Cohort analysis of desmopressin effect on hematoma expansion in patients with spontaneous intracerebral hemorrhage and documented pre-ictus antiplatelet use.

Antiplatelet therapy at the time of spontaneous intracerebral hemorrhage (sICH) may increase risk for hemorrhage expansion and mortality. Current guidelines recommend considering a single dose of desmopressin in sICH associated with cyclooxygenase-1 inhibitors or adenosine diphosphate receptor inhibitors. Adult subjects with sICH and concomitant antiplatelet therapy admitted to a large, tertiary care center were included. We sought to compare the risk of hematoma expansion in patients that received desmopressin for antiplatelet reversal in the setting of sICH to similar patients that did not receive desmopressin. The primary outcomes were the incidence of relative and absolute hematoma expansion. In total, 71 patients (29 received desmopressin, 42 did not receive desmopressin) were analyzed. All patients in the desmopressin group received a 0.3 mcg/kg intravenous dose prior to hematoma expansion assessment. Relative hematoma expansion occurred in 5/29 (17%) with desmopressin compared to 11/42 (26%) without desmopressin (OR 0.59 [95% CI 0.18-1.92]). Absolute hematoma expansion occurred in 9/29 (30%) with desmopressin compared to 12/42 (28%) without desmopressin (OR 1.13 [95% CI 0.40-3.16]). Multiple logistic regression controlling for significant covariates did not reveal a significant effect of desmopressin on relative or absolute hematoma expansion (OR 0.65 [95% CI 0.18-2.43] and OR 1.55 [0.48-4.99], respectively). We failed to find evidence that desmopressin administration for antiplatelet reversal in sICH reduces the incidence of hematoma expansion. Larger studies, focusing on the early phase of sICH, are needed to characterize the clinical efficacy and safety of desmopressin for antiplatelet reversal before widespread implementation.

Comparison of catheter-related large vein thrombosis in centrally inserted versus peripherally inserted central venous lines in the neurological intensive care unit.

OBJECTIVE: To compare cumulative complication rates of peripherally (PICC) and centrally (CICVC) inserted central venous catheters, including catheter-related large vein thrombosis (CRLVT), central line-associated bloodstream infection (CLABSI), and line insertion-related complications in neurological intensive care patients. METHODS: Retrospective cohort study and detailed chart review for 431 consecutive PICCs and 141 CICVCs placed in patients under neurological intensive care from March 2008 through February 2010. Cumulative incidence of CRLVT, CLABSI, and line insertion-related complications were compared between PICC and CICVC groups. Risk factors for CRLVT including mannitol therapy during dwell time, previous history of venous thromboembolism, surgery longer than 1h during dwell time, and line placement in a paretic arm were also compared between groups. RESULTS: During the study period, 431 unique PICCs were placed with cumulative incidence of symptomatic thrombosis of 8.4%, CLABSI 2.8%, and line insertion-related complications 0.0%. During the same period, 141 unique CICVCs were placed with cumulative incidence of symptomatic thrombosis of 1.4%, CLABSI 1.4%, and line insertion-related complications 0.7%. There was a statistically significant difference in CRLVT with no difference in CLABSI or line insertion-related complications. CONCLUSIONS: In neurological critical care patients, CICVCs appear to have a better risk profile compared to PICCs, with a decreased risk of CRLVT. As use of PICCs in critical care patients increases, a prospective randomized trial comparing PICCs and CICVCs in neurological critical care patients is necessary to assist in choosing the appropriate catheter and to minimize risks of morbidity and mortality associated with central venous access.

Cumulative incidence and predictors of neurosurgical interventions following nonsevere traumatic brain injury with mildly abnormal head imaging findings.

BACKGROUND: Incidence and predictors of neurosurgical interventions following nonsevere traumatic brain injury (TBI) with mildly abnormal head computed tomographic (CT) findings are poorly defined. Despite this, neurosurgical consultation is routinely requested in this patient population. Our objective was to determine incidence of neurosurgical intervention in this patient population and identify clinical and radiographic features predicting the subsequent need for these interventions. METHODS: We identified all consecutive adult patients with nonsevere TBI admitted from January 1, 2001, through December 31, 2010. The definitions of "mildly abnormal initial head CT findings" and "neurosurgical interventions" were determined a priori by author consensus. Cumulative incidence of neurosurgical interventions was determined, and multivariate logistic regression was used to identify independent predictors of neurosurgical intervention. RESULTS: Of 677 patients, 51 underwent neurosurgical intervention for a cumulative incidence of 7.5%. Only 1.6% required an intracranial procedure. In adjusted analysis, presence of coagulopathy (odds ratio [OR], 2.21; 95% confidence interval [CI], 1.13-4.3; p = 0.02), suspected cerebrospinal fluid leak (OR, 11.36; 95% CI, 2.83-45.58; p = 0.001), any basal cistern or sylvian fissure subarachnoid hemorrhage (OR, 2.94; 95% CI, 1.56-5.57; p = 0.001), depressed skull fracture (OR, 2.84; 95% CI, 1.29-6.28; p = 0.01), or unstable repeated head CT findings (OR, 2.81; 95% CI, 1.52-5.2; p = 0.001) remained an independent predictor of the need for subsequent neurosurgical intervention. CONCLUSION: Among patients with nonsevere TBI and mildly abnormal head imaging findings in which routine neurosurgical consultation is obtained, there is a low incidence of neurosurgical interventions. Our findings suggest that routine early neurosurgical consultation in this patient population may not be necessary; however, this should be tested in a prospective, comparative study. LEVEL OF EVIDENCE: Prognostic study, level III; therapeutic study, level IV.

