Intrathecal administration of colistin for meningitis due to New Delhi metallo-ß-lactamase 1(NDM-1)-producing Klebsiella pneumoniae.

Infection by bacteria carrying New Delhi metallo-ß-lactamase 1 (NDM-1) is becoming a global health problem. We report a case of meningitis caused by NDM-1-producing Klebsiella pneumoniae, for which intrathecal administration of colistin was curative. A previously healthy 38-year-old Japanese man, who lived in Hyderabad, India, suddenly collapsed and was brought to a local hospital. He was diagnosed with subarachnoid hemorrhage and underwent emergency surgery which included partial skull removal. Approximately 1 month after surgery, he was repatriated to Japan and was admitted to our institution with information that he had been treated for multi-drug resistant Acinetobacter infection with colistin. A week after admission, he developed aspiration pneumonia due to NDM-1-producing K. pneumoniae, which was successfully treated by intravenous (IV) administration of colistin. Subsequently, he underwent a surgical procedure to repair his skull defect. He developed high-grade fever and altered mental status on postoperative day 2. NDM-1-producing K. pneumoniae was identified in the cerebrospinal fluid, establishing the diagnosis of meningitis. Although IV colistin was only partially effective, intrathecal colistin (10 mg daily by lumbar puncture for 14 days) successfully eradicated the meningitis. Because of economic globalization, NDM-1-producing bacteria may be brought to Japan by those who are repatriated after sustaining critical illnesses and being treated in foreign countries. This report may provide useful information on the treatment of central nervous system infection by NDM-1-producing bacteria.

Cardiac wall motion abnormality after bleeding from vertebral artery aneurysms.

OBJECTIVE: Lesions in the medulla oblongata may be causally associated with cardiac wall motion abnormality (WMA). Although subarachnoid hemorrhage (SAH) patients occasionally develop WMA, the relationship between aneurysmal locations and the frequency of WMA has rarely been investigated. The objective of this study was to evaluate whether the frequency of WMA was higher after the rupture of vertebral artery (VA) aneurysms than that of non-VA aneurysms. METHODS: We performed a retrospective chart analysis of 244 SAH patients who underwent transthoracic echocardiography and plasma catecholamine measurements. The frequencies of WMA and electrocardiographic (ECG) abnormalities were compared among patients classified by the location of aneurysms. Multivariate regression analysis was conducted to identify variables correlated with WMA. Furthermore, the relationship between plasma catecholamine levels and aneurysmal locations was evaluated. RESULTS: The frequency of WMA was significantly higher in patients with VA aneurysms than in those with non-VA aneurysms (45 vs. 22 %, p = 0.01). However, there was no significant difference in the frequency of ECG abnormalities. Multivariate regression analysis showed that VA aneurysms (OR, 3.317; 95 % CI, 1.129-9.745), poor-grade SAH (OR, 2.733; 95 % CI, 1.320-5.658) and concomitant hydrocephalus (OR, 3.658; 95 % CI, 1.690-7.917) correlated with WMA. There were no significant intergroup differences in plasma catecholamine levels. CONCLUSION: VA aneurysms are close to several medullary nuclei that integrate autonomic inputs. A transient deformation and ischemia of the medulla oblongata caused by the mechanical stress related to the rupture of a VA aneurysm and/or a concomitant hydrocephalus may be responsible for the disproportionately high frequency of WMA.

Association between elevated plasma norepinephrine levels and cardiac wall motion abnormality in poor-grade subarachnoid hemorrhage patients.

Patients with aneurysmal subarachnoid hemorrhage (SAH) are frequently complicated by acute cardiac dysfunctions, including cardiac wall motion abnormality (WMA). Massive release of catecholamine into the systemic circulation after aneurysmal rupture is believed to result in WMA, and poor-grade SAH seems to be the most important risk factor. However, plasma catecholamine levels have rarely been measured in SAH patients with WMA, and previous studies indicated that the elevated levels might not necessarily predict WMA. The objective of this study is (1) to evaluate relationship between WMA and plasma catecholamine levels in poor-grade SAH patients in the acute phase and (2) to clarify clinical characteristics of SAH patients with WMA. Among 142 poor-grade (World Federation of Neurosurgical Societies grades IV and V) SAH patients, 48 underwent both transthoracic ultrasound and measurement of plasma catecholamine levels within 24 h of SAH onset. They were divided into WMA+ (n = 23) and WMA- (n = 25) groups, and intergroup comparison was made on demographics, plasma catecholamine levels, and outcomes. Plasma norepinephrine levels were significantly higher in WMA+ group than in WMA- group (2,098.4 ± 1,773.4 vs. 962.9 ± 838.9 pg/mL, p = 0.02), and the former showed significantly worse outcomes 90 days after admission. There were no intergroup differences in the plasma levels of epinephrine. Plasma norepinephrine levels were inversely correlated with left ventricular ejection fraction. Multivariate logistic regression analysis revealed that increased plasma norepinephrine levels were predictive of WMA, although age, female sex, and grade V SAH were not. This retrospective study highlights the role of norepinephrine in pathogenesis of SAH-induced WMA.

