Search

OBJECTIVES: To estimate the impact of goal-directed therapy on outcome after traumatic brain injury, our team applied goal-directed therapy to standardize care in patients with moderate to severe traumatic brain injury, who were enrolled in a large multicenter clinical trial. DESIGN: Planned secondary analysis of data from Progesterone for the Treatment of Traumatic Brain Injury III, a large, prospective, multicenter clinical trial. SETTING: Forty-two trauma centers within the Neurologic Emergencies Treatment Trials network. PATIENTS: Eight-hundred eighty-two patients were enrolled within 4 hours of injury after nonpenetrating traumatic brain injury characterized by Glasgow Coma Scale score of 4–12. MEASUREMENTS AND MAIN RESULTS: Physiologic goals were defined a priori in order to standardize care across 42 sites participating in Progesterone for the Treatment of Traumatic Brain Injury III. Physiologic data collection occurred hourly; laboratory data were collected according to local ICU protocols and at a minimum of once per day. Physiologic transgressions were predefined as substantial deviations from the normal range of goal-directed therapy. Each hour where goal-directed therapy was not achieved was classified as a “transgression.” Data were adjudicated electronically and via expert review. Six-month outcomes included mortality and the stratified dichotomy of the Glasgow Outcome Scale-Extended. For each variable, the association between outcome and either: 1) the occurrence of a transgression or 2) the proportion of time spent in transgression was estimated via logistic regression model. RESULTS: For the 882 patients enrolled in Progesterone for the Treatment of Traumatic Brain Injury III, mortality was 12.5%. Prolonged time spent in transgression was associated with increased mortality in the full cohort for hemoglobin less than 8 gm/dL (p = 0.0006), international normalized ratio greater than 1.4 (p < 0.0001), glucose greater than 180 mg/dL (p = 0.0003), and systolic blood pressure less than 90 mm Hg (p < 0.0001). In the patient subgroup with intracranial pressure monitoring, prolonged time spent in transgression was associated with increased mortality for intracranial pressure greater than or equal to 20 mm Hg (p < 0.0001), glucose greater than 180 mg/dL (p = 0.0293), hemoglobin less than 8 gm/dL (p = 0.0220), or systolic blood pressure less than 90 mm Hg (p = 0.0114). Covariates inversely related to mortality included: a single occurrence of mean arterial pressure less than 65 mm Hg (p = 0.0051) or systolic blood pressure greater than 180 mm Hg (p = 0.0002). CONCLUSIONS: The Progesterone for the Treatment of Traumatic Brain Injury III clinical trial rigorously monitored compliance with goal-directed therapy after traumatic brain injury. Multiple significant associations between physiologic transgressions, morbidity, and mortality were observed. These data suggest that effective goal-directed therapy in traumatic brain injury may provide an opportunity to improve patient outcomes.

Secondary cerebral insults can adversely affect patients with traumatic brain injury. By contrast, the incidence of secondary cerebral insults after aneurysmal subarachnoid hemorrhage (SAH) and their impact on outcome have been less well studied.Four hundred and twenty-one patients with SAH who underwent surgical occlusion of their ruptured aneurysm and who received intensive care unit care for ≥48 hours were retrospectively identified from a prospective observational database. Patients were managed according to standard recommendations for SAH. Three secondary cerebral insults were examined: hypotension (90 mmHg systolic), hypoxia (PaoA secondary cerebral insult was observed in 309 (73.4%) patients including 135 (32.1%) who had multiple insults. There was an association between worse clinical grade and development of secondary insults (P = 0.0002), particularly multiple insults (P0.0001). When stratified by clinical grade, single (adjusted odds ratio [OR], 2.23; 95% confidence interval [CI], 1.10-4.51; P = 0.026) and multiple (adjusted OR, 4.37; 95% CI, 2.14-8.93; P0.0001) secondary cerebral insults were associated with worse outcome. In multivariate analysis and controlling for age, admission clinical grade, severity of SAH on computed tomography, intracerebral hematoma, increased intracranial pressure (20 mm Hg), rebleed, intraoperative rupture, and hydrocephalus, secondary cerebral insults were independently associated with poor outcome (adjusted OR, 2.45; 95% CI, 1.20-5.02; P = 0.014).Secondary cerebral insults (hypoxia, hypotension, and hyperglycemia) are common after SAH, including among patients with a good clinical grade. These insults after SAH are associated with worse outcome. These data suggest that prevention of secondary cerebral insults may provide an opportunity to improve patient outcome after SAH.

Study design Retrospective medical record review and literature review. Objective To identify cases where a cerebrospinal fluid (CSF) leak occurred during an anterior cervical discectomy and fusion (ACDF) and to create a management algorithm based on the findings. Summary of background data ACDF is a commonly performed spinal operation. It is effective with very low complication rates. One rare complication of ACDF is a CSF leak. There is limited information on the management of CSF leaks after ACDF and management is on a surgeon-by-surgeon basis. Methods We reviewed 3 surgeons' case logs and identified cases where a CSF leak was encountered during ACDF and reviewed the patients' medical records, operative reports and imaging to determine how these leaks were managed. We also performed a PubMed search for articles about the presentation and management of CSF leaks after ACDF. Results Thirteen CSF leaks were identified in 1223 ACDFs, corresponding to a CSF leak rate of 1%. Of these, 9 were successfully treated with intraoperative repair. Postoperative lumbar drainage was used in the remaining 4 patients and was successful in 1 patient. Three patients underwent neck re-exploration and attempted delayed repair. Three patients, including one who was found to have hydrocephalus, ultimately required continuous CSF diversion via shunting. We identified 7 case reports of CSF leak in ADCF in the literature and 1 article that reviewed the prevalence and management of this complication. Conclusion CSF leak after ACDF is an uncommon complication that can usually be repaired. We provide a stepwise management strategy for CSF leaks in ACDF.

Increased intracranial pressure (ICP) is associated with worse outcome after traumatic brain injury (TBI), but whether its management improves the outcome is unclear. In this review, we will examine the implications of the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure (BEST TRIP) trial, evidence for an influence of ICP care on outcome, and a need for greater understanding of the pathophysiology than just ICP through multimodal monitoring (MMM) to enhance the outcome.The primary impact of the BEST TRIP trial, a randomized clinical trial that examined two TBI management strategies, one that used an ICP monitor, is in research and should not alter clinical practice. Analyses of large databases suggest TBI care based on the Brain Trauma Foundation guidelines and management of intracranial hypertension can improve patient outcome. However, accumulating evidence demonstrates there are several mechanisms of secondary brain injury (SBI), for example, microvascular dysfunction or alterations in glucose utilization that cannot be detected using an ICP monitor. In these patients, growing clinical evidence suggests that MMM can help manage SBI and improve TBI outcome.ICP-based monitoring and treatment alone may not be enough to enhance TBI outcome, but ICP and cerebral perfusion pressure therapy remain important in TBI care. Although high-quality evidence for MMM is limited, it should be more widely adapted to better understand the complex pathophysiology after TBI, better target care, and identify new therapeutic opportunities.

