External Ventricular Drainage: A Practical Guide for Neuro-Anesthesiologists.

External ventricular drainage is often considered a life-saving treatment in acute hydrocephalus. Given the large number of discussion points, the ideal management of EVD has not been completely clarified. The objective of this study was to review the most relevant scientific evidence about the management of EVD in its main clinical scenarios. We reviewed the most recent and relevant articles about indications, timing, management, and complications of EVD in neurocritical care, with particular interest in patients with subarachnoid hemorrhage (SAH), severe traumatic brain injury (TBI), and intraventricular hemorrhage (IVH) using the following keywords alone or matching with one another: intracranial pressure, subarachnoid hemorrhage, traumatic brain injury, intraventricular hemorrhage, external ventricular drainage, cerebrospinal shunt, intracranial pressure monitoring, and ventriculoperitoneal shunt. In the management of EVD in SAH, the intermittent drainage strategy is burdened with an elevated risk of complications (e.g., clogged catheter, hemorrhage, and need for replacement). There seems to be more ventriculoperitoneal shunt dependency in rapid weaning approach-managed patients than in those treated with the gradual weaning approach. Although there is no evidence in favor of either strategy, it is conventionally accepted to adopt a continuous drainage approach in TBI patients. Less scientific evidence is available in the literature regarding the management of EVD in patients with severe TBI and intraparenchymal/intraventricular hemorrhage. EVD placement is a necessary treatment in several clinical scenarios. However, further randomized clinical trials are needed to clarify precisely how EVD should be managed in different clinical scenarios.

Hyponatremia Related to Neurocritical Care: Focus on Diagnosis and Therapy: A Systematic Review.

INTRODUCTION: Hyponatremia is the most frequently occurring electrolyte disorder in neurocritical care and traumatic brain injury, aneurysmal subarachnoid hemorrhage (SAH), neurosurgery, and ischemic stroke are the clinical conditions more often associated with this condition. SIADH and CSWS are the main causes of hyponatremia in neurologically ill patients. Since hyponatremia is a negative prognostic factor for neurocritical patients, early diagnosis and consequent targeted therapy are of fundamental importance. The present review was carried out to provide a brief recap on the main causes and management of hyponatremia in the neurocritical patient. METHODS: A methodical search of the medical literature using the online database MEDLINE was carried out and studies comprising case reports, prospective and retrospective observational studies, or randomized controlled clinical trials in which there is a diagnosis of hyponatremia in neurocritical patients were included. RESULTS: 18 articles were analyzed, consisting of 8 case reports, 4 case series, 3 prospective trials, 1 retrospective study, and 1 multicenter trial. A total of 1371 patients from 18 studies were included. Patients' average age was 29.28 ± 20.9, respectively. TBI was the main cause of hyponatremia in the literature reviewed; 12 studies were about the relationship between TBI and hyponatremia, 2 studies about stroke, 2 studies about SAH and 1 about hyponatremia postneurosurgical procedure. DISCUSSION: Hyponatremia is the most common electrolyte disorder in hospitalized patients and the main scenarios of hyponatremic neurocritical patients are subarachnoid hemorrhage, ischemic stroke, traumatic brain injury and iatrogenic hyponatremia due to neurosurgical cases. CONCLUSION: Hyponatremia is a frequent finding in neurocritical care and is also a recognized negative prognostic factor leading to increased mortality and ICU length hospitalization. Its diagnosis and therapy are essential for correct neurocritical management. The most common cause of serum sodium abnormality is SIADH, and an early diagnosis for target treatment is paramount to prevent delayed symptoms and complications.

Complications of cranioplasty in relationship to traumatic brain injury: a systematic review and meta-analysis.

Despite being a common procedure, cranioplasty (CP) is associated with a variety of serious, at times lethal, complications. This study explored the relationship between the initial injury leading to decompressive craniectomy (DC) and the rates and types of complications after subsequent CP. It specifically compared between traumatic brain injury (TBI) patients and patients undergoing CP after DC for other indications.A comprehensive search of PubMed, Scopus, and the Cochrane Library databases using PRISMA guidelines was performed to include case-control studies, cohorts, and clinical trials reporting complication data for CP after DC. Information about the patients' characteristics and the rates of overall and specific complications in TBI and non-TBI patients was extracted, summarized, and analyzed.A total of 59 studies, including the authors' institutional experience, encompassing 9264 patients (4671 TBI vs. 4593 non-TBI) met the inclusion criteria; this total also included 149 cases from our institutional series. The results of the analysis of the published series are shown both with and without our series 23 studies reported overall complications, 40 reported infections, 10 reported new-onset seizures, 13 reported bone flap resorption (BFR), 5 reported post-CP hydrocephalus, 10 reported intracranial hemorrhage (ICH), and 8 reported extra-axial fluid collections (EFC). TBI was associated with increased odds of BFR (odds ratio [OR] 1.76, p < 0.01) and infection (OR 1.38, p = 0.02). No difference was detected in the odds of overall complications, seizures, hydrocephalus, ICH, or EFC.Awareness of increased risks of BFR and infection after CP in TBI patients promotes the implementation of new strategies to prevent these complications especially in this category of patients.

Minimally invasive procedure for removal of infected ventriculoatrial shunts.

