Discontinuation of Cerebro-Spinal Fluid (CSF) Drainage in Acute Hydrocephalus: A Prospective Cohort Study and Exploratory Data Analysis.

BACKGROUND: The optimal management of CSF drainage in acute hydrocephalus, in particular when to initiate drain weaning, remains uncertain. This study aimed to evaluate the impact of timing and method of drain weaning on patient outcomes. METHODS: This prospective observational study in a large-volume tertiary neuroscience centre included all adult patients who required temporary CSF drainage for acute hydrocephalus of any cause between January 2020 and March 2021. Contemporaneous data collection was conducted, including patient demographics, time to clamp, weaning methods, and clinical outcomes of hospital length of stay (LOS), rate of shunt insertion, drain-related infections, and mechanical complications. Univariate and multivariate statistical analyses were performed to identify the independent associations of timing-related factors. RESULTS: A total of 69 patients were included (mean age = 59.4 years). A total of 59% had CSF diversion for aneurysmal subarachnoid haemorrhage, and 88% had EVD drainage. The length of drainage prior to the first clamp was significantly associated with the overall length of drainage (p < 0.0001), LOS (p = 0.004), and time to shunt (p = 0.02) following multivariate adjustment. For each day delayed in initiating the drain challenge, the overall LOS increased by an additional 1.25 days. There was no association between the weaning method and LOS, the rate of shunting, or CNS infection; however, those in the gradually weaned group had more mechanical complications, such as drain blockage or CSF leakage, than those rapidly weaned (p = 0.03) after adjustment. DISCUSSION: This study recommends challenging the drain early via a rapid wean to reduce LOS, mechanical complications, and possibly infections. The consequences of temporary CSF diversion have significant implications at financial and patient levels, but the quality of evidence regarding weaning remains poor. Further randomised multicentre studies and national databases of practice are required to allow definitive conclusions to be drawn.

Liberalization of the Systemic Glucose Management is Associated with a Reduced Frequency of Neuroglucopenia in Subarachnoid Hemorrhage Patients: An Observational Cohort Study.

BACKGROUND: Pathologically low brain glucose levels, referred to as neuroglucopenia, are associated with unfavorable outcomes in neurocritical care patients. We sought to investigate whether an increase in serum glucose levels would be associated with a reduction of neuroglucopenia. METHODS: In this retrospective analysis of prospectively collected data, we included 55 consecutive patients with spontaneous subarachnoid hemorrhage who underwent cerebral microdialysis (CMD) monitoring. Neuroglucopenia was defined as CMD-glucose levels < 0.7 mmol/l. We identified systemic glucose liberalization events, defined as a day with median serum glucose levels < 150 mg/dl, followed by a day with median serum glucose levels > 150 mg/dl, and compared concentrations of cerebral metabolites between these days. Unfavorable outcome was defined as modified Rankin Scale score ≥ 3 at 3 months after the bleeding. RESULTS: Episodes of neuroglucopenia were more frequent in patients with unfavorable outcome (19.8% [19.3-20.3%] vs. 10.9% [10.4-11.5%], p = 0.007). Sixty-nine systemic glucose liberalization events were identified in 40 patients. Blood glucose levels increased from 141.2 (138.7-143.6) mg/dl to 159.5 (157.0-162.2) mg/dl (p < 0.001), CMD-glucose levels increased from 1.44 (1.39-1.50) mmol/l to 1.68 (1.62-1.75) mmol/l (p = 0.001), and the frequency of neuroglucopenia decreased from 24.7% (22.9-26.5%) to 20.2% (18.7-21.8%) (p = 0.002) during these events. Liberalization was not associated with changes in CMD-lactate, CMD-pyruvate, CMD-lactate-to-pyruvate ratio, CMD-glutamate, or CMD-glycerol. CONCLUSIONS: In conclusion, the liberalization of serum glucose concentrations to levels between 150 and 180 mg/dl was associated with a significant reduction of neuroglucopenia.

Energy Expenditure in Critically Ill Patients with Aneurysmal Subarachnoid Hemorrhage, Intracerebral Hemorrhage, and Traumatic Brain Injury-A Prospective Observational Study.