Background The optimal red blood cell transfusion (RBCT) trigger for patients with aneurysmal subarachnoid hemorrhage (SAH) is unknown. In patients with cerebral vasospasm, anemia may increase susceptibility to ischemic injury; conversely, RBCT may worsen outcome given known deleterious effects. Objective To examine the association between RBCT, delayed cerebral ischemia (DCI), vasospasm, and outcome after SAH. Methods A total of 421 consecutive patients with SAH, admitted to a neurocritical care unit at a university-affiliated hospital and who underwent surgical occlusion of their ruptured aneurysm were retrospectively identified from a prospective observational database. Propensity score methods were used to reduce the bias associated with treatment selection. Results Two hundred and sixty-one patients (62.0%) received an RBCT. Angiographic vasospasm (odds ratio [OR] 1.6; 95% confidence interval [CI], 1.1–2.3; P = 0.025) but not severe angiographic spasm, DCI, or delayed infarction was associated with RBCT. A total of 283 patients (67.2%) experienced a favorable outcome, defined as good or moderately disabled on the Glasgow Outcome Scale; 47 (11.2%) were severely disabled or vegetative and 91 patients (21.6%) were dead at 6-month follow-up. Among patients who survived ≥2 days, RBCT was associated with unfavorable outcome (OR, 2.6; 95% CI, 1.6–4.1). Transfusion of ≥3 units of blood was associated with an increased incidence of unfavorable outcome. Propensity analysis to control for the probability of exposure to RBCT conditional on observed covariates measured before RBCT indicates that RBCT is associated with unfavorable outcome in the absence of DCI (OR, 2.17; 95% CI, 1.56–3.01; P P = 0.65). Conclusions Blood transfusions are associated with unfavorable outcome after SAH particularly when DCI is absent. Propensity analysis suggests that RBCT may be associated with poor outcome rather than being a marker of disease severity. However, when DCI is present, RBCT may help improve outcome.

To investigate the relationship between hemoglobin (Hgb) and brain tissue oxygen tension (PbtO(2)) after severe traumatic brain injury (TBI) and to examine its impact on outcome.This was a retrospective analysis of a prospective cohort of severe TBI patients whose PbtO(2) was monitored. The relationship between Hgb-categorized into four quartiles (≤9; 9-10; 10.1-11;11 g/dl)-and PbtO(2) was analyzed using mixed-effects models. Anemia with compromised PbtO(2) was defined as episodes of Hgb ≤ 9 g/dl with simultaneous PbtO(2)20 mmHg. Outcome was assessed at 30 days using the Glasgow outcome score (GOS), dichotomized as favorable (GOS 4-5) vs. unfavorable (GOS 1-3).We analyzed 474 simultaneous Hgb and PbtO(2) samples from 80 patients (mean age 44 ± 20 years, median GCS 4 (3-7)). Using Hgb11 g/dl as the reference level, and controlling for important physiologic covariates (CPP, PaO(2), PaCO(2)), Hgb ≤ 9 g/dl was the only Hgb level that was associated with lower PbtO(2) (coefficient -6.53 (95 % CI -9.13; -3.94), p0.001). Anemia with simultaneous PbtO(2)20 mmHg, but not anemia alone, increased the risk of unfavorable outcome (odds ratio 6.24 (95 % CI 1.61; 24.22), p = 0.008), controlling for age, GCS, Marshall CT grade, and APACHE II score.In this cohort of severe TBI patients whose PbtO(2) was monitored, a Hgb level no greater than 9 g/dl was associated with compromised PbtO(2). Anemia with simultaneous compromised PbtO(2), but not anemia alone, was a risk factor for unfavorable outcome, irrespective of injury severity.

BACKGROUND Prediction of clinical course and outcome after severe traumatic brain injury (TBI) is important. OBJECTIVE To examine whether clinical scales (Glasgow Coma Scale [GCS], Injury Severity Score [ISS], and Acute Physiology and Chronic Health Evaluation II [APACHE II]) or radiographic scales based on admission computed tomography (Marshall and Rotterdam) were associated with intensive care unit (ICU) physiology (intracranial pressure [ICP], brain tissue oxygen tension [PbtO2]), and clinical outcome after severe TBI. METHODS One hundred one patients (median age, 41.0 years; interquartile range [26-55]) with severe TBI who had ICP and PbtO2 monitoring were identified. The relationship between admission GCS, ISS, APACHE II, Marshall and Rotterdam scores and ICP, PbtO2, and outcome was examined by using mixed-effects models and logistic regression. RESULTS Median (25%-75% interquartile range) admission GCS and APACHE II without GCS scores were 3.0 (3-7) and 11.0 (8-13), respectively. Marshall and Rotterdam scores were 3.0 (3-5) and 4.0 (4-5). Mean ICP and PbtO2 during the patients' ICU course were 15.5 ± 10.7 mm Hg and 29.9 ± 10.8 mm Hg, respectively. Three-month mortality was 37.6%. Admission GCS was not associated with mortality. APACHE II (P = .003), APACHE-non-GCS (P = .004), Marshall (P < .001), and Rotterdam scores (P < .001) were associated with mortality. No relationship between GCS, ISS, Marshall, or Rotterdam scores and subsequent ICP or PbtO2 was observed. The APACHE II score was inversely associated with median PbtO2 (P = .03) and minimum PbtO2 (P = .008) and had a stronger correlation with amount of time of reduced PbtO2. CONCLUSION Following severe TBI, factors associated with outcome may not always predict a patient's ICU course and, in particular, intracranial physiology.

