RESUMEN
BACKGROUND AND PURPOSE: The optimal patient sedation during mechanical thrombectomy for ischemic stroke in the extended time window is unknown. The purpose of this study was to assess the impact of patient sedation on outcome in patients undergoing thrombectomy 6-16 hours from stroke onset. MATERIALS AND METHODS: Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3 (DEFUSE 3) was a multicenter, randomized, open-label trial of thrombectomy for ICA and M1 occlusions in patients 6-16 hours from stroke onset. Subjects underwent thrombectomy with either general anesthesia or conscious sedation at the discretion of the treating institution. RESULTS: Of the 92 patients who were randomized to intervention, 26 (28%) underwent thrombectomy with general anesthesia and 66 (72%) underwent thrombectomy with conscious sedation. Baseline clinical and imaging characteristics were similar among all groups. Functional independence at 90 days was 23% for general anesthesia, 53% for conscious sedation, and 17% for medical management (P = .009 for general anesthesia versus conscious sedation). Conscious sedation was associated with a shorter time from arrival in the angiosuite to femoral puncture (median, 14 versus 18 minutes; P = 0.05) and a shorter time from femoral puncture to reperfusion (median, 36 versus 48 minutes; P = .004). Sixty-six patients were treated at sites that exclusively used general anesthesia (n = 14) or conscious sedation (n = 52). For these patients, functional independence at 90 days was significantly higher in the conscious sedation subgroup (58%) compared with the general anesthesia subgroup (21%) (P = .03). CONCLUSIONS: Patients who underwent thrombectomy with conscious sedation in the extended time window experienced a higher likelihood of functional independence at 90 days, a lower NIHSS score at 24 hours, and a shorter time from femoral puncture to reperfusion compared with those who had general anesthesia. This effect remained robust in institutions that only treated patients with a single anesthesia technique.
Asunto(s)
Anestesia General/métodos , Sedación Consciente/métodos , Procedimientos Endovasculares/métodos , Accidente Cerebrovascular/cirugía , Trombectomía/métodos , Anciano , Isquemia Encefálica/complicaciones , Isquemia Encefálica/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Accidente Cerebrovascular/etiología , Resultado del TratamientoRESUMEN
Der grobe ischämische Hemisphäreninfarkt ("large hemispheric infarction", LHI, Synonym maligner Mediainfarkt, MMI) ist eine schwerwiegende neurologische Erkrankung mit hoher Mortalität und Morbidität. Sowohl behandelnde Ärzte als auch Angehörige sehen sich insbesondere hinsichtlich konservativer Therapiemaßnahmen mit einer schwachen Datenlange konfrontiert. Aktuelle Leitlinien zur allgemeinen Schlaganfallbehandlung legen den Hauptfokus auf Risikofaktoren, Prävention und das akute Rekanalisierungsmanagement, beinhalten aber nur sehr limitierte Empfehlungen zur ggf. folgenden spezifischen intensivmedizinischen Behandlung. Um diese Lücke zu füllen, wurde kürzlich eine interdisziplinäre Konsensus-Konferenz der Neurocritical Care Society (NCS) und der Deutschen Gesellschaft für NeuroIntensiv- und Notfallmedizin (DGNI) zum intensivmedizinischen Management des MMI organisiert. Experten aus Neurologie, Neurointensivmedizin, Neurochirurgie, Neuroradiologie und Neuroanästhesie aus Europa und Nordamerika wurden auf Basis ihrer Expertise und ihrer Forschungsschwerpunkte ausgewählt. Arbeitsgruppen zu einzelnen Schwerpunktthemen erarbeiteten eine Reihe zentraler klinischer Fragestellungen zu diesem Thema und erstellten auf dem Boden der aktuellen Datenlage nach dem System Grading of Recommendation Assessment, Development and Evaluation (GRADE) Empfehlungen. Dies ist eine kommentierte Kurzfassung derselben.(AU)
Large hemispheric infarction (LHI), synonymously called malignant middle cerebral artery (MCA) infarction, is a severe neurological disease with a high mortality and morbidity. Treating physicians as well as relatives are often faced with few and low quality data when attempting to apply optimal treatment to these patients and make decisions. While current stroke treatment guidelines focus on risk factors, prevention and acute management, they include only limited recommendations concerning intensive care management of LHI. The Neurocritical Care Society (NCS) and the German Society for Neurocritical and Emergency Medicine (DGNI) organized an interdisciplinary consensus conference on intensive care management of LHI to meet this demand. European and American experts in neurology, neurocritical care, neurosurgery, neuroradiology and neuroanesthesiology were selected based on their expertise and research focus. Subgroups for several main topics elaborated a number of central clinical questions concerning this topic and evaluated the quality of the currently available data according to the grading of recommendation assessment, development and evaluation (GRADE) guideline system. Subsequently, evidence-based recommendations were compiled after weighing the advantages against the disadvantages of certain management options. This is a commented abridged version of the results of the consensus conference.(AU)