BACKGROUND: Energy expenditure (EE) in patients with aneurysmal subarachnoid hemorrhage (SAH) may differ from other intracranial pathologies, such as intracerebral hemorrhage (ICH) or traumatic brain injury (TBI), due to an activation of the sympathetic nervous system. Indirect calorimetry (IC) is recommended, but is not always available. We study EE, catabolism, and metabolic stress in patients with SAH, TBI, ICH, and sepsis as controls. METHODS: A prospective observational study was conducted in the intensive care units of the University Medical Center Hamburg-Eppendorf, Germany. IC was used to measure EE on days 2-3, 5-7, and 10-15 post-admission. Urinary catecholamines, metabolites, and urine urea were also measured. Statistical analysis included t-tests, Chi-square tests, and generalized mixed models. RESULTS: We included 110 patients-43 SAH patients (13 with the surgical securing of the aneurysm and 30 with coil embolization of the aneurysm), 22 TBI patients, 23 ICH patients, and 22 controls. The generalized linear mixed model analysis for groups and timepoints including age, height, and weight as covariates revealed a significantly lower EE at timepoint 1 for ICH versus SAH-interventional (p = 0.003) and versus the control (p = 0.004), as well as at timepoint 2 for ICH versus SAH-interventional (p = 0.002) and versus SAH-surgical (p = 0.013) with a lower EE in ICH patients. No significant differences between groups were found for EE at the other timepoints, or concerning urine urea and measurements of catecholamines in urine. CONCLUSIONS: In patients with SAH, ICH, and TBI, no meaningful differences in EE were detected compared to septic critically ill patients, except for a lower EE in ICH patients in the early phase.

Stroke: Evolution of newer treatment modalities for acute ischemic stroke.

Acute ischemic stroke is one of the leading causes of morbidity and mortality worldwide. Restoration of cerebral blood flow to affected ischemic areas has been the cornerstone of therapy for patients for eligible patients as early diagnosis and treatment have shown improved outcomes. However, there has been a paradigm shift in the management approach over the last decade, and with the emphasis currently directed toward including newer modalities such as neuroprotection, stem cell treatment, magnetic stimulation, anti-apoptotic drugs, delayed recanalization, and utilization of artificial intelligence for early diagnosis and suggesting algorithm-based management protocols.

Aspiration of Subdural Hygroma Using Augmented Reality Neuronavigation: A Case Report.

Augmented reality (AR) is emerging as a key technology in neurosurgery. Projecting three-dimensional (3D) anatomic models onto the surgical field provides unique operative information to make procedures safer and more efficient. A small footprint, rapid registration AR system was used for bedside guidance during aspiration of a subdural hygroma. A 77-year-old male presented for resection of a suprasellar tumor and subsequently developed a large bilateral subdural hygroma. We performed the aspiration of the hygroma at the bedside using AR guidance. The AR system allowed for precise needle placement during the aspiration. The aim of this report was to demonstrate the clinical feasibility of integrating a novel AR system into the clinical workflow of a bedside procedure. As AR continues to expand in the field, the benefits of this technology for various procedures will become more evident.

Sedation Vacations in Neurocritical Care: Friend or Foe?

PURPOSE OF REVIEW: To evaluate the role of sedation vacations in optimizing patient outcomes and enhancing the quality of care in neurological intensive care units (ICUs). We discuss the importance of sedation management in neurocritical care, considering recent research findings and clinical guidelines. RECENT FINDINGS: Recent studies have highlighted the significance of sedation interruption protocols in improving patient outcomes in the ICU setting. Evidence suggests that daily sedation interruptions can reduce the duration of mechanical ventilation, ICU length of stay, and mortality rates. However, the implementation of these protocols requires careful consideration of patient-specific factors and a multidisciplinary approach. Sedation vacations play a critical role in neurocritical care by reducing mechanical ventilation duration, ICU stay length, and mortality rates. Despite the benefits, the presence of complications must be addressed to avoid adverse outcomes. Continued research is necessary to refine these strategies and improve guideline quality, ensuring safe and effective sedation management in critically ill neurological patients.

Ketamine plus midazolam compared to midazolam infusion for the management of refractory status epilepticus.