Brain tissue oxygen (PbtO(2)) monitoring is used in severe traumatic brain injury (TBI) patients. How brain reduced PbtO(2) should be treated and its response to treatment is not clearly defined. We examined which medical therapies restore normal PbtO(2) in TBI patients.Forty-nine (mean age 40 ± 19 years) patients with severe TBI (Glasgow Coma Scale [GCS] ≤ 8) admitted to a University-affiliated, Level I trauma center who had at least one episode of compromised brain oxygen (PbtO(2)25 mmHg for10 min), were retrospectively identified from a prospective observational cohort study. Intracranial pressure (ICP), cerebral perfusion pressure (CPP), and PbtO(2) were monitored continuously. Episodes of compromised PbtO(2) and brain hypoxia (PbtO(2)15 mmHg for10 min) and the medical interventions that improved PbtO(2) were identified.Five hundred and sixty-four episodes of compromised PbtO2 were identified from 260 days of PbtO2 monitoring. Medical management used in a "cause-directed" manner successfully reversed 72% of the episodes of compromised PbtO(2), defined as restoration of a "normal" PbtO(2) (i.e. ≥ 25 mmHg). Ventilator manipulation, CPP augmentation, and sedation were the most frequent interventions. Increasing FiO(2) restored PbtO(2) 80% of the time. CPP augmentation and sedation were effective in 73 and 66% of episodes of compromised brain oxygen, respectively. ICP reduction using mannitol was effective in 73% of treated episodes, though was used only when PbtO(2) was compromised in the setting of elevated ICP. Successful medical treatment of brain hypoxia was associated with decreased mortality. Survivors (n = 38) had a 71% rate of response to treatment and non-survivors (n = 11) had a 44% rate of response (P = 0.01).Reduced PbtO(2) may occur in TBI patients despite efforts to maintain CPP. Medical interventions other than those to treat ICP and CPP can improve PbtO(2). This may increase the number of therapies for severe TBI in the ICU.

How body position influences brain tissue oxygen (PbtO2) and intracranial pressure (ICP) in critically ill neurosurgical patients remains poorly defined. In a prospective observational repeated measures study, we examined the effects of 12 different body positions on neurodynamic and hemodynamic outcomes. Thirty-three consecutive patients (mean +/- SD, age = 48.3 +/- 16.6 years; 22 men), admitted after traumatic brain injury, subarachnoid hemorrhage, or craniotomy for tumor, were evaluated in a neurocritical care unit at a level 1 academic trauma center. Patients were eligible if the admission score in the Glasgow Coma Scale was < or =8 and they had a Licox CMP Monitoring System (Integra Neurosciences, Plainsboro, NJ). Patients were exposed to all 12 positions in random order. Changes from baseline to the 15-minute postposition assessment mean change scores showed a downward trend for PbtO2 for all positions with statistically significant decreases observed for supine head of bed (HOB) elevated 30 degrees and 45 degrees (p < .01) and right and left lateral positioning HOB 30 degrees (p < .05). ICP decreased with supine HOB 45 degrees (p < .01) and knee elevation, HOB 30 degrees and 45 degrees (p < .05), and increased (p < .05) with right and left lateral HOB 15 degrees. Hemodynamic parameters were similar in the various positions. Positioning practices can positively or negatively affect PbtO2 and ICP and fluctuate with considerable variability among patients. Nurses must consider potential effects of turning, evaluate changes with positioning on the basis of monitoring feedback from multimodality devices, and make independent clinical judgments about optimal positions to maintain or improve cerebral oxygenation.

Transport of critically ill intensive care unit (ICU) patients may be hazardous. In this study, we examined the use of a portable head CT scanner (CereTom) in the ICU to assess its feasibility, safety, and radiological quality. Two hundred and twenty-five portable head CT scans were obtained from 114 patients (mean age = 57 +/- 18 years) treated in a neurosurgical intensive care unit at a university-based Level I trauma center. Patient radiological and ICU records were retrospectively reviewed. The vast majority of portable CT scans were performed after an intracranial procedure (24%) due to neurological deterioration (16%) or in routine follow-up (16%). Diagnostic quality was judged to be adequate, and no scans needed to be repeated because of poor quality. No scans were complicated by accidental disconnection of an intravenous line. In ventilated patients, there were no interruptions in mechanical ventilation and no inadvertent extubations. In addition, continuous intracranial monitoring, when in use, remained connected. The average total time to perform a portable head CT scan was 19.5 +/- 3.5 min. The actual scan time was 2.5 +/- 0.7 min. These results suggest that the portable CT scanner (CereTom) is feasible, easy to use, and safe and provides adequate radiological quality for diagnostic decisions.

We analyzed the impact of shivering on brain tissue oxygenation (PbtO(2)) during induced normothermia in patients with severe brain injury.We studied patients with severe brain injury who developed shivering during induced normothermia. Induced normothermia was applied to treat refractory fever (body temperature [BT]or =38.3 degrees C, refractory to conventional treatment) using a surface cooling device with computerized adjustment of patient BT target to 37 +/- 0.5 degrees C. PbtO(2), intracranial pressure, mean arterial pressure, cerebral perfusion pressure, and BT were monitored continuously. Circulating water temperature of the device system was measured to assess the intensity of cooling.Fifteen patients (10 with severe traumatic brain injury, 5 with aneurysmal subarachnoid hemorrhage) were treated with induced normothermia for an average of 5 +/- 2 days. Shivering caused a significant decrease in PbtO(2) levels both in SAH and TBI patients. Compared to baseline, shivering was associated with an overall reduction of PbtO(2) from 34.1 +/- 7.3 to 24.4 +/- 5.5 mmHg (P0.001). A significant correlation was found between the magnitude of shivering-associated decrease of PbtO(2) (DeltaPbtO(2)) and circulating water temperature (R = 0.82, P0.001).In patients with severe brain injury treated with induced normothermia, shivering was associated with a significant decrease of PbtO(2), which correlated with the intensity of cooling. Monitoring of therapeutic cooling with computerized thermoregulatory systems may help prevent shivering and optimize the management of induced normothermia. The clinical significance of shivering-induced decrease in brain tissue oxygenation remains to be determined.