Predictive Value of Motor Evoked Potential Monitoring during Surgery of Unruptured Anterior Circulation Cerebral Aneurysms.

OBJECTIVE AND BACKGROUND: Surgery of unruptured aneurysms is always a great challenge to neurovascular surgeons because no postoperative neurological deficits should be expected postoperatively as the patients are fully asymptomatic before the surgery. Here, we present our experience with selective motor evoked potential (MEP) monitoring of our patients in a 2-year time window. PATIENTS AND METHODS: From 2012 to 2014, 27 patients with unruptured intracranial aneurysms were operated in our institute with the help of MEP monitoring. All patients underwent endoscope-assisted microsurgery with pre- and post-clipping indocyanine green angiography. RESULTS: In this period, no mortality was observed, but 18.5% of the patients developed postoperative deficits which showed good recovery in all cases. Overall, MEP showed about 90% accuracy in predicting postoperative deficits. CONCLUSIONS: MEP as a part of multimodality monitoring of aneurysm surgeries is a valuable tool to improve the outcome. However, we should know its limitations as its results are not always consistent with the outcome.

Subarachnoid hemorrhage caused by an undifferentiated sarcoma of the sellar region.

BACKGROUND: It is rare for patients with pituitary apoplexy to exhibit concomitant subarachnoid hemorrhage (SAH). Only a handful of patients with pituitary apoplexy have developed such hemorrhagic complications, and histopathological examination revealed pituitary adenoma as the cause of SAH. CASE REPORT: A previously healthy 35-year-old woman was brought to our institution after complaining of severe headache and left monocular blindness. Brain computed tomography showed a diffuse SAH with a central low density. Subsequently, the brain magnetic resonance imaging revealed an intrasellar mass with heterogeneous contrast enhancement. The patient was presumptively diagnosed with SAH secondary to hemorrhagic pituitary adenoma and underwent transcranial surgery to remove both the tumor and subarachnoid clot. A histological evaluation of the surgical specimen revealed malignant cells with strong predilection for vascular invasion. Following immunohistochemical evaluation, the tumor was negative for the majority of tumor markers and was positive only for vimentin and p53; thus, a diagnosis of undifferentiated sarcoma was established. CONCLUSIONS: This case was informative in the respect that tumors other than pituitary adenoma should be included in the differential diagnosis of patients with pituitary apoplexy.

Improvement in patient outcomes following endovascular treatment of WFNS grade V subarachnoid haemorrhage from 2000 to 2014.

Patient outcomes following grade V subarachnoid haemorrhage (SAH) have been dismal, although they may have improved following recent technological advances in endovascular treatment (EVT). A single-centre, retrospective study was conducted to evaluate whether outcomes have improved from 2000 to 2014 for patients with World Federation of Neurosurgical Societies (WFNS) grade V SAH. Coiling has been the preferred first-line treatment for grade V SAH patients in our institution since 2000. Patients who underwent EVT (n=115) were grouped on the basis of their hospital admission year: 2000-2004 (n=44), 2005-2009 (n=37) and 2010-2014 (n=34). Patient demographics, outcomes and in-hospital mortality rates were compared between the groups. Patient outcomes at discharge were evaluated using the Glasgow Outcome Scale (GOS), with GOS scores of 4-5 defined as favourable outcomes. There were no significant intergroup differences in patient demographics. In addition, there were no significant differences in the frequencies of favourable outcomes (14% in 2000-2004, 16% in 2005-2009 and 26% in 2010-2014). Mortality rates were 52% in 2000-2004, 43% in 2005-2009 and 24% in 2010-2014, with a significantly lower mortality rate in 2010-2014 than in 2000-2004 (p=0.01). Both perioperative rebleeding and delayed cerebral ischaemia decreased over time; however, multivariate regression analysis showed that the former contributed more to the decrease in mortality. Age was the only variable associated with favourable outcomes. The results of this study indicate that EVT is an appropriate therapeutic option for grade V SAH patients. However, multi-centre, prospective trials are required to provide evidence-based verification of the efficacy of EVT.

Neurogenic stunned myocardium associated with pediatric brain tumor may not be catecholamine-induced.