BACKGROUND: Ventriculoatrial shunts were one of the most common treatments of hydrocephalus in pediatric and adult patients up to about 40 years ago. Thereafter, due to the widespread recognition of the severe cardiac and renal complications associated with ventriculoatrial shunts, they are almost exclusively implanted when other techniques fail. However, late infection or atrial thrombi of previously implanted shunts require removal of the atrial catheter several decades after implantation. Techniques derived from management of central venous access catheters can avoid cardiothoracic surgery in such instances. METHODS: We retrospectively investigated all the patients requiring removal of a VA shunt for complications treated in the last 5 years in our institution. RESULTS: We identified two patients that were implanted 28 and 40 years earlier. Both developed endocarditis with a large atrial thrombus and were successfully treated endovascularly. The successful percutaneous removal was achieved by applying, for the first time in this setting, the endoluminal dilation technique as proposed by Hong. After ventriculoatrial shunt removal and its substitution with an external drainage, both patients where successfully weaned from the need for a shunt and their infection resolved. CONCLUSION: Patients carrying a ventriculoatrial shunt are now rarely seen and awareness of long-term ventriculoatrial shunt complications is decreasing. However, these complications must be recognized and treated by shunt removal. Endovascular techniques are appropriate even in the presence of overt endocarditis, atrial thrombi, and tight adherence to the endocardial wall. Moreover, weaning from shunt dependence is possible even decades after shunting.

Mild head trauma in elderly patients: experience of an emergency department.

INTRODUCTION: We evaluated the risk profile of elderly patients who came to the emergency department for mild head trauma. The primary goal was to determine the difference in the incidence of posttraumatic intracranial hemorrhage (ICH) after minor head injury (MHI). The secondary objective was to assess worse outcome, such as: hospitalization rate, rate of re-admission, need of neurosurgery. We also assess the admission process times and length of hospital stay. The ultimate goal was to optimize the diagnostic-observational management of minor head trauma in elderly patients. MATERIAL AND METHODS: We evaluated all patients with MHI who came to our emergency department during 2017 and 2018. All patients underwent computed tomography. RESULTS: We enrolled 2325 patients, of whom 1094 were 75 years of age or older. The population was divided into two categories according to age: The "elderly population" was 75 or older, and the younger patients were younger than 75. The elderly population, in comparison with the younger patients, had a higher rate of ICH (12.1% versus 5.1%), a higher hospitalization rate (11.7% versus 5.5%), and a higher rate of readmission within 30 days (6.8% versus 3.2%). The elderly population also had longer admission process times (8 h, 25 min, versus 4 h, 09 min) and longer lengths of hospital stay (9 h, 41 min, versus 5 h, 29 min). Of the younger patients, 92% (versus 41% of the elderly population) did not take any drugs, 6% (versus 39%) were receiving antiplatelet therapy, 1% (versus 13%) took vitamin K antagonists, and 1% (versus 7%) took oral direct-acting anticoagulants. Logistic regression models revealed that a 1-year increase in age raised the risk of bleeding by 2% on average; this finding was statistically significant (odds ratio [OR], 1023/year, p < 0.001). The rate of ICH increased significantly after the age of 75, by 180% (OR, 2.82; p < 0.001). CONCLUSIONS: These data suggest that age is an independent risk factor for ICH, whereby the age of 75 entails a 180% increase in the risk of bleeding.

Trauma Coagulopathy and Its Outcomes.

Background and Objectives: Trauma coagulopathy begins at the moment of trauma. This study investigated whether coagulopathy upon arrival in the emergency room (ER) is correlated with increased hemotransfusion requirement, more hemodynamic instability, more severe anatomical damage, a greater need for hospitalization, and hospitalization in the intensive care unit (ICU). We also analyzed whether trauma coagulopathy is correlated with unfavorable indices, such as acidemia, lactate increase, and base excess (BE) increase. Material and Methods: We conducted a prospective, monocentric, observational study of all patients (n = 503) referred to the Department of Emergency and Acceptance, IRCCS Fondazione Policlinico San Matteo, Pavia, for major trauma from 1 January 2018 to 30 January 2019. Results: Of the 503 patients, 204 had trauma coagulopathy (group 1), whereas 299 patients (group 2) did not. Group 1 had a higher hemotransfusion rate than group 2. In group 1, 15% of patients showed hemodynamic instability compared with only 8% of group 2. The shock index (SI) distribution was worse in group 1 than in group 2. Group 1 was more often hypotensive, tachycardic, and with low oxygen saturation, and had a more severe injury severity score than group 2. In addition, 47% of group 1 had three or more body districts involved compared with 23% of group 2. The hospitalization rate was higher in group 1 than in group 2 (76% vs. 58%). The length of hospitalization was >10 days for 45% of group 1 compared with 28% of group 2. The hospitalization rate in the ICU was higher in group 1 than in group 2 (22% vs. 14.8%). The average duration of ICU hospitalization was longer in group 1 than in group 2 (12.5 vs. 9.78 days). Mortality was higher in group 1 than in group 2 (3.92% vs. 0.98%). Group 1 more often had acidemia and high lactates than group 2. Group 1 also more often had BE <-6. Conclusions: Trauma coagulopathy patients, upon arrival in the ER, have greater hemotransfusion (p = 0.016) requirements and need hospitalization (p = 0.032) more frequently than patients without trauma coagulopathy. Trauma coagulopathy seems to be more present in patients with a higher injury severity score (ISS) (p = 0.000) and a greater number of anatomical districts involved (p = 0.000). Head trauma (p = 0.000) and abdominal trauma (p = 0.057) seem related to the development of trauma coagulopathy. Males seem more exposed than females in developing trauma coagulopathy (p = 0.018). Upon arrival in the ER, the presence of tachycardia or alteration of SI and its derivatives can allow early detection of patients with trauma coagulopathy.