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Humanos , Infarto Cerebral , Cuidados Críticos , Servicios Médicos de Urgencia , Factores de RiesgoRESUMEN
Large hemispheric infarction (LHI), synonymously called malignant middle cerebral artery (MCA) infarction, is a severe neurological disease with a high mortality and morbidity. Treating physicians as well as relatives are often faced with few and low quality data when attempting to apply optimal treatment to these patients and make decisions. While current stroke treatment guidelines focus on risk factors, prevention and acute management, they include only limited recommendations concerning intensive care management of LHI. The Neurocritical Care Society (NCS) and the German Society for Neurocritical and Emergency Medicine (DGNI) organized an interdisciplinary consensus conference on intensive care management of LHI to meet this demand. European and American experts in neurology, neurocritical care, neurosurgery, neuroradiology and neuroanesthesiology were selected based on their expertise and research focus. Subgroups for several main topics elaborated a number of central clinical questions concerning this topic and evaluated the quality of the currently available data according to the grading of recommendation assessment, development and evaluation (GRADE) guideline system. Subsequently, evidence-based recommendations were compiled after weighing the advantages against the disadvantages of certain management options. This is a commented abridged version of the results of the consensus conference.
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Infarto Cerebral/diagnóstico , Infarto Cerebral/terapia , Cuidados Críticos/normas , Servicios Médicos de Urgencia/normas , Neurología/normas , Guías de Práctica Clínica como Asunto , AlemaniaRESUMEN
BACKGROUND AND PURPOSE: With advances in neuroimaging, unruptured cerebral aneurysms are being diagnosed more frequently. Until 1995, surgical clipping of the aneurysm was the only treatment available. Since then, a less invasive endovascular technique has been found effective in a trial of ruptured aneurysms. No efficacy studies comparing the 2 procedures for unruptured aneurysms exist to guide clinical decisions. The objective of this study was to assess effectiveness and outcomes of endovascular versus neurosurgical treatment for unruptured intracranial aneurysms. METHODS: This was a retrospective cohort study, using data collected over a 1-year time interval (between 1998 and 2000), from 429 hospitals, in 18 states, and representing 58% of the US population. A total of 2535 treated, unruptured cerebral aneurysm cases were evaluated. The measurements used were effectiveness as measured by hospital discharge outcomes: 1) mortality (in-hospital death), 2) adverse outcomes (death or discharge to a rehabilitation or nursing facility), 3) length of stay, and 4) hospital charges. Univariate analyses compared endovascular versus neurosurgical discharge outcomes. Multivariable models were adjusted for age, sex, region, Medicaid insurance status, year, hospital case volume, comorbidity score, and admission source. RESULTS: Endovascular treatment was associated with fewer adverse outcomes (6.6% versus 13.2%), decreased mortality (0.9% versus 2.5%), shorter lengths of stay (4.5 versus 7.4 days), and lower hospital charges (42,044 dollars versus 47,567 dollars) compared with neurosurgical treatment (P < .05). After multivariable adjustment, neurosurgical cases had 70% greater odds of an adverse outcome, 30% increased hospital charges, and 80% longer length of stay compared with endovascular cases (P < .05). CONCLUSIONS: The current analysis indicates that endovascular therapy is associated with significantly less morbidity, less mortality, and decreased hospital resource use at discharge, compared with conventional neurosurgical treatment for all unruptured aneurysms. Endovascular therapy, as a treatment alternative to surgical clipping, should be offered as a viable therapeutic option for all patients considering treatment of an unruptured cerebral aneurysm.