Risk factors associated with peripherally inserted central venous catheter-related large vein thrombosis in neurological intensive care patients.

PURPOSE: Using Virchow's triad as a framework, we sought to identify risk factors independently associated with symptomatic peripherally inserted central venous catheter (PICC)-related large vein thrombosis (PRLVT) in neurological intensive care patients. METHODS: A retrospective cohort study and detailed chart review were performed for 431 consecutive PICCs placed in patients admitted to our neurological intensive care unit between March 2008 and February 2010. Variables theorized to potentially increase the risk of PRLVT were abstracted from the medical record. Each variable was then tested for its independent association with PRLVT. RESULTS: During the study period, 431 PICCs were placed with an incidence rate for symptomatic thrombosis of 8.4%. In adjusted analysis, catheter placement in a paretic arm (OR, 9.85; 95% CI, 4.42-21.95), surgery longer than 1 h during dwell time of the catheter (OR, 3.26; 95% CI, 1.48-7.17), a history of venous thromboembolism (OR, 6.66; 95% CI, 2.38-18.62), and mannitol use (OR, 3.27; 95% CI 1.27-8.43) were independently associated with the development of thrombosis. CONCLUSIONS: Alterations in blood flow and consistency, but not vessel injury, appear associated with symptomatic thrombosis following placement of PICCs in neurological intensive care patients. Mannitol use and placement in a paretic arm are potentially modifiable risk factors. Given the high incidence rate of symptomatic thrombosis, future studies should focus on comparing cumulative complications of centrally inserted venous catheters and PICCs in intensive care patients.

Fulminant chemical ventriculomeningitis following intrathecal liposomal cytarabine administration.

Intrathecal liposomal cytarabine (ITLC) has shown prolonged time to neurological deterioration in some patients with leptomeningeal spread of breast cancer. We describe a patient with fulminant chemical ventriculomeningitis leading to cerebral edema and death following ITLC administration. A 56-year-old Caucasian female developed progressive headache, depressed level of consciousness and adventitious movements immediately following ITLC. Neurological examination was normal prior to injection. This progressed to loss of all brainstem function and a head CT scan demonstrated diffuse cerebral edema. Due to the absence of neurological function on examination, the family opted to withdraw care. To our knowledge we report the first patient with fulminant chemical ventriculomeningitis leading to cerebral edema and death following ITLC administration. Adjunctive glucocorticoids are recommended. Treatment options are limited and complicated by the liposomal formulation of intrathecal cytarabine.

Decompressive hemicraniectomy in a 19-month-old female after malignant cerebral infarction.

Malignant cerebral infarction is a life-threatening condition with case fatality rates of approximately 80% in adults with malignant infarction of the middle cerebral artery. No medical treatment has been proven effective for this condition. Decompressive hemicraniectomy within 48 h of massive cerebral infarction significantly reduces mortality and improves outcome in adults 18-60 years of age. However, there is very limited data available about the role of decompressive hemicraniectomy in children with acute malignant cerebral infarction. We present the case of a 19-month-old female who presented with progressive encephalopathy and right hemiparesis. Computed tomography and magnetic resonance imaging of the brain showed massive cerebral infarction in the distribution of the left carotid artery with midline shift and impeding brain stem herniation. She underwent emergent decompressive hemicraniectomy with duraplasty and placement of an intracranial pressure monitor. Intracranial pressure was controlled with sedation and the patient was extubated on postoperative day 4. Extensive stroke workup was negative. Cranioplasty was performed at 3 months post-op. At the 6-month follow-up, she had an excellent recovery (modified Rankin scale of 1). Decompressive hemicraniectomy should be considered for the treatment of cerebral edema in children with malignant cerebral infarction. This may improve mortality and functional outcome compared to medical therapy alone. Due to the rare occurrence of stroke in children, more reports of decompressive hemicraniectomy are encouraged.