BACKGROUND: Data for the use of ketamine (Ket) in treatment of refractory and super-refractory status epilepticus (RSE, SRSE) is lacking despite its widespread growing use. We examined the efficacy of ketamine plus midazolam (MDZ) infusions for treating RSE versus midazolam alone. We hypothesized that ketamine initiation would result in earlier seizure termination. METHODS: Data was obtained from electronic health records (EHR) of adult patients who received intravenous anesthetic agents for RSE in our neurointensive care unit. Two cohorts were identified. The MDZ cohort received midazolam as the only intravenous anesthetic agent for RSE. The Ket+MDZ cohort received midazolam infusion followed by ketamine infusion. The primary outcomes were time from midazolam infusion start to SE end in both cohorts, and time from ketamine infusion start (Ket Start) to SE end in the Ket+MDZ cohort versus midazolam infusion start (MDZ start) to SE end in the MDZ cohort. RESULTS: 73 patients were included (MDZ cohort n=17, Ket + MDZ cohort n=56). Cohorts did not differ significantly in age, sex, race, RSE etiology, or GCS on admission. Mean APACHE II score was higher in the Ket +MDZ cohort (26 ± 7.32 SD) versus the MDZ cohort (22 ± 5.89 SD)(P=.015). In survival analyses, cohorts did not differ significantly in time from midazolam start to SE end (HR=0.965, 95 % CI=0.556-1.673, P=.899; median [IQR]: MDZ: 25 h [4.5-58]; Ket+MDZ: 21.5 h [IQR 13.5-49]). Time from Ket start (Ket+MDZ group) versus time from MDZ start (MDZ group) to SE end was significantly shorter in the Ket+MDZ cohort (HR=1.895, 95 % CI=1.083-3.314, P=.025). The pattern of results was similar when including APACHE II and MDZ maximum dosage as covariates. CONCLUSION: Time to SE end was significantly shorter after addition of ketamine infusion to midazolam infusion, versus after initiation of midazolam infusion monotherapy. Patients with higher disease severity favored Ket+MDZ. Randomized controlled trials are warranted in determining optimal anesthetics in RSE and SRSE.

Time to maximum pupil constriction is variable in neurocritical care patients.

Quantitative pupillometry (QP) use has grown exponentially. Each QP scan captures images of the pupil before, during, and after light exposure to provide component measures of the pupillary light reflex (PLR). This study explores if the time to maximum constriction (tMC) is uniform among neuroscience intensive care unit (NSICU) patients. The study enrolled 50 NSICU patients with normal PLR values in a cross-sectional study and adhered to the standard of care for pupil assessments to collect data on tMC within (comparing left eye and right eye) and between patients. The mean tMC of 0.97 (0.17) s was normally distributed across all patients and ranged from 0.46 s to 1.35 s. The mean tMC was similar for the left pupil (0.98 [0.16]s) and right pupil (0.96 [0.18]s; P =.546). The within-subject mean difference (left versus right eye) tMC was 0.13 (0.12)s and ranged from 0.0 to 0.56 s. The between-subject mean tMC was 0.97 (0.17) s and ranged from 0.46 s to 1.35 s. The tMC does not occur at a fixed point in time. Clinical applications that seek to characterize pupil health should account for varied tMC and explore relationships to discrete outcomes to determine the clinical usefulness of tMC.

Clinical Significance of the Control CT Rotterdam Score Compared With the Admission CT Rotterdam Score in Patients With Isolated Severe Traumatic Brain Injury in the Intensive Care Unit.

BACKGROUND: The Rotterdam scale is one of the most commonly used radiological scales for evaluating and predicting outcomes in traumatic brain injury (TBI) cases. Given the evolving nature of TBI, our study is designed to compare the Rotterdam score of computed tomography (CT) findings upon admission (Rotterdam score I) with the score after 72 hours (Rotterdam score II) of treatment in the trauma intensive care unit (ICU). METHODS: A retrospective observational study was conducted on 54 patients who received intensive care treatment for isolated severe TBI over five years. We included severe TBI patients with no age restrictions who required admission to the ICU within 12 hours of the onset of trauma. An initial Rotterdam CT score was obtained via a CT head scan within four hours of the trauma, followed by a control CT head scan 72 hours after ICU admission. It was essential to have documentation on the clinical and laboratory treatment course and access to radiological CT diagnostics. Receiver operating characteristic (ROC) curves were employed in this study to evaluate the accuracy of diagnostic tests, such as the Rotterdam score. The ROC curves provided a graphical representation of the tests' diagnostic performance, which helped assess their effectiveness. RESULTS: There was a significant difference (p < 0.001) in the diagnostic scores of CT scans upon admission (Rotterdam score I) and control CT scans after 72 hours (Rotterdam score II) in the total sample. The Rotterdam score I was notably higher, 3.6 (±0.8), in patients requiring neurosurgical intervention compared to those who did not, 2.8 (±0.9), with significance (p = 0.003). The Rotterdam score I demonstrated a substantial predictive value for unfavorable outcomes (p = 0.048), as did the Rotterdam score II after the 72-hour mark (p = 0.006). CONCLUSION: The control Rotterdam score 72 hours after admission predicts mortality in isolated TBI patients more significantly than the Rotterdam score determined at the patient's admission to the intensive care unit.