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Craneotomía , Embolización Terapéutica , Aneurisma Intracraneal/terapia , Evaluación de Procesos y Resultados en Atención de Salud/estadística & datos numéricos , Adulto , Anciano , Estudios de Cohortes , Análisis Costo-Beneficio , Craneotomía/economía , Craneotomía/mortalidad , Evaluación de la Discapacidad , Embolización Terapéutica/economía , Embolización Terapéutica/mortalidad , Femenino , Precios de Hospital , Mortalidad Hospitalaria , Humanos , Aneurisma Intracraneal/mortalidad , Tiempo de Internación , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/mortalidad , Estudios Retrospectivos , Resultado del Tratamiento , Estados UnidosRESUMEN
OBJECTIVE: To study the impact of neurologic prognostication on the decision to withdraw life-sustaining therapies (LST) in comatose patients resuscitated after cardiac arrest. METHODS: The authors prospectively studied a consecutive series of post-resuscitation comatose patients referred for neurologic prognostication at a single center for 4 years. For most patients, neurologic prognostication was not sought due to early death or rapid return to consciousness. Prognostication was based on Glasgow Coma Score (GCS) and Brainstem Reflex Score (BRS), with EEG and cortical evoked potentials (CEP), which were graded as benign, uncertain, and malignant. The outcomes were as follows: survivors (Group S), brain or cardiac death (Group D), and death from withdrawal of life sustaining therapy (Group W). In Group W, the time interval to withdrawal of LST was analyzed by EEG and CEP grades. RESULTS: Of 58 patients studied, 10 were in Group S, 8 in Group D, and 40 in Group W. Initial median GCS and BRS was similar for all groups with significant improvement noted in Group S, but not in Group D or Group W. In Group W, CEP grade correlated with the median duration of continued therapy before a decision to withdraw LST: 7 days for benign CEP, 2 days for uncertain CEP, and 1 day for malignant CEP, p = 0.0004. CONCLUSION: In patients with poor neurologic recovery early after resuscitation from cardiac arrest, physicians appear to use the cortical evoked potential grade to estimate prognosis. Cortical evoked potential grade correlated with the waiting time until life sustaining therapies were withdrawn after no improvement in neurologic examination was seen.
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Apoyo Vital Cardíaco Avanzado/métodos , Potenciales Evocados/fisiología , Paro Cardíaco/terapia , Adulto , Anciano , Coma/complicaciones , Estimulación Eléctrica/métodos , Electroencefalografía/métodos , Femenino , Escala de Coma de Glasgow/estadística & datos numéricos , Paro Cardíaco/diagnóstico , Paro Cardíaco/etiología , Humanos , Masculino , Persona de Mediana Edad , Examen Neurológico , Pronóstico , Estudios Prospectivos , Estudios Retrospectivos , Factores de TiempoRESUMEN
The authors tested the effect of uncoupling and removal of the treating physician from organ and tissue donation requests on consent rates for donation in the neurocritical care unit. After a neurointensivist-led policy change, consent rates increased from 23.1 to 36.5% (odds ratio = 1.9, p = 0.01), whereas there was no change in other hospital units. This supports such a policy change and shows a positive effect of a neurointensivist on organ and tissue procurement.
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Muerte Encefálica , Personal de Salud , Unidades de Cuidados Intensivos , Relaciones Profesional-Familia , Consentimiento por Terceros , Obtención de Tejidos y Órganos/métodos , Conflicto de Intereses , Cultura , Hospitales Universitarios , Hospitales Urbanos , Humanos , Motivación , Política Organizacional , Estudios Prospectivos , Consentimiento por Terceros/estadística & datos numéricos , Factores de Tiempo , Donantes de Tejidos , Obtención de Tejidos y Órganos/organización & administración , Obtención de Tejidos y Órganos/estadística & datos numéricosRESUMEN
The aim of the present study was to report on the utility of continuous Pcsf monitoring in establishing the diagnosis of idiopathic intracranial hypertension without papilledema (IIHWOP) in chronic daily headache (CDH) patients. We report a series of patients (n = 10) with refractory headaches and suspected IIHWOP referred to us for continuous Pcsf monitoring between 1991 and 2000. Pcsf was measured via a lumbar catheter and analysed for mean, peak, highest pulse amplitude and abnormal waveforms. A 1-2 day trial of continuous controlled CSF drainage (10 cc/ h) followed Pcsf monitoring. Response to CSF drainage was defined as improvement in headache symptoms. Patients with abnormal waveforms underwent a ventriculoperitoneal (VPS) or lumboperitoneal (LPS) shunt insertion. All patients had normal resting Pcsf (8 +/- 1 mmHg) defined as ICP < 15 mmHg. During sleep, all patients had B-waves and 90% had plateau waves or near plateau waves. All patients underwent either a VPS or LPS procedure. All reported improvement of their headache after surgery. Demonstration of pathological Pcsf patterns by continuous Pcsf monitoring was essential in confirming the diagnosis of IIHWOP, and provided objective evidence to support the decision for shunt surgery. Increased Pcsf was seen mostly during sleep and was intermittent, suggesting that Pcsf elevation may be missed by a single spot-check LP measurement. The similarity between IIHWOP and CDH suggests that continuous Pcsf monitoring in CDH patients may have an important diagnostic role that should be further investigated.
