logistic regression, and Cox regression analysis was used to compare patients with SA vs DA. RESULTS: Three aneurysms related to arteriovenous malformation were excluded. Five patients were conservatively managed. Of the 30 treated cases, more patients with a DA presented in poor grade (6/13 vs 2/17 SA; P = .035). More DA patients required an EVD (85% vs 29%; P = .003), VP shunt (54% vs 6%; P = .003), tracheostomy (46% vs 6%; P < .01), and nasogastric feeding (85% vs 35%; P = .007). The median length of stay (41 vs 17 d, P < .001) was longer, and the age and injury severity adjusted odds of discharge home were significantly lower in the DA group (P = .008). Thirty-day mortality was not significantly different (23% of DA vs 24% of SA; P = .2). CONCLUSION: The presentation, clinical course, and outcomes differ in patients with DA vs SA of the PICA and VA.

Predictors of Outcome in Aneurysmal Subarachnoid Hemorrhage Patients: Observations From a Multicenter Data Set.

BACKGROUND AND PURPOSE: The mortality and morbidity after aneurysmal subarachnoid hemorrhage has improved because of better diagnosis, early treatment to secure the aneurysm, and better management of disease-specific complications. With these improvements in care, it is not clear if the previously identified independent predictors of a negative outcome have changed. The aim of this study was to identify the independent predictors of an unfavorable outcome (Glasgow Outcome Score 1, 2, and 3) in aneurysmal subarachnoid hemorrhage patients. METHODS: Univariate and multivariate analysis of prospectively collected data on patients presenting with an aneurysmal subarachnoid hemorrhage was performed. Outcome was assessed at discharge. Data were collected from 14 centers in the United Kingdom over a period of 4 years (September 2011-2015). RESULTS: The median age (interquartile range) at presentation of 3341 patients with aneurysmal subarachnoid hemorrhage was 55 (18) years. Most patients were female (n=2288 [68.5%]), presented in good grade (2397 [70%]; World Federation of Neurological Surgeons grade 1 and 2), and were treated by endovascular coiling (n=2600; 75%). The independent predictors of an unfavorable outcome (95% confidence interval [CI]) were increasing age (odds ratio [OR], 1.04; 95% CI, 1.03-1.05; P<0.001), World Federation of Neurological Surgeons grade (OR, 2.06; 95% CI, 1.91-2.22; P<0.001), preoperative rebleeding (OR, 7.41; 95% CI, 4.48-12.30; P<0.001), need for cerebrospinal fluid diversion (OR, 3.25; 95% CI, 2.58-4.09; P<0.001), and delayed cerebral ischemia (OR, 2.21; 95% CI, 1.72-2.83; P<0.001). CONCLUSIONS: These data suggest that potentially modifiable risk factors of preoperative rebleeding and delayed cerebral ischemia are associated with unfavorable outcomes. Understanding the reasons why patients requiring cerebrospinal fluid diversion have 3.25-fold higher adjusted odds of a poor outcome at discharge needs to be studied.

Short-term neurocognitive and symptomatic outcomes following mild traumatic brain injury: A prospective multi-centre observational cohort study.

OBJECTIVE: To determine the short-term cognitive and symptomatic outcome following mild traumatic brain injury. METHODS: Setting: Emergency Departments of two UK tertiary referral hospitals. PARTICIPANTS: Adult patients presenting to the Emergency Departments of the Royal London Hospital and Salford Royal Hospital with suspected traumatic brain injury within 24 hours and Glasgow Coma Score > 8. A non-TBI comparison group included adult patients with no head or neck injury. DESIGN: Prospective multi-centre cohort study. MAIN MEASURES: The Standardized Assessment of Concussion (SAC), the Concussion Symptom Inventory (CSI) and total number of symptoms, measured at baseline and 72 hours. RESULTS: This study enrolled 189 patients with and 51 patients without TBI. Patients with TBI had marked cognitive impairment which persisted at 72 hours (SAC score at baseline = 25 [23-27] vs 72 hours = 25 [22-27]; p = 0.1). Patients with TBI had persistent high symptom severity, although this had decreased at 72 hours (CSI score at baseline = 9 [4-22] vs 72 hours = 5 [1-19], p = 0.002). A similar pattern was observed with the total number of symptoms (baseline = 4 [2-8] vs 72 hours = 0 [0-4]; p < 0.001). Patients with TBI had worse neurocognitive function, higher overall symptom severity and higher total number of symptoms compared with patients without TBI. Patients without TBI' neurocognitive function and symptom severity remained constant, but the number of symptoms reduced between baseline and 72 hours. CONCLUSION: There is a cognitive deficit and symptom burden in patients with mild TBI presenting to the Emergency Department which persists at 72 hours.

Implementation of a care bundle and evaluation of risk factors for surgical site infection in cranial neurosurgery.

OBJECTIVES: Surgical site infection [SSI] increases mortality, morbidity and length of hospital stay. Peri-operative 'care bundles' have reduced SSI in some fields of surgery. The aim of this study was to determine the impact of bundle compliance on SSI in patients undergoing a craniotomy. PATIENTS AND METHOD: Cohort study of patients [N=1253] undergoing a craniotomy over 17 months at a single centre. SSI was defined as arising within 30days of operation or 1year where an implant(s) remains. 'Bundle compliance' required administration of antibiotics <60min of induction, maintenance of intraoperative blood sugar (BM) <11mmol and temperature at >36°C. SSI incidence was compared between bundle compliant and non-compliant groups. Case mix adjustment was performed using binary logistic regression. RESULTS: Over the study period, 1253 procedures were carried out and 66 patients (5.3%) developed a SSI. The majority (38, 57.6%) of these cultured Staphyloccoccus species. Only the use of an implant was found to be an independent risk factor for SSI [AOR 2.5, p<0.005, 95%CI 1.4, 4.3]. The use of the bundle did not reduce the occurrence of SSI. CONCLUSIONS: An evidence-based bundle did not reduce SSI in this neurosurgical series. The use of an implant was an independent risk factor of its occurrence.