Hidden role of microglia during neurodegenerative disorders and neurocritical care: A mitochondrial perspective.

The incidence of aging-related neurodegenerative disorders and neurocritical care diseases is increasing worldwide. Microglia, the main inflammatory cells in the brain, could be potential viable therapeutic targets for treating neurological diseases. Interestingly, mitochondrial functions, including energy metabolism, mitophagy and transfer, fission and fusion, and mitochondrial DNA expression, also change in activated microglia. Notably, mitochondria play an active and important role in the pathophysiology of neurodegenerative disorders and neurocritical care diseases. This review briefly summarizes the current knowledge on mitochondrial dysfunction in microglia in neurodegenerative disorders and neurocritical care diseases and comprehensively discusses the prospects of the application of neurological injury prevention and treatment targets by mitochondria.

Progress of Brain Hypothermia Treatment for Severe Subarachnoid Hemorrhage-177 Cases Experienced and a Narrative Review.

The benefits of hypothermia for the treatment of subarachnoid hemorrhage (SAH) remain controversial. In 1999, we initiated brain hypothermia treatment (BHT) in the hyperacute phase to mitigate the evolution of early brain injury in patients with World Federation of Neurological Surgeons (WFNS) grade V SAH. In June 2014, we introduced endovascular cooling to maintain normothermia for seven days following the initial BHT period. Immediately after the decision to treat the sources of bleeding, cooling was initiated, with a target temperature of 33-34°C. Bleeding sources were extirpated primarily by clipping with decompressive craniectomy. Patients were rewarmed at a rate of ≤1°C/day after ≥48 hours of surface cooling. After being rewarmed to 36°C, temperatures were controlled with antipyretic (chronologically divided into groups A-C with 47, 46, and 46 patients, respectively) or endovascular (group D, 38 patients) cooling. Overall, 177 patients (median age, 62 [52-68] years; 94 [53.1%] women; onset-to-arrival time, 36 minutes [28-50]) were included. The median Glasgow Coma Scale (GCS) score upon admission was 4 (3-6). Median core body temperature was 36 (35.3-36.6)°C on arrival, 34.6 (34.0-35.3)°C on entering the operating room, 33.8 (33.4-34.3)°C upon starting the microsurgical or interventional radiology procedure, and 33.7 (33.3-34.2)°C upon admission to the intensive care unit. There were no significant differences in age, sex, GCS score, pupillary findings, location of bleeding sources, or treatment methods. There were 69 (39.0%) overall favorable outcomes (modified Rankin Scale score of 0-3) at 6 months and 11 (23.4%), 18 (39.1%), 17 (37.0%), and 23 (60.5%) in groups A-D, respectively (p = 0.0065). The outcomes of patients with WFNS grade V SAH improved over time. Herein, we report our experience using BHT for severe SAH through a narrative review.

Integration of Palliative Care in Neurosurgical Critical Care : Insights from a Single-Center Perspective.