Objectives: Aneurysmal subarachnoid hemorrhage (SAH) is a devastating disorder that still requires much clinical study. However, the decision to participate in a randomized clinical trial, particularly a neuroemergency trial, is a complex one. The purposes of this survey were to determine who would participate in a randomized clinical trial that intended to examine transfusion practices after SAH, to identify who could serve as potential proxy decision-makers, and to find which patient characteristics were associated with the decision to participate. Methods: This was a cross-sectional study using a self-administered questionnaire, composed of a brief description of the proposed trial followed by questions about participation using a 5-point Likert scale. Information sought included potential decision-maker, demographic data, setting and reason for current health care access, and personal or family history of neurologic injury. Results: Nine-hundred five subjects were enrolled during emergency department (ED) visits, office visits, hospital admissions, or online, during a 1-month period: 63% were women and 46% were white. Nonneurologic problems were the leading reason (90%) for health care access, but 45% had a personal or family history of neurologic injury. Overall, 54% (95% confidence interval [CI] = 51% to 57%) of subjects stated they would definitely or probably consent to participate. No subject characteristics were associated with this decision: age (p = 0.28), sex (p = 0.16), race/ethnicity (p = 0.07), education (p = 0.44), religion (p = 0.42), clinical setting (p = 0.14), reason for visit (p = 0.58), and/or history of neurologic injury (p = 0.33). The vast majority (88%) identified a family member as the proxy decision-maker, again without differences among groups. Conclusions: Greater than half of respondents stated they would participate in a proposed emergency treatment trial for SAH. Our survey suggests that the decision to participate is highly individualized, because no demographic, pathologic, historical, or access-related predictors of choice were found. Educational materials designed for this type of trial would need to be broad-based. Family members should be considered as proxy decision-makers where permitted by federal and local regulations.

OBJECTIVE: Tuberculous meningitis (TBM) is a massive global problem. The mortality and morbidity associated with the severe form of the disease are exceptionally high. Even when increased intracranial pressure is treated and full conventional therapy is commenced, cerebral ischemia can develop and is associated with a particularly poor prognosis. We sought to evaluate our experience with two patients with severe TBM and cerebral oxygenation monitoring. DESIGN: Case report. SETTING: Red Cross Children's Hospital, Cape Town. PATIENTS: Two comatose patients with TBM. INTERVENTIONS: Targeted interventions against low cerebral oxygenation in one patient. MEASUREMENTS AND MAIN RESULTS: Cerebral tissue oxygenation (Ptio2) was measured. In both patients, Ptio2 monitoring demonstrated delayed cerebral ischemia despite the institution of full conventional therapy and the control of intracranial pressure. These data confirm that the vascular involvement in TBM is potentially progressive and that failure to diagnose infarction initially is not merely due to a delay in the radiologic appearance. The first patient developed extensive infarction, consistent with Ptio2 readings, and subsequently died after treatment withdrawal. Intervention in the second patient successfully reversed a precipitous decline of the Ptio2 readings and may have prevented infarction in this patient. CONCLUSIONS: The development of delayed cerebral ischemia in TBM despite treatment is confirmed in these two patients. The reversal of a decline in Ptio2 readings suggests a possible benefit for cerebral oxygenation monitoring in selected patients with severe TBM.

The authors present the case of a 5-year-old child with severe traumatic brain injury in whom decompressive hemicraniectomy was performed for progressive increased intracranial pressure (ICP) unresponsive to medical treatment. Data from ICP and cerebral tissue oxygenation monitoring in the contralateral hemisphere were recorded, which demonstrated the immediate and delayed mechanical and physiological changes occurring after bony and dural decompression.The role of the procedure and that of the monitoring approach are discussed.

Object Control of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) is the foundation of traumatic brain injury (TBI) management. In this study, the authors examined whether conventional ICP- and CPP-guided neurocritical care ensures adequate brain tissue O2 in the first 6 hours after resuscitation. Methods Resuscitated patients with severe TBI (Glasgow Coma Scale score ≤ 8 and Injury Severity Scale score ≥ 16) who were admitted to a Level I trauma center and who underwent brain tissue O2 monitoring within 6 hours of injury were evaluated as part of a prospective observational database. Therapy was directed to maintain an ICP of 25 mm Hg or less and a CPP of 60 mm Hg or higher. Data from a group of 25 patients that included 19 men and six women (mean age 39 ± 20 years) were examined. After resuscitation, ICP was 25 mm Hg or less in 84% and CPP was 60 mm Hg or greater in 88% of the patients. Brain O2 probes were allowed to stabilize; the initial brain tissue O2 level was 25 mm Hg or less in 68% of the patients, 20 mm Hg or less in 56%, and 10 mm Hg or less in 36%. Nearly one third (29%) of patients with ICP readings of 25 mm Hg or less and 27% with CPP levels of 60 mm Hg or greater had severe cerebral hypoxia (brain tissue O2 ≤10 mm Hg). Nineteen patients had both optimal ICP (≤25 mm Hg) and CPP (> 60 mm Hg); brain tissue O2 was 20 mm Hg or less in 47% and 10 mm Hg or less in 21% of these patients. The mortality rate was higher in patients with reduced brain tissue O2. Conclusions Brain resuscitation based on current neurocritical care standards (that is, control of ICP and CPP) does not prevent cerebral hypoxia in some patients. This finding may help explain why secondary neuronal injury occurs in some patients with adequate CPP and suggests that the definition of adequate brain resuscitation after TBI may need to be reconsidered.

To determine a) whether packed red blood cell transfusion (RBCT) increases local brain tissue oxygen partial pressure (Pbto2) in a neurocritical care population; and b) what (if any) demographic, clinical, or physiologic variables mediate the assumed change.Prospective observational study.A neurosurgical intensive care unit at a university-based level I trauma center and tertiary care hospital.Thirty-five consecutive volume-resuscitated patients with subarachnoid hemorrhage or traumatic brain injury, without cardiac disease, requiring Pbto2 monitoring and receiving RBCT were studied between October 2001 and December 2003.None.The following physiologic variables were measured and compared 1 hr before and after RBCT: Pbto2, intracranial pressure, cerebral perfusion pressure, hemoglobin oxygen saturation (Sao2), Fio2, hemoglobin, and hematocrit. An increase in Pbto2 was observed in 26 of the 35 patients (74%). In nine patients, Pbto2 decreased after RBCT. The mean (+/-sd) increase in Pbto2 for all patients was 3.2 +/- 8.8 mm Hg (p = .02), a 15% change from baseline (1 hr before RCBT). This Pbto2 increase was associated with a significant mean increase in hemoglobin and hematocrit after RBCT (1.4 +/- 1.1 g/dL and 4.2% +/- 3.3%, respectively; both p.001). Cerebral perfusion pressure, Sao2, and Fio2 were similar before and after RBCT. Among the 26 patients whose Pbto2 increased, the mean increase in Pbto2 was 5.1 +/- 9.4 mm Hg or a 49% mean increase (p.01).RBCT is associated with an increase in Pbto2 in most patients with subarachnoid hemorrhage or traumatic brain injury. This mean increase appears to be independent of cerebral perfusion pressure, Sao2, and Fio2. Further study is required to determine why Pbto2 decreases in some patients after RBCT.