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Trastornos de Cefalalgia/líquido cefalorraquídeo , Hipertensión Intracraneal/líquido cefalorraquídeo , Papiledema/líquido cefalorraquídeo , Adulto , Algoritmos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico/métodosRESUMEN
BACKGROUND: Small, unrandomized studies have indicated that pharmacologically induced blood pressure elevation may improve function in ischemic stroke, presumably by improving blood flow to ischemic, but noninfarcted tissue (which may be indicated by diffusion-perfusion mismatch on MRI). We conducted a pilot, randomized trial to evaluate effects of pharmacologically induced blood pressure elevation on function and perfusion in acute stroke. METHODS: Consecutive series of patients with large diffusion-perfusion mismatch were randomly assigned to induced blood pressure elevation ('treated' patients, n = 9) or conventional management ('untreated' patients, n = 6). RESULTS: There were no significant differences between groups at baseline. NIH Stroke Scale (NIHSS) scores were lower (better) in treated versus untreated patients at day 3 (mean 5.6 vs. 12.3; p = 0.01) and week 6-8 (mean 2.8 vs. 9.7; p < 0.04). Treated (but not untreated) patients showed significant improvement from day 1 to day 3 in NIHSS score (from mean 10.2 to 5.6; p < 0.002), cognitive score (from mean 58.7 to 27.9% errors; p < 0.002), and volume of hypoperfused tissue (mean 132 to 58 ml; p < 0.02). High Pearson correlations between the mean arterial pressure (MAP) and accuracy on daily cognitive tests indicated that functional changes were due to changes in MAP. CONCLUSION: Results warrant a full-scale, double-blind clinical trial to evaluate the efficacy and risk of induced blood pressure elevation in selective patients with acute/subacute stroke.
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Presión Sanguínea/fisiología , Circulación Cerebrovascular/fisiología , Fludrocortisona/uso terapéutico , Midodrina/uso terapéutico , Fenilefrina/uso terapéutico , Recuperación de la Función/fisiología , Cloruro de Sodio/uso terapéutico , Accidente Cerebrovascular/tratamiento farmacológico , Accidente Cerebrovascular/fisiopatología , Vasoconstrictores/uso terapéutico , Adulto , Anciano , Anciano de 80 o más Años , Presión Sanguínea/efectos de los fármacos , Circulación Cerebrovascular/efectos de los fármacos , Quimioterapia Combinada , Femenino , Fludrocortisona/administración & dosificación , Estudios de Seguimiento , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Midodrina/administración & dosificación , Fenilefrina/administración & dosificación , Proyectos Piloto , Recuperación de la Función/efectos de los fármacos , Cloruro de Sodio/administración & dosificación , Accidente Cerebrovascular/patología , Factores de Tiempo , Vasoconstrictores/administración & dosificaciónRESUMEN
BACKGROUND AND PURPOSE: Current transcranial Doppler criteria for vasospasm after aneurysmal subarachnoid hemorrhage are not age specific. We analyzed the effect of age on cerebral blood flow velocity changes after subarachnoid hemorrhage and constructed an age-adjusted predictive model of cerebral blood flow velocity in subarachnoid hemorrhage patients. METHODS: We identified patients with aneurysmal subarachnoid hemorrhage admitted between 1991 and 1999 with a prospective transcranial Doppler database. Eighty-one patients, with complete medical records and transcranial Doppler examinations of the vessels of interest, were included. Patients were subdivided into 2 groups by age: younger, <68 years of age (n=47) and older, >/=68 years of age (n=34). Maximum mean flow velocity and incidence of symptomatic vasospasm were reported. Linear and nonlinear regression analyses were performed. RESULTS: Middle cerebral artery and internal carotid artery mean flow velocity were lower in older patients (median 76 versus 114 cm/s and 76 versus 126 cm/s, respectively; P<0.003). Incidence of symptomatic vasospasm was lower in older patients (44% versus 66%; P=0.05). Older patients developed symptomatic vasospasm at lower middle cerebral artery (median 57 versus 103 cm/s; P=0.04) and internal carotid artery (median 54 versus 81 cm/s, P=0.02) mean flow velocity. Relationship between middle cerebral artery and internal carotid artery mean flow velocity and age was quadratic (ANOVA, P<0.0001). CONCLUSIONS: Older patients have a lower incidence of symptomatic vasospasm, and such vasospasm develops at lower cerebral blood flow velocity than younger patients. A quadratic relationship was found between age and cerebral blood flow velocity. This model could be used to create an age-adjusted nomogram that might improve diagnostic capabilities of transcranial Doppler.