Objective: Palliative care is a specialized approach designed to enhance the quality of life for both patients and their families, offering patient-centered care through comprehensive assessment and care planning. However, the integration of palliative care within neuro-critical care settings has been relatively understudied. This descriptive study aims to identify the characteristics, palliative care needs, and outcomes of patients referred to palliative care services during admission to the neurosurgical intensive care unit (NS-ICU). Methods: A retrospective analysis of adults admitted to the NS-ICU at a referral hospital between December 2019 and December 2021 was conducted. The study focused on those referred to the inpatient palliative care team with diagnoses of non-traumatic brain hemorrhage, traumatic brain injury, or brain neoplasm. Excluded were patients who died before palliative care consultation or lacked sufficient information. The investigation assessed demographic and clinical characteristics at consultation, along with post-consultation hospital outcomes derived from medical records and interview notes. Results: In this study involving 38 enrolled patients, the median age was 65, with 42.1% females. The most prevalent diagnosis was non-traumatic brain hemorrhage (47.4%). Reasons for palliative care consultation included psychosocial support (95%), goal-of-care discussions (68%), decision-making support (50%), and communication facilitation (39%). The median time from NS-ICU admission to consultation was 3.5 days (range: 1-8 days), and all interviews involved family members. Key decision topics encompassed mechanical ventilation (23.7%) and tracheostomy (21.1%). Patient preferences for life-sustaining treatment could be estimated in only 47.4% of cases, often resulting in treatment disagreement. Among the 38 patients, 26 (68.4%) died during admission. Before the consultation, full code status, partial code status, and comfort care alone were reported as 32%, 66%, and 2%, respectively; post-consultation, these figures shifted to 11%, 42%, and 47%, respectively. Conclusion: Palliative care was predominantly sought for psychosocial support and discussions concerning goals of care. Despite challenges in ascertaining patient treatment preferences, palliative care consultations proved invaluable in aiding family members and facilitating treatment decision-making. Our study suggests the potential integration of palliative care within neuro-critical care, contributing to a heightened utilization of comfort care at the end-of-life.

Noninvasive Method Using Mechanical Extensometer for the Estimation of Intracranial Compliance by Repeated Measures Agreement Analysis.

BACKGROUND: Intracranial compliance refers to the relationship between changes in volume and the resultant changes in intracranial pressure (ICP). This study aimed to assess the agreement of a noninvasive ICP waveform device for the estimation of compliance compared with invasive ICP monitoring employing three distinct methods. METHODS: We conducted a retrospective analysis of ICP waveform morphology recorded through both invasive (external ventricular drain) and noninvasive (mechanical extensometer) methods in adult patients with acute brain injury admitted to a neurointensive care unit between August 2021 and August 2022. Compliance was calculated as the amplitude of the fundamental component of cerebral arterial blood volume (estimated with concurrent Transcranial Doppler [TCD] recordings), divided by the amplitude of the fundamental component of the invasive and noninvasive ICP waveforms. Subsequently, we assessed the agreement between invasive and noninvasive intracranial compliance by repeated measures correlation coefficient analysis using three methods: TCD-derived, P2/P1 ratio, and time-to-peak (TTP). A linear mixed-effects model was used to compute the concordance correlation coefficient, total deviation index, and coefficient of individual agreement. Coverage probability plot was calculated to estimate the percent of observations within different cut points for each of the three methods. RESULTS: A total of 21 patients were identified for this study. Repeated measures correlation analysis showed a strong correlation (R = 0.982, 95% confidence interval [0.980-0.984], p < 0.0001) between log-transformed noninvasive and invasive compliance. Agreement statistics for TCD, P2/P1 ratio, and TTP indicated that although the concordance correlation coefficient was highest for log(TCD) values, TTP and P2:P1 ratio measures had better agreement with total deviation index and coverage probability plot analyses. CONCLUSIONS: Repeated measures correlations suggest that ICP waveform analyses may offer a more accurate estimate of compliance than TCD-derived methods for noninvasive ICP monitoring. Further validations studies are warranted to confidently establish this method as an indicator of intracranial compliance.

Comparison of Telemedicine-Administered Thrombolytic Therapy for Acute Ischemic Stroke by Neurology Subspecialty: A Cross-Sectional Study.