INTRODUCTION Increasing costs and concerns about blood supply safety have led to a reevaluation of blood transfusion practices. This study was undertaken to examine blood use during aneurysm surgery. METHODS We performed a retrospective analysis of hospital records including operative, anesthetic, and nursing notes, computed tomographic scans, and four-vessel angiographic films of 547 patients undergoing surgery for ruptured and unruptured cerebral aneurysms at Harborview Medical Center in Seattle. During the review period, the transfusion threshold was not altered. RESULTS A total of 134 patients (24.5%) received an intraoperative blood transfusion (median number of units, 2; range, 1–17). Preoperative factors associated with intraoperative blood use included older patient age (P < 0.001), lower hematocrit level on admission (P = 0.007), ruptured rather than unruptured aneurysm (P = 0.004), severe intraventricular hemorrhage (P = 0.03), and larger aneurysm size (P = 0.004). Factors not associated with intraoperative blood transfusion included past medical history (including cardiac or pulmonary disease), admission clinical grade after aneurysm rupture, findings such as hydrocephalus on computed tomographic scanning, and aneurysm location and aneurysm neck-to-fundus ratio. Also associated with blood transfusion during surgery were intraoperative aneurysm rupture (P < 0.0001), intracerebral hematoma evacuation (P = 0.02), and obliteration of multiple aneurysms (P = 0.002). Among patients who received an intraoperative transfusion, those who experienced an aneurysm rupture required an average of 3.6 ± 0.35 units, whereas patients who did not have a rupture required 1.9 ± 0.12 units (P = 0.001). Postoperatively, a total of 244 patients (44.6%), including 77 who received blood intraoperatively, required a blood transfusion (median number of units, 2; range, 1–31). Postoperative blood transfusion was associated with the treatment of patients with subarachnoid hemorrhage (P < 0.0001), particularly among poor-grade patients who developed medical complications. CONCLUSION Blood transfusion can be expected in one in five patients undergoing aneurysm surgery. Reducing intraoperative rupture may reduce the need for blood products.

To evaluate the nutritional intake and status of HIV-1 seropositive patients, as well as the relationship between malnutrition and disease stage.A cross-sectional study.The Immunology Clinic at the Pelonomi Hospital in Bloemfontein, South Africa.Eighty-one HIV/AIDS patients in different stages of disease were recruited consecutively from January to May 1995. Eleven of these patients were followed in 1997.Anthropometric data including current weight, height, triceps skinfold thickness, mid-upper-arm circumference, body mass index and bone-free arm muscle area were collected. Nutrient intake was estimated using a diet history in combination with a standardised food frequency questionnaire. The patients were divided into 3 groups according to their CD4+ T cell counts.The men were leaner (BMI = 18.9) than the women (BMI = 22.7) and patients with a CD4+ T cell count200 (stage III) tended to have the lowest median values for all anthropometric measurements. More than half the patients had a low intake (67% of the recommended dietary allowances) of vitamin C, vitamin B6, vitamin D, vitamin A, calcium, iron and zinc.The results confirms that HIV/AIDS patients from this population are malnourished. There was, however, no association between disease stage and nutritional status. Nutritional supplementation of HIV/AIDS patients should be considered, as this might lead to improved immune function in these patients.

TWENTY CONSECUTIVE PATIENTS were treated for symptomatic thoracic disc herniation with the transpedicular approach. Most patients had severe, incapacitating local or radicular pain. Myelopathy was uncommon as magnetic resonance imaging allowed an early diagnosis. Computed tomography, after myelography, provided further information necessary for surgical planning. Three patients had disc disease at two levels. Nine central and 14 lateral disc herniations were found. Disc calcification or an associated osteophyte was identified in six instances. Although the size of the disc herniation correlated with the amount of cord compression, no radiological features were found to be correlated with neurological function. The transpedicular approach was used in all patients. New curettes, specifically designed for the procedure, allowed the removal of all discs, including central and calcified fragments. A modified arthroscope was used to confirm neural decompression in some instances. One year after surgery, all 20 patients were significantly improved and 8 patients were asymptomatic. Apart from the duration of the symptoms, no other factors were found to affect outcome. The findings suggest that the prognosis of thoracic disc herniation is excellent if the disease is recognized early. The transpedicular approach, using curettes specifically designed for the procedure, can be an effective and safe method of surgical decompression in carefully selected patients.

Follow-up head CT scans are important in neurocritical care but involve intrahospital transport that may be associated with potential hazards including a deleterious effect on brain tissue oxygen pressure (PbtO(2)). Portable head CT (pHCT) scans offer an alternative imaging technique without a need for patient transport. In this study, the investigators examined the effects of pHCT scans on intracranial pressure (ICP), cerebral perfusion pressure (CPP), and PbtO(2) in patients with severe brain injury.Fifty-seven pHCT scans were obtained in 34 patients (mean age of 42 ± 15 years) who underwent continuous ICP, CPP, and PbtO(2) monitoring in the neuro intensive care unit at a university-based Level I trauma center. Patient ICU records were retrospectively reviewed and physiological data obtained during the 3 hours before and after pHCT scans were examined.Before pHCT, the mean ICP and CPP were 14.3 ± 7.4 and 78.9 ± 20.2 mm Hg, respectively. Portable HCT had little effect on ICP (mean ICP 14.1 ± 6.6 mm Hg, p = 0.84) and CPP (mean CPP 81.0 ± 19.8 mm Hg, p = 0.59). The mean PbtO(2) was similar before and after pHCT (33.2 ± 17.0 mm Hg and 31.6 ± 15.9 mm Hg, respectively; p = 0.6). Ten episodes of brain hypoxia (PbtO(2)15 mm Hg) were observed before pHCT; these episodes prompted scans. Brain hypoxia persisted in 5 patients after pHCT despite treatment. No new episodes of brain hypoxia were observed during or after pHCT.These data suggest that pHCT scans do not have a detectable effect on a critically ill patient's ICP, CPP, or PbtO(2).