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Envejecimiento , Circulación Cerebrovascular , Modelos Cardiovasculares , Hemorragia Subaracnoidea/fisiopatología , Vasoespasmo Intracraneal/fisiopatología , Adulto , Distribución por Edad , Factores de Edad , Anciano , Anciano de 80 o más Años , Velocidad del Flujo Sanguíneo , Angiografía Cerebral , Arterias Cerebrales/diagnóstico por imagen , Arterias Cerebrales/fisiopatología , Comorbilidad , Demografía , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Análisis de Regresión , Estudios Retrospectivos , Sensibilidad y Especificidad , Hemorragia Subaracnoidea/epidemiología , Ultrasonografía Doppler Transcraneal , Vasoespasmo Intracraneal/diagnóstico , Vasoespasmo Intracraneal/epidemiologíaRESUMEN
The authors report an unusual case of a patient with low-pressure hydrocephalus and a ventriculopleural shunt, in whom routine respiratory management performed using positive-pressure ventilation caused shunt obstruction and coma. While the patient received positive-pressure ventilation with external cerebrospinal fluid (CSF) drainage at subatmospheric pressure, the ventricles returned to normal size and the coma rapidly reversed. After the authors' recognition of the effect of positive-pressure ventilation on intrapleural pressure and ventriculopleural shunt function, and the subsequent removal of positive-pressure ventilation, CSF flow through the shunt resumed and the patient's coma resolved.
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Derivaciones del Líquido Cefalorraquídeo , Hidrocefalia/cirugía , Respiración con Presión Positiva , Complicaciones Posoperatorias/etiología , Coma/etiología , Coma/cirugía , Falla de Equipo , Humanos , Hidrocefalia/etiología , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/cirugía , Recurrencia , Reoperación , VentriculostomíaRESUMEN
BACKGROUND AND PURPOSE: Anecdotal reports suggest that a loss of distinction between gray (GM) and white matter (WM) as adjudged by CT scan predicts poor outcome in comatose patients after cardiac arrest. To address this, we quantitatively assessed GM and WM intensities at various brain levels in comatose patients after cardiac arrest. METHODS: Patients for whom consultation was requested within 24 hours of a cardiac arrest were identified with the use of a computerized database that tracks neurological consultations at our institution. Twenty-five comatose patients were identified for whom complete medical records and CT scans were available for review. Twenty-five consecutive patients for whom a CT scan was interpreted as normal served as controls. Hounsfield units (HUs) were measured in small defined areas obtained from axial images at the levels of the basal ganglia, centrum semiovale, and high convexity area. RESULTS: At each level tested, lower GM intensity and higher WM intensity were noted in comatose patients compared with normal controls. The GM/WM ratio was significantly lower among comatose patients compared with controls (P:<0.0001, rank sum test). There was essentially no overlap in GM/WM ratios between control and study patients. The difference was greatest at the basal ganglia level. We also observed a marginally significant difference in the GM/WM ratio at the basal ganglia level between those patients who died and those who survived cardiac arrest (P:=0. 035, 1-tailed t test). Using receiver operating characteristic curve analysis, we determined that a difference in GM/WM ratio of <1.18 at the basal ganglia level was 100% predictive of death. At the basal ganglia level, none of 12 patients below this threshold survived, whereas the survival rate was 46% among patients in whom the ratio was >1.18. The empirical risk of death was 21.67 for comatose patients with a value below threshold. CONCLUSIONS: The ratio in HUs of GM to WM provides a reproducible measure of the distinction between gray and white matter. A lower GM/WM ratio is observed in comatose patients immediately after cardiac arrest. The basal ganglia level seems to be the most sensitive location on CT for measuring this relationship. Although a GM/WM ratio <1.18 at this level predicted death in this retrospective study, the difference in this study is not robust enough to recommend that management decisions be dictated by CT results. The results, however, do warrant consideration of a prospective study to determine the reliability of CT scanning in predicting outcome for comatose patients after cardiac arrest.