A rare case of pediatric neurogenic stunned myocardium (NSM) associated with a brain tumor is reported. A previously healthy 6-year-old boy presented with coma, and imaging studies revealed a brain tumor. On hospitalization day 3, he developed NSM and neurogenic pulmonary edema necessitating intensive cardiopulmonary support. Although blood marker levels of cardiac injury were elevated, his plasma and urinary norepinephrine levels were within normal limits. His cardiorespiratory functions markedly improved by hospitalization day 8. This case report may be one of the first to document plasma and urinary catecholamine levels in pediatric NSM. While solid conclusion cannot be drawn based on experience from a single case, these results suggest that pediatric NSM may not be catecholamine-induced.

Relationship between systolic blood pressures measured in emergency department and outcomes in patients with subarachnoid hemorrhage.

Aim: High blood pressure is observed frequently in patients with subarachnoid hemorrhage who present to the emergency department. Although extremely high blood pressure is known to predict poor outcomes in patients with spontaneous intracerebral hemorrhage, the relationship between high blood pressure and outcomes has been studied less frequently in patients with subarachnoid hemorrhage. Methods: A retrospective study was carried out to evaluate whether high blood pressure observed in the emergency department was predictive of poor outcomes in patients with subarachnoid hemorrhage. Three-hundred and twelve subarachnoid hemorrhage patients who were admitted to our institution were quadrichotomized based on their initial systolic blood pressure: <140 mmHg (n = 60), 140-184 mmHg (n = 144), 185-219 mmHg (n = 64), and ≥220 mmHg (n = 44). Demographics including subarachnoid hemorrhage severity (World Federation of Neurosurgical Societies grade) and outcome variables evaluated with the modified Rankin scale 30 days after admission were compared among the four blood pressure groups. Furthermore, an effort was made to delineate a threshold value of systolic blood pressure predictive of outcomes by receiver operating characteristic curve analysis. Results: The frequency of grade V subarachnoid hemorrhage in the ≥220 mmHg group (55%) was significantly higher than in the other three blood pressure groups. The frequency of patients scoring 5-6 on the modified Rankin scale in the ≥220 mmHg group (54%) was significantly higher than in the other three blood pressure groups. The cut-off systolic blood pressure value predicting poor outcomes (modified Rankin scale 5-6) determined by receiver operating characteristic curve analysis was 189 mmHg. Conclusions: The higher proportion of grade V patients may be responsible for the worse outcomes in the group with systolic blood pressure ≥220 mmHg. Initial systolic blood pressure ≥220 mmHg may be a crude indicator of poor outcomes in patients with subarachnoid hemorrhage.

Role of catecholamines in acute hypertensive response: subarachnoid hemorrhage versus spontaneous intracerebral hemorrhage.

BACKGROUND AND OBJECTIVE: Acute hypertensive response, defined as systolic blood pressure (SBP) 140 mmHg or more within 24 h of onset, is frequently observed in hemorrhagic stroke patients. Although catecholamine surge is pivotal in its pathogenesis, few studies have evaluated the relationship between admission SBP and plasma catecholamine levels. PATIENTS AND METHODS: A prospective observational study was carried out to investigate potential differences in the acute hypertensive reaction between subarachnoid hemorrhage (SAH) and spontaneous intracerebral hemorrhage (SICH) by analyzing 200 SAH and 200 SICH patients. In each category, patients were quadrichotomized on the basis of their SBPs in emergency department: less than 140 mmHg, 140-184 mmHg, 185-219 mmHg, and 220 mmHg or more. The plasma catecholamine levels were compared among the four groups. Furthermore, multivariate regression analyses were carried out to identify variables correlated with hypertensive emergency (SBP≥185 mmHg). RESULTS: In SAH patients, there was a proportional increase in norepinephrine levels relative to the graded SBPs, and norepinephrine levels in the 220 mmHg or more group were significantly higher than those in the less than 140 mmHg group (1596±264 vs. 853±124 pg/ml, P=0.03). By contrast, no proportional increase in norepinephrine levels to the graded SBPs was observed in SICH patients. Multivariate regression analyses showed that the initial Glasgow Coma Scale scores of 8 or less (odds ratio 2.251, 95% confidence interval 1.002-5.117) and plasma norepinephrine levels (odds ratio 1.002, 95% confidence interval 1.001-1.003) were correlated with hypertensive emergency in SAH patients. By contrast, none of the variables evaluated were correlated with hypertensive emergency in SICH patients. CONCLUSION: An acute hypertensive response may be more complex, multifactorial, and less catecholamine dependent in SICH patients compared with SAH patients.

Are admission systolic blood pressures predictive of outcomes in patients with spontaneous intracerebral haemorrhage after aggressive blood pressure management?