The object of this study was to determine whether brain tissue oxygen (PbtO(2))-based therapy or intracranial pressure (ICP)/cerebral perfusion pressure (CPP)-based therapy is associated with improved patient outcome after severe traumatic brain injury (TBI).Seventy patients with severe TBI (postresuscitation GCS scoreor = 8), admitted to a neurosurgical intensive care unit at a university-based Level I trauma center and tertiary care hospital and managed with an ICP and PbtO(2) monitor (mean age 40 +/- 19 years [SD]) were compared with 53 historical controls who received only an ICP monitor (mean age 43 +/- 18 years). Therapy for both patient groups was aimed to maintain ICP20 mm Hg and CPP60 mm Hg. Patients with PbtO(2) monitors also had therapy to maintain PbtO(2)20 mm Hg.Data were obtained from 12,148 hours of continuous ICP monitoring and 6,816 hours of continuous PbtO(2) monitoring. The mean daily ICP and CPP and the frequency of elevated ICP (20 mm Hg) or suboptimal CPP (60 mm Hg) episodes were similar in each group. The mortality rate was significantly lower in patients who received PbtO(2)-directed care (25.7%) than in those who received conventional ICP and CPP-based therapy (45.3%, p0.05). Overall, 40% of patients receiving ICP/CPP-guided management and 64.3% of those receiving PbtO(2)-guided management had a favorable short-term outcome (p = 0.01). Among patients who received PbtO(2)-directed therapy, mortality was associated with lower mean daily PbtO(2) (p0.05), longer durations of compromised brain oxygen (PbtO(2)20 mm Hg, p = 0.013) and brain hypoxia (PbtO(2)15 mm Hg, p = 0.001), more episodes and a longer cumulative duration of compromised PbtO(2) (p0.001), and less successful treatment of compromised PbtO(2) (p = 0.03).These results suggest that PbtO(2)-based therapy, particularly when compromised PbtO(2) can be corrected, may be associated with reduced patient mortality and improved patient outcome after severe TBI.

OBJECTIVE: Transport of critically ill intensive care unit patients may be hazardous. We examined whether brain oxygen (brain tissue oxygen partial pressure [PbtO2]) is influenced by transport to and from a follow-up head computed tomography (transport head computed tomography [tHCT]) scan. METHODS: Forty-five patients (24 men, 21 women; Glasgow Coma Scale score ≤8; mean age, 47.3 ± 19.0 years) who had a traumatic brain injury (n = 26) or subarachnoid hemorrhage (n = 19) were retrospectively identified from a prospective observational cohort of PbtO2 monitoring in a neurosurgical intensive care unit at a university-based level I trauma center. PbtO2, intracranial pressure, and cerebral perfusion pressure were monitored continuously and compared during the 3 hours before and after 100 tHCT scans. RESULTS: The mean PbtO2 before and after the tHCT scans for all 100 scans was 37.9 ± 19.8 mm Hg and 33.9 ± 17.2 mm Hg, respectively (P = .0001). A decrease in PbtO2 (>5%) occurred after 54 tHCTs (54%) and in 36 patients (80%). In instances in which a decrease occurred, the average decrease in mean, minimum, and maximum PbtO2 was 23.6%, 29%, and 18.1%, respectively. This decrease was greater when PbtO2 was compromised (

BACKGROUND Increased intracranial pressure (ICP) can cause brain ischemia and compromised brain oxygen (PbtO2 < or = 20 mm Hg) after severe traumatic brain injury (TBI). OBJECTIVE We examined whether decompressive craniectomy (DC) to treat elevated ICP reduces the cumulative ischemic burden (CIB) of the brain and therapeutic intensity level (TIL). METHODS Ten severe TBI patients (mean age, 31.4 +/- 14.2 years) who had continuous PbtO2 monitoring before and after delayed DC were retrospectively identified. Patients were managed according to the guidelines for the management of severe TBI. The CIB was measured as the total time spent between a PbtO2 of 15 to 20, 10 to 15, and 0 to 10 mm Hg. The TIL was calculated every 12 hours. Mixed-effects models were used to estimate changes associated with DC. RESULTS DC was performed on average 2.8 days after admission. DC was found to immediately reduce ICP (mean [SEM] decrease was 7.86 mm Hg [2.4 mm Hg]; P = .005). TIL, which was positively correlated with ICP (r = 0.46, P < or = .001), was reduced within 12 hours after surgery and continued to improve within the postsurgical monitoring period (P

This study examines the effect of an increase in the inspired fraction of oxygen (FiO2) on brain tissue oxygen (PbO2) in children with severe traumatic brain injury (TBI).A prospective observational study of patients who underwent PbO2 monitoring and an oxygen challenge test (temporary increase of FiO2 for 15 min) was undertaken. Pre- and post-test values for arterial partial pressure of oxygen (PaO2), PbO2, and arterial oxygen content (CaO2) were examined while controlling for any changes in arterial carbon dioxide tension and cerebral perfusion pressure during the test. Baseline transcranial Doppler studies were done. Outcome was assessed at 6 months.A total of 43 tests were performed in 28 patients. In 35 tests in 24 patients, the PbO2 monitor was in normal-appearing white matter and in eight tests in four patients, the monitor was in a pericontusional location. When catheters were pericontusional or in normal white matter the baseline PbO2/PaO2 ratio was similar. PaO2 (P0.0001) and PbO2 (P0.0001) significantly increased when FiO2 was increased. The magnitude of the PbO2 response (PbO2) was correlated with PaO2 (P0.0001, R(2) = 0.37) and CaO2 (P = 0.001, R(2) = 0.23). The PbO2/PaO2 ratio (oxygen reactivity) varied between patients, was related to the baseline PbO2 (P = 0.001, r = 0.54) and was inversely related to outcome (P = 0.02, confidence interval 0.03-0.78).Normobaric hyperoxia increases PbO2 in children with severe TBI, but the response is variable. The magnitude of this response is related to the change in PaO2 and the baseline PbO2. A greater response appears to be associated with worse outcome.

Study objective We improve our understanding of the community consultation process for acute neurologic emergency trials conducted under the federal regulations for Exception From Informed Consent (EFIC) for emergency research. Methods We performed a qualitative study using focus groups to collect data from patients with a previous stroke or brain injury and their families and from young men at risk for traumatic brain injury. Discussions were transcribed, coded, and analyzed for major themes and subthemes. Results Five focus groups, involving 40 participants, were convened. Major themes included the awareness and understanding of key clinical trial concepts, including prominent concerns about placebo and therapeutic misconception; inability to obtain informed consent and acceptable surrogate decisionmaking; EFIC in emergency research and whether existing regulations are acceptable; specific trial design problems, including comparison to standard of care versus 2 competing active therapies; and community consultation and representation. Conclusion In this study sample, EFIC trials were deemed appropriate and acceptable for acute neurologic emergency research. Education, along with open discussion about basic clinical research concepts, disease- and trial-specific information, and potential surrogate decisionmaking, was essential to determine the acceptability of an EFIC trial. Approval by institutional review boards was highly regarded as a means of human protection and effective community consultation for such trials. A data repository of information gained from similar qualitative research may help investigators and regulators who wish to plan, conduct, review, and provide oversight for acute neurologic emergency trials under EFIC regulations.