Background and Purpose: To determine if any difference exists in safety and outcomes of thrombolytic therapy for acute ischemic stroke administered via telemedicine, based on the subspeciality of the treating neurologist. Methods: We performed a retrospective cross-sectional study using data from our local stroke registry of thrombolytic therapy administered via telemedicine at our rural stroke network over 5 years. The cohort was divided in 2 groups based on the subspecialty of the treating neurologist: vascular neurology (VN) and neurocritical care (NCC). Demographics, clinical characteristics, stroke metrics, thrombolytic complications, and final diagnosis were reviewed. In-hospital mortality and mRS and 30 days were noted. Results: Among 142 patients who received thrombolytic therapy via telemedicine, 44 (31%) were treated by VN specialists; 98 (69%) by NCC specialist. There was no difference in baseline characteristics and stroke metrics between the 2 groups. Compared to NCC, VN had a trend toward higher, but non-significant, sICH (6% vs 1%, P = 0.05). In a logistic regression analysis, correcting for NIHSS, SBP, door-to-needle time, and use of antiplatelet therapy, the type of neurology subspecialty was not independently associated with development of sICH (OR: 0.141, SE: 0.188, P = 0.141). The rate of in-hospital mortality was also similar between VN and NCC (7% vs 5%, P = 0.8). In a model that accounted for stroke severity, no association was established between the type of neurology subspecialty and mRS at 30 days (OR: 1.589, SE: 0.662, P = 0.266). Conclusions: Safety and outcome of thrombolytic therapy via telemedicine was not influenced by the subspecialty of treating neurologist. Our study supports the expansion of telemedicine for acute stroke patients in rural and underserved areas.

Volatile Sedation in Neurointensive Care Patients After Aneurysmal Subarachnoid Hemorrhage: Effects on Delayed Cerebral Ischemia, Cerebral Vasospasm, and Functional Outcome.

BACKGROUND: Volatile anesthetics have shown neuroprotective effects in preclinical studies, but clinical data on their use after aneurysmal subarachnoid hemorrhage (aSAH) are limited. This study aimed to analyze whether the use of volatile anesthetics for neurocritical care sedation affects the incidence of delayed cerebral ischemia (DCI), cerebral vasospasm (CVS), DCI-related infarction, or functional outcome. METHODS: Data were retrospectively collected for ventilated aSAH patients (2016-2022), who received sedation for at least 180 hours. For comparative analysis, patients were assigned to a control and a study group according to the sedation used (intravenous vs. volatile sedation). Logistic regression analysis was performed to identify independent predictors of DCI, CVS, DCI-related infarction, and functional outcome. RESULTS: Ninety-nine patients with a median age of 58 years (interquartile range: 52-65 years) were included. Forty-seven patients (47%) received intravenous sedation, while 52 patients (53%) received (additional) volatile sedation with isoflurane (n = 30, 58%) or sevoflurane (n = 22, 42%) for a median duration of 169 hours (range: 5-298 hours). There were no significant differences between the 2 groups regarding the occurrence of DCI, angiographic CVS, DCI-related infarction, or functional outcome. In a multivariable logistic regression analysis, the use of volatile anesthetics had no impact on the incidence of DCI-related infarction or the patients' functional outcome. CONCLUSIONS: Volatile sedation in aSAH patients is not associated with the incidence of DCI, CVS, DCI-related infarction, or functional outcome. Although we could not demonstrate neuroprotective effects of volatile anesthetics, our results suggest that volatile sedation after aSAH has no negative effect on the patient's outcome.

Transient Cerebral Circulation Arrest in SAH.

How to cite this article: Salhotra R. Transient Cerebral Circulation Arrest in SAH. Indian J Crit Care Med 2024;28(6):620-621.

Paradoxical Brain Herniation: An Unexpected Diagnosis.

Paradoxical herniation is a dreadful neurosurgical complication often underdiagnosed, which typically becomes evident over the course of weeks to months after the initial intervention. Here we present a unique case with manifestations in the post-operative period. A patient initially referred to neurosurgery for a meningioma underwent an uneventful surgical excision, followed by the transient placement of a lumbar drain for 48 hours. On the first post-operative day, the patient exhibited progressively altered neurological status, with corresponding imaging revealing a transfalcine herniation, necessitating emergent decompressive craniectomy. Despite the medical and surgical interventions, there were continuous signs of neurological and imaging worsening, with increase in herniation, which led to the diagnosis suspicion of a paradoxical brain herniation. Consequently, a rapid reversal of neurological deficits was observed after applying maneuvers to augment the intracranial pressure, followed by cranioplasty. This case illustrates the utmost importance of clinical suspicion for the uncommon complications of neurointerventions.

