Predicting Ventriculoperitoneal Shunt Dependence in High Grade Aneurysmal Subarachnoid Hemorrhage.

INTRODUCTION: Aneurysmal subarachnoid hemorrhage (aSAH) commonly presents with hydrocephalus due to obstruction of cerebrospinal fluid (CSF) passage across the ventricular system in the brain. Placement of an external ventricular device (EVD) and in some cases ventriculoperitoneal shunt (VPS) are often necessary for patients requiring prolonged CSF diversion. The study aimed at evaluating critical factors that play a role in determining the need for extended extraventricular drainage. METHODS: We performed a retrospective observational cohort study of two groups of patients with radiological imaging confirmed high grade aSAH (Hunt & Hess grades 3-5) who required VPS placement, shunt-dependent group, and who did not require long term CSF diversion, non-shunt-dependent group. We collected and analyzed data regarding the daily CSF output for 10 days following EVD placement, daily EVD height, intracranial pressure (ICP) and cerebral perfusion pressure (CPP), indicators of hydrocephalus, and CSF characteristics. RESULTS: The cohort, comprising of 8 patients in the shunt-dependent group and 32 patients in the non-shunt-dependent group, displayed median daily CSF output of 275.1 mL/day and 193.4 mL/day, respectively (P = .0005). ROC curve for CSF drainage for the two groups showed an area under the curve (AUC) of 0.71 with a 95% confidence interval (CI) 0.65 to 0.77. Qualitative analysis of CSF characteristics revealed that the shunt-dependent group had more proteinaceous, darker red color, and greater proportion of red blood cells (RBCs) although not statistically significant. CONCLUSIONS: Determinants of prolonged CSF drainage requirements in patients with high grade aSAH are not fully elucidated to this date and there is no standardized protocol for CSF diversion. Our study revealed potential markers that can be used in the assessment for the need for long term CSF diversion. Our limited sample size necessitates further research to establish clear correlations and cutoffs of these parameters in predicting long term CSF diversion requirements.

Where Does the Time Go? The Effect of Protocols for Stroke Last Known Well Documentation on Intravenous Recombinant Tissue Plasminogen Activator Delivery in the Northeast.

BACKGROUND: Despite significant efforts to improve thrombolytic use in the United States, only a small number of patients with ischemic stroke are currently treated. Although there are a number of contraindications to tissue plasminogen activator use, many patients are excluded because of the narrow therapeutic time window, which is determined by the "last known well" (LKW) time. However, it is unclear how the LKW is obtained and documented in the acute hospital setting. METHODS: We surveyed hospitals throughout the Northeast region to determine if they had established protocols for documenting LKW times. Treatment rates as reported to Get with The Guidelines Stroke were then compared in hospitals with and without established protocols for documenting LKW times. RESULTS: The majority of hospitals (73%) lacked established protocols for LKW documentation. Those without established protocols more often missed this variable when reporting to Get With The Guidelines-Stroke. Treatment rates were low overall (7%), although rates in patients who presented within 2 hours of symptom onset were high in hospitals whether they had an established protocol (86%) or not (87%). However, the lack of documentation of LKW is common and could influence the treatment rates if patients are erroneously excluded from treatment. CONCLUSIONS: Improved documentation of LKW times should be attempted. The addition of this variable to existing protocols could more accurately track the number of patients ineligible for treatment based on delayed presentation.

Compliance with joint commission measures in state-designated stroke centers.

BACKGROUND: Comparison of state-designated primary and comprehensive stroke centers (PSCs and CSCs) with regard to adherence to nationally accepted performance standards are scarce. The objective of this study was to examine if a significant association exists between level of designation and fulfillment of Joint Commission (JC) stroke core measures. METHODS: A retrospective comparative data analysis of the New Jersey acute stroke registry for the calendar years 2010 and 2011 was performed. JC core measures were compared by hospital level (PSCs vs CSCs). Adjusted odds ratios (aOR) were estimated for association between hospital levels and fulfillment of JC core measures. Median door-to-thrombolytic time was also compared. RESULTS: There were 36,892 acute stroke admissions. PSCs had 60% of the patients, whereas CSCs had 40%. Hemorrhagic stroke admissions were about 2 times more frequent at CSCs than PSCs (13.3% and 7.1%, respectively). CSCs adhered better to 6 of the 8 JC measures than PSCs. Of eligible patients, 19.5% received thrombolytic therapy at CSCs compared to 9.6% at PSCs, with a 44% difference in provision of thrombolytic therapy (aOR = 0.28, 95% confidence interval: 0.24-0.34). Median door-to-thrombolytic drug times was 65 minutes at CSCs compared to 74.0 minutes at PSCs (P < 0.0001). CONCLUSIONS: New Jersey state-designated CSCs are better at adhering to the JC core stroke measures and have shorter door-to-thrombolytic drug times.