OBJECTIVE: High blood pressure (HBP) is observed frequently in patients with spontaneous intracerebral haemorrhage (SICH). Although HBP at admission has been associated with poor outcomes, most studies from which such conclusions were derived had been carried out decades earlier, when aggressive BP management was not implemented. In our institution, SICH patients showing HBP undergo aggressive BP management by intravenous nicardipine with target systolic BP (SBP) less than 140 mmHg. We investigated whether responsiveness to intravenous nicardipine, haematoma expansion rate and activity of daily living 90 days after admission differed by the degree of admission SBP. PATIENTS AND METHODS: A retrospective study was carried out by reviewing charts of 120 SICH patients admitted within 6 h of onset who were quadrichotomized on the basis of SBP: <140 mmHg (n=6), 140-184 mmHg (n=49), 185-219 mmHg (n=38) and ≥220 mmHg (n=27). The six patients with SBP less than 140 mmHg were excluded, and demographic and outcome variables of the latter three groups were compared. Whether plasma catecholamine levels differed among the three groups was also investigated. RESULTS: Optimal BP management (target SBP<140 mmHg) within 2 h of arrival was achieved in 98%, haematoma expansion occurred in 7% and the 90-day mortality rate was 11%. Responsiveness to intravenous nicardipine, haematoma expansion rate and activity of daily living were not significantly different. Furthermore, plasma catecholamine levels did not differ significantly. CONCLUSION: The lack of difference in the demographic and outcome variables in SICH patients managed by aggressive treatment to normalize the BP indicates that the previously reported association between HBP at admission and poor outcomes needs to be re-evaluated.

Early rebleeding in patients with subarachnoid haemorrhage under intensive blood pressure management.

The objective of this study was to report the frequency and clinical characteristics of early rebleeding in subarachnoid haemorrhage (SAH) patients who underwent intensive blood pressure (BP) management. Patients with aneurysmal SAH frequently present to the emergency department (ED) with elevated BP. Intensive BP management has been recommended to lower the risk of early rebleeding. However, few studies have reported the frequency of early rebleeding in SAH patients undergoing BP management. In our institution, SAH patients with systolic BP (SBP)>140 mmHg received continuous intravenous nicardipine to maintain their SBP within 120±20 mmHg after diagnosis. An attempt to implement intensive BP management was made on 309 consecutive SAH patients who presented to our ED within 48 hours of SAH onset. Overall, 24 (7.8%) of the 309 patients sustained early rebleeding. Fifteen patients sustained early rebleeding before the implementation of BP management, and the other nine sustained early rebleeding after the implementation of BP management. Therefore, the frequency of early rebleeding under BP management was 3.1% (9/294). When the 309 patients were dichotomised using ED SBP of 140 mmHg as a cut off (SBP>140 mmHg; n=239 versus SBP⩽140 mmHg; n=70), the latter counter-intuitively exhibited a significantly higher frequency of early rebleeding (5.9% versus 14.2%; p=0.04). This relatively low frequency of early rebleeding under BP management may be acceptable. However, early rebleeding is not eradicated even with strict BP control as factors other than elevated BP are involved. ED SBP within the target range (SBP⩽140 mmHg) does not negate the risk of early rebleeding. Other treatment options that reduce the risk should also be explored.

Role of endoscopy in multi-modality monitoring during aneurysm surgery: A single center experience with 175 consecutive unruptured aneurysms.

OBJECTIVE AND BACKGROUND: Unruptured aneurysm surgery is a challenge to all vascular neurosurgeons as the patient is asymptomatic and no even slight neurological deficits should be expected postoperatively. To this aim, multi-modality checking of the vessels during the surgery is highly recommended to assure of the patency of the parent and perforator arteries next to an aneurysm. In this paper, we present our experience in the last 1.5 years with emphasis on the role of endoscope assisted microsurgery. METHODS: One hundred and seventy-five patients with unruptured intracranial aneurysms were operated in our institute in the last 1½ years. All patients underwent endoscope assisted microsurgery with pre- and post-clipping indocyanine green angiography. In selected cases, motor evoked potential monitoring was implemented. RESULTS: No mortality was observed in this period, and only 6 patients (3.4%) suffered new permanent neurological deficits postoperatively. Our illustrative cases show how endoscopy may help the surgeon to visualize hidden vessels behind and medial to an aneurysm. CONCLUSIONS: Our results indicated that multi-modality monitoring during unruptured aneurysm surgeries is associated with excellent outcome. Endoscope is able to show blind corners during aneurysm surgery which cannot be routinely observed with microscope and its application in aneurysm surgery assists the surgeon to make certain of complete neck clipping and preservation of perforating arteries around the aneurysm.