Effect of weekend admission on in-hospital mortality and functional outcomes for patients with acute subarachnoid haemorrhage (SAH).

BACKGROUND: Aneurysmal subarachnoid haemorrhage (aSAH) is an acute cerebrovascular event with high socioeconomic impact as it tends to affect younger patients. The recent NCEPOD study looking into management of aSAH has recommended that neurovascular units in the United Kingdom should aim to secure cerebral aneurysms within 48 h and that delays because of weekend admissions can increase the mortality and morbidity attributed to aSAH. METHOD: We used data from a prospective audit of aSAH patients admitted between January 2009 and December 2011. The baseline demographic and clinical features of the weekend and weekday groups were compared using the chi-squared test and T-test. Cox proportional hazards models (Proc Phreg in SAS) were used to calculate the adjusted overall hazard of in-hospital death associated with admission on weekend, adjusting for age, sex, baseline WFNS grade, type of treatment received and time from scan to treatment. Sliding dichotomy analysis was used to estimate the difference in outcomes after SAH at 3 months in weekend and weekday admissions. RESULTS: Those admitted on weekends had a significantly higher scan to treatment time (83.05 ± 83.4 h vs 40.4 ± 53.4 h, P < 0.0001) and admission to treatment (71.59 ± 79.8 h vs 27.5 ± 44.3 h, P < 0.0001) time. After adjustments for adjusted for relevant covariates weekend admission was statistically significantly associated with excess in-hospital mortality (HR = 2.1, CL [1.13-4.0], P = 0.01). After adjustments for all the baseline covariates, the sliding dichotomy analysis did not show effects of weekend admission on long-term outcomes on the good, intermediate and worst prognostic bands. CONCLUSIONS: This study provides important data showing excess in-hospital mortality of patients with SAH on weekend admissions served by the United Kingdom's National Health Service.; However, there were no effects of weekend admission on long-term outcomes.

Cerebrospinal Fluid Infection Associated with Silver-Impregnated External Ventricular Drain Catheters.

OBJECTIVE: Silver-impregnated external ventricular drains (EVDs) have reduced the number of cases of ventriculitis. Risk factors for developing ventriculitis associated with plain EVD catheters have been well documented and incorporated into clinical practice, but risk factors in association with silver EVDs are unknown. Therefore, we sought to determine the risk factors for developing ventriculitis in patients with a silver EVD. METHODS: Prospectively collected data on consecutive patients undergoing insertion of a silver-impregnated EVD between October 2011 and September 2013 were analyzed. Cerebrospinal fluid (CSF) infection was defined as positive CSF microbiologic culture. Univariate and multivariate regression was performed to identify independent risk factors for CSF infection. RESULTS: There were 362 EVDs placed in 263 patients (142 women; median age 52 years; interquartile range, 40-62 years). There were 15 infections (6.4 per 1000 days of EVD drainage) recorded. Gram-negative organisms (8 of 15) were most commonly observed, although Staphylococcus was the most common genus (7 of 15; 46%) identified. Univariate analysis indicated that patients requiring EVD replacement (P < 0.0001), patients requiring bilateral EVDs (P < 0.0001), and patients with a CSF leak (P < 0.0001) were at increased risk of infection. Only need for EVD replacement remained significant on multivariate analysis (P < 0.0001, odds ratio = 15.9, confidence interval = 4.5-55.9). CONCLUSIONS: We identified an infection rate of 5.2% in this large contemporary series of patients undergoing silver EVD insertion according to a set protocol. These data suggest that targeting strategies to reduce Staphylococcus species is important, and increased vigilance for an increased incidence of gram-negative organisms is needed. Decreasing the need for EVD replacement is important in reducing infection rates further.

Systematic Review and Meta-Analysis of Preoperative Antisepsis with Combination Chlorhexidine and Povidone-Iodine.

Importance Effective preoperative antisepsis is recognized to prevent surgical site infection (SSI), although the definitive method is unclear. Many have compared chlorhexidine (CHG) with povidone-iodine (PVI), but there is emerging evidence for combination usage. Objective To conduct a systematic review and meta-analysis to evaluate if combination skin preparation (1) reduces colonization at the operative site and (2) prevents SSI compared with single-agent use. Data Sources A literature search of MEDLINE, Embase, and Cochrane Database of Clinical Trials was performed. Study Selection Comparative, human trials considering the combination use of CHG and PVI, as preoperative antisepsis, to single-agent CHG or PVI use were included. Studies were excluded from meta-analysis if the use or absence of alcohol was inconsistent between study arms. Data Extraction and Synthesis The study was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Main Outcomes and Measures The primary outcome for meta-analysis was surgical site infection. The secondary outcome was colonization at the operative site. Results Eighteen publications with a combination of CHG and PVI use were identified. Of these, 12/14 inferred promise for combination usage, including four trials eligible for meta-analysis. Only one trial reported SSI as its outcome. The remaining three considered bacterial colonization. Combination preparation had a pooled odds ratio for complete decolonization of 5.62 (95% confidence interval 3.2 to 9.7, p < 0.00001). There was no evidence of heterogeneity (Cochran's Q 2.1, 2 df , p = 0.35). Conclusions and Relevance There is emerging, albeit low-quality, evidence in favor of combination CHG and PVI preoperative antisepsis. Further rigorous investigation is indicated.