Augmented Reality-Guided External Ventricular Drain Placement: A Case Report.

The placement of an external ventricular drain (EVD) is a critical neurosurgical procedure used to relieve intracranial pressure in patients with conditions such as hydrocephalus, traumatic brain injury, and intracranial hemorrhage. Traditional methods rely heavily on anatomical landmarks and the surgeon's experience, which can lead to variability in outcomes and increased risk of complications. Neuronavigation, while available, is infrequently used due to the size, cost, and set-up times associated with these devices. This report explores the use of a headset-based augmented reality (AR) system for guidance during the EVD placement procedure. We describe an AR system that overlays a 3D model of the patient's cranial anatomy, derived from preoperative imaging, onto the patient's head. This system is a head-mounted display and utilizes a rapid fiducial-less registration to provide the surgeon with visualization of 3D anatomy, and targeted trajectories. The system was used with a 32-year-old patient undergoing EVD placement prior to a cranioplasty. Due to the atypical cranial anatomy and due to prior procedures and midline shift, this relatively high-risk catheter placement was an ideal circumstance for the use of AR guidance during the EVD placement. This report described an early use of AR for EVD placement and represents a substantial advancement in neurosurgical practice, offering enhanced precision, efficiency, and safety. Further large-scale studies are warranted to validate these findings and explore the broader applicability of AR in other neurosurgical procedures.

Novel Treatment Modality for Chimeric Antigen Receptor T-cell Therapy Complications: A Case Report.

Immune cell-associated neurotoxicity syndrome (ICANS) and cytokine release syndrome (CRS) are both common adverse effects of chimeric antigen receptor (CAR) T-cell therapy. Blinatumomab is a commonly used CAR T-cell treatment in patients with B-cell acute lymphoblastic leukemia (B-ALL). Our patient presented with an extensive past medical history, including refractory B-ALL, and developed CRS and ICANS following treatment with blinatumomab CAR-T cell therapy. Early clinical detection of ICANS, monitoring using immune effector cell encephalopathy scores, following the appropriate protocol for ICANS grade, and adding anakinra (IL-1 receptor antagonist) were crucial steps in managing his condition. The approach to managing and monitoring this patient was unique in that we added anakinra to the standard treatment regimen. With this report, we emphasize the need for further research regarding CAR T-cell therapeutic regimens and how to decrease the morbidity and mortality of its adverse effects.

Sedation Intensity in Patients with Moderate to Severe Traumatic Brain Injury in the Intensive Care Unit: A TRACK-TBI Cohort Study.

BACKGROUND: Interventions to reduce intracranial pressure (ICP) in patients with traumatic brain injury (TBI) are multimodal but variable, including sedation-dosing strategies. This article quantifies the different sedation intensities administered in patients with moderate to severe TBI (msTBI) using the therapy intensity level (TIL) across different intensive care units (ICUs), including the use of additional ICP-lowering therapies. METHODS: Within the prospective Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study, we performed a retrospective analysis of adult patients with msTBI admitted to an ICU for a least 5 days from seven US level 1 trauma centers who received invasive ICP monitoring and intravenous sedation. Sedation intensity was classified prospectively as one of three ordinal levels as part of the validated TIL score, which were collected at least once a day. RESULTS: A total of 127 patients met inclusion criteria (mean age 41.6 ± 17.7 years; 20% female). The median Injury Severity Score was 27 (interquartile range 17-33), with a median admission Glasgow Coma Score of 3 (interquartile range 3-7); 104 patients had severe TBI (82%), and 23 patients had moderate TBI (18%). The sedation intensity score was highest on the first ICU day (2.69 ± 1.78), independent of patient severity. Time to reaching each sedation intensity level varied by site. Sedation level I was reached within 24 h for all sites, but sedation levels II and III were reached variably between days 1 and 3. Sedation level III was never reached by two of seven sites. The total TIL score was highest on the first ICU day, with a modest decrease for each subsequent ICU day, but there was high site-specific practice-pattern variation. CONCLUSIONS: Intensity of sedation and other therapies for elevated ICP for patients with msTBI demonstrate large practice-pattern variation across level 1 trauma centers within the TRACK-TBI cohort study, independent of patient severity. Optimizing sedation strategies using patient-specific physiologic and pathoanatomic information may optimize patient outcomes.