OBJECTIVE: Red blood cell transfusion (RBCT) is associated with medical complications in general medical and surgical patients. We examined the hypothesis that RBCT during intensive care unit (ICU) care is associated with medical complications after subarachnoid hemorrhage (SAH). METHODS: We retrospectively analyzed a prospective observational database containing 421 patients with SAH (mean age, 51.5 years; standard deviation, 14.6 years). Logistic regression models were used to adjust for age, admission hemoglobin (Hgb), clinical grade, average ICU Hgb, and symptomatic vasospasm. RESULTS:Two hundred fourteen patients received an RBCT during their ICU stay. Medical complications were identified in 156 patients and were more common in those who received blood (46%) than in those who did not (29.8%) (P < .001). Major medical complications (cardiac, pulmonary, renal, or hepatic) occurred in 111 patients, and minor complications (eg, skin rash, deep vein thrombosis) occurred in 45 patients. Any non-central nervous system infection (n =183 ; P < .001), including pneumonia (n = 103; P < .001) or septicemia (n = 36; P=.02), was more common with RBCT. Central nervous system infections (meningitis, cranial wound, n = 15) also were associated with RBCT (P = .03). Mechanically ventilated patients (n = 259) were more likely to have received an RBCT than those who did not (P < .001). When logistic regression was used to control for age, admission clinical grade and Hgb, average ICU Hgb, symptomatic vasospasm, and other admission variables associated with outcome, the following factors (odds ratio; 95% confidence interval) were associated with RBCT: any medical complication (1.8; 1.1-3.0), major medical complications (2.1; 1.2-3.7), any infection (2.8; 1.7-4.5), pneumonia (2.6; 1.5-4.7), septicemia (2.9; 1.2-6.8), and need for mechanical ventilation (2.8; 1.5-5.1). CONCLUSION: These data suggest that RBCTs are associated with medical complications after SAH. However, the data do not infer causation, and further study is necessary to better define the indications for transfusion after SAH.

Cerebral pressure autoregulation is an important neuroprotective mechanism that stabilizes cerebral blood flow when blood pressure (BP) changes. In this study the authors examined the association between autoregulation and clinical factors, BP, intracranial pressure (ICP), brain tissue oxygen tension (PbtO(2)), and outcome after pediatric severe traumatic brain injury (TBI). In particular we examined how the status of autoregulation influenced the effect of BP changes on ICP and PbtO(2).In this prospective observational study, 52 autoregulation tests were performed in 24 patients with severe TBI. The patients had a mean age of 6.3 +/- 3.2 years, and a postresuscitation Glasgow Coma Scale score of 6 (range 3-8). All patients underwent continuous ICP and PbtO(2) monitoring, and transcranial Doppler ultrasonography was used to examine the autoregulatory index (ARI) based on blood flow velocity of the middle cerebral artery after increasing mean arterial pressure by 20% of the baseline value. Impaired autoregulation was defined as an ARI0.4 and intact autoregulation as an ARIor= 0.4. The relationships between autoregulation (measured as both a continuous and dichotomous variable), outcome, and clinical and physiological variables were examined using multiple logistic regression analysis.Autoregulation was impaired (ARI0.4) in 29% of patients (7 patients). The initial Glasgow Coma Scale score was significantly associated with the ARI (p = 0.02, r = 0.32) but no other clinical factors were associated with autoregulation status. Baseline values at the time of testing for ICP, PbtO(2), the ratio of PbtO(2)/PaO(2), mean arterial pressure, and middle cerebral artery blood flow velocity were similar in the patients with impaired or intact autoregulation. There was an inverse relationship between ARI (continuous and dichotomous) with a change in ICP (continuous ARI, p = 0.005; dichotomous ARI, p = 0.02); that is, ICP increased with the BP increase when ARI was low (weak autoregulation). The ARI (continuous and dichotomous) was also inversely associated with a change in PbtO(2) (continuous ARI, p = 0.002; dichotomous ARI, p = 0.02). The PbtO(2) increased when BP was increased in most patients, even when the ARI was relatively high (stronger autoregulation), but the magnitude of this response was still associated with the ARI. There was no relationship between the ARI and outcome.These data demonstrate the influence of the strength of autoregulation on the response of ICP and PbtO(2) to BP changes and the variability of this response between individuals. The findings suggest that autoregulation testing may assist clinical decision-making in pediatric severe TBI and help better define optimal BP or cerebral perfusion pressure targets for individual patients.

Vasospasm is a leading cause of morbidity and death following aneurysmal subarachnoid hemorrhage (SAH). It is important to predict which patients are at risk for vasospasm so that interventions can be made. There are several potential risk factors for vasospasm, one of which is age. However, the effect of age on vasospasm, particularly symptomatic vasospasm, remains controversial.Three hundred ninety-one patients were retrospectively identified from a prospective observational database of patients with SAH who had been admitted to a single center. Demographic and clinical data were recorded, and cerebral angiograms obtained at admission and between 5 and 10 days later were compared. The relationship between age and angiographic and symptomatic vasospasms was examined using logistic regression techniques.Mild (86 patients), moderate (69 patients), severe (56 patients), and no angiographic vasospasms (180 patients) were documented by comparing admission and follow-up angiograms in each patient. Symptomatic vasospasm was identified in 69 patients (17.6%). Angiographic vasospasm was more frequent as age decreased. Except in patients30 years old, the frequency of symptomatic vasospasm also increased with decreasing age (p = 0.0001). After adjusting for variables known to be associated with vasospasm, an advanced age was associated with a reduced incidence of any angiographic vasospasm (OR 0.96, 95% CI 0.94-0.97), severe angiographic vasospasm (OR 0.96, 95% CI 0.95-0.98), and symptomatic vasospasm (OR 0.98, 95% CI 0.96-0.99).Results in this study show that a younger age is associated with an increased incidence of angiographic and symptomatic vasospasm.

There has been a resurgence of interest in decompressive craniectomy for traumatic brain injury (TBI), but the impact of craniectomy on intracranial pressure (ICP) and cerebral oxygenation has not been well described for diffuse injury in children.ICP and brain tissue oxygenation (PbtO2) changes after decompressive craniectomy for diffuse brain swelling after TBI in children were analysed.Decompressive craniectomy was performed for diffuse brain swelling in 18 children under 15 years old. For 8 patients, craniectomy was performed as an emergency for malignant brain swelling, and in 10, for sustained ICP25 mmHg refractory to conventional medical treatment. In 6 of these patients, PbtO2 was also monitored. Median ICP was reduced from 40 mmHg before craniectomy to 16 mmHg for 24 hours thereafter, and PbtO2 improved from a median of 17.4 to 43.4 mmHg. Clinical outcome was favourable in 78%.In selected pediatric patients with TBI, craniectomy for diffuse brain swelling can significantly improve ICP and cerebral oxygenation control. The use of the procedure in appropriate settings does not appear to increase the proportion of disabled survivors.

