Dural Traction a Possible Cause of Hemodynamic Changes During Single-Level Transforaminal Lumbar Interbody Fusion.

BACKGROUND: Lumbar spinal surgery may be associated with electrophysiologic and hemodynamic abnormalities during the procedure. CASE DESCRIPTION: A 58-year-old man with grade II L4-5 spondylolisthesis and degenerative changes underwent single-level transforaminal lumbar interbody fusion. During decompression of the L4 foramina, distraction of the disc space, and placement of the interbody cage and pedicle screws, episodes of extreme bradycardia with up to 5 seconds of asystole were detected on electrocardiogram and invasive hemodynamic monitoring. The events correlated with and possibly could have been a result of traction on the dura mater. CONCLUSIONS: Anesthesia providers should be aware of electrophysiologic and hemodynamic abnormalities during lumbar spinal surgery and the need to respond appropriately with sympathomimetic or vagolytic interventions.

Predictors of Functional Outcome After Subdural Hematoma: A Prospective Study.

BACKGROUND: Although the incidence of subdural hematoma (SDH) has increased in the US in the last decade, limited prospective data exist examining risk factors for poor outcome. METHODS: A prospective, observational study of consecutive SDH patients was conducted from 7/2008 to 11/2011. Baseline clinical data, hospital and surgical course, complications, and imaging data were compared between those with good versus poor 3-month outcomes (modified Rankin Scores [mRS] 0-3 vs. 4-6). A multivariable logistic regression model was constructed to identify independent predictors of poor outcome. RESULTS: 116 SDH patients (18 acute, 56 mixed acute/subacute/chronic, 42 subacute/chronic) were included. At 3 months, 61 (53 %) patients had good outcomes (mRS 0-3) while 55 (47 %) were severely disabled or dead (mRS 4-6). Of those who underwent surgical evacuation, 54/94 (57 %) had good outcomes compared to 7/22 (32 %) who did not (p = 0.030). Patients with mixed acuity or subacute/chronic SDH had significantly better 3-month mRS with surgery (median mRS 1 versus 5 without surgery, p = 0.002) compared to those with only acute SDH (p = 0.494). In multivariable analysis, premorbid mRS, age, admission Glasgow Coma Score, history of smoking, and fever were independent predictors of poor 3-month outcome (all p < 0.05; area under the curve 0.90), while SDH evacuation tended to improve outcomes (adjusted OR 3.90, 95 % CI 0.96-18.9, p = 0.057). CONCLUSIONS: Nearly 50 % of SDH patients were dead or moderate-severely disabled at 3 months. Older age, poor baseline, poor admission neurological status, history of smoking, and fever during hospitalization predicted poor outcomes, while surgical evacuation was associated with improved outcomes among those with mixed acuity or chronic/subacute SDH.

The Role of FEIBA in Reversing Novel Oral Anticoagulants in Intracerebral Hemorrhage.

BACKGROUND: Activated prothrombin complex concentrates factor eight inhibitor bypassing activity (FEIBA) has been recommended for reversing novel oral anticoagulants (NOAC) in the context of intracerebral hemorrhage (ICH), though few clinical studies report its use. METHODS: A prospective study of patients with spontaneous ICH was conducted from May 2013 to May 2015. Hospital complications including hemorrhage (gastrointestinal bleeding, anemia requiring transfusion, and surgical site bleeding) and thrombosis (pulmonary embolus, deep vein thrombosis, ischemic stroke, and myocardial infarction) were recorded. All ICH patients underwent baseline head CT and a follow-up stability scan in 6 h. NOAC taken within 48 h of presentation was reversed with FEIBA (50 u/kg) per protocol. Three-month outcomes were assessed using the modified rankin score (mRS). RESULTS: Of 127 ICH patients enrolled, 6 (5 %) had NOAC-related ICH including: oral factor XA inhibitor N = 5 (4 %; N = 4 rivaroxaban, N = 1 apixaban] and direct thrombin inhibitor N = 1 (0.8 %; dabigatran). The indication for NOAC was atrial fibrillation in all patients and the median CHADS2-VASC score was 4 (range 2-5). The median admission NIHSS was 2 (range 0-14) and the median ICH volume was 8 mL (range 1-20). Five patients (3 rivaroxaban, 1 apixaban, 1 dabigatran) presented within 48 h and received FEIBA within a median of 13 h (range 10-29 h) from their last NOAC dose and 8 h (range 4.5-20) from the time last known well. None of the patients had ICH expansion, hemorrhagic, or thrombotic complications. Three-month median mRS was 1 (range 0-6). CONCLUSION: In this small case series, reversal of NOAC with FEIBA was not associated with ICH expansion or any thrombotic or hemorrhagic complications.