Background and Purpose— The optimal hemoglobin (Hgb) target after aneurysmal subarachnoid hemorrhage is not precisely known. We sought to examine the threshold of Hgb concentration associated with an increased risk of cerebral metabolic dysfunction in patients with poor-grade subarachnoid hemorrhage. Methods— Twenty consecutive patients with poor-grade subarachnoid hemorrhage who underwent multimodality neuromonitoring (intracranial pressure, brain tissue oxygen tension, cerebral microdialysis) were studied prospectively. Brain tissue oxygen tension and extracellular lactate/pyruvate ratio were used as markers of cerebral metabolic dysfunction and the relationship between Hgb concentrations and the incidence of brain hypoxia (defined by a brain tissue oxygen tension 40) was analyzed. Results— Compared with higher Hgb concentrations, a Hgb concentration P =0.02), higher lactate/pyruvate ratio (29 [interquartile range, 25 to 38] versus 36 [interquartile range, 26 to 59], P =0.16), and an increased incidence of brain hypoxia (21% versus 52%, P P =0.03). On multivariable analysis, a Hgb concentration P P =0.02) after adjusting for cerebral perfusion pressure, central venous pressure, PaO 2 /FIO 2 ratio, and symptomatic vasospasm. Conclusions— A Hgb concentration

Background and Purpose— The purpose of this study was to analyze whether fever control attenuates cerebral metabolic distress after aneurysmal subarachnoid hemorrhage (SAH). Methods— Eighteen SAH patients, who underwent intracranial pressure (ICP) and cerebral microdialysis monitoring and were treated with induced normothermia for refractory fever (body temperature ≥38.3°C, despite antipyretics), were studied. Levels of microdialysate lactate/pyruvate ratio (LPR) and episodes of cerebral metabolic crisis (LPR >40) were analyzed during fever and induced normothermia, at normal and high ICP (>20 mm Hg). Results— Compared to fever, induced normothermia resulted in lower LPR (40±24 versus 32±9, P P P P Conclusions— Fever control is associated with reduced cerebral metabolic distress in patients with SAH, irrespective of ICP.

Brain tissue oxygen tension (PbtO2) monitoring is used increasingly in adult severe traumatic brain injury (TBI) management. Several factors are known to influence PbtO2 in adults, but the variables that affect PbtO2 in pediatric TBI are not well described. This study examines the relationships between PbtO2 and (1) physiological markers of potential secondary insults commonly used in pediatric TBI, in particular intracranial pressure (ICP), cerebral perfusion pressure (CPP), and systemic hypoxia, and (2) other clinical factors and treatment received that may influence PbtO2. In this prospective observational study, 52 children (mean age, 6.5 ± 3.4 years; range, 9 months to 14 years old) with severe TBI and a median post-resuscitation Glasgow Coma Score (GCS) of 5 were managed with continuous PbtO2 monitoring. The relationships between PbtO2 parameters ( $${\text{PbtO}}_{2_{{\text{low}}} } $$ , PbtO2

Intracranial pressure (ICP) monitoring and cerebral perfusion pressure (CPP) management are the current standards to guide care of severe traumatic brain injury (TBI). However, brain hypoxia and secondary brain injury can occur despite optimal ICP and CPP. In this study, we used brain tissue oxygen tension (PbtO(2)) monitoring to examine the association between multiple patient factors, including PbtO(2), and outcome in pediatric severe TBI.In this prospective observational study, 52 children (less than 15 years) with severe TBI were managed with continuous PbtO(2) and ICP monitoring. The relationships between outcome [Glasgow Outcome Score (GOS) and Pediatric Cerebral Performance Category Scale] and clinical, radiologic, treatment, and physiological variables, including PbtO(2), were examined using multiple logistic regression analysis.Outcome was favorable in 40 patients (77%) and unfavorable (mortality, 9.6%; n = 5) in 12 (23%). In univariate analysis, the following variables had a significant association with unfavorable outcome: initial GCS, computed tomography classification, ICP(peak), mICP(24), mICP, CPP(low), CPP(40), pupil reactivity, PbtO(2)(low), PbtO(2)5 mmHg, PbtO(2)10 mmHg, mPbtO(2)(24), and time-severity product. PbtO(2) parameters had the strongest independent association with poor outcome in multiple regression analysis. In particular, when PbtO(2) was5 mmHg for1 h, the adjusted OR for poor outcome was 27.4 (95% confidence interval, 1.9-391). No variables apart from PbtO(2) were independently associated with mortality when controlled for PbtO(2).Reduced PbtO(2) is shown to be an independent factor associated with poor outcome in pediatric severe TBI in the largest study to date. It appears to have a stronger association with outcome than conventionally evaluated measures.

To analyze the effect of tight glycemic control with the use of intensive insulin therapy on cerebral glucose metabolism in patients with severe brain injury.Retrospective analysis of a prospective observational cohort.University hospital neurologic intensive care unit.Twenty patients (median age 59 yrs) monitored with cerebral microdialysis as part of their clinical care.Intensive insulin therapy (systemic glucose target: 4.4-6.7 mmol/L [80-120 mg/dL]).Brain tissue markers of glucose metabolism (cerebral microdialysis glucose and lactate/pyruvate ratio) and systemic glucose were collected hourly. Systemic glucose levels were categorized as within the target "tight" (4.4-6.7 mmol/L [80-120 mg/dL]) vs. "intermediate" (6.8-10.0 mmol/L [121-180 mg/dL]) range. Brain energy crisis was defined as a cerebral microdialysis glucose0.7 mmol/L with a lactate/pyruvate ratio40. We analyzed 2131 cerebral microdialysis samples: tight systemic glucose levels were associated with a greater prevalence of low cerebral microdialysis glucose (65% vs. 36%, p0.01) and brain energy crisis (25% vs.17%, p0.01) than intermediate levels. Using multivariable analysis, and adjusting for intracranial pressure and cerebral perfusion pressure, systemic glucose concentration (adjusted odds ratio 1.23, 95% confidence interval [CI] 1.10-1.37, for each 1 mmol/L decrease, p0.001) and insulin dose (adjusted odds ratio 1.10, 95% CI 1.04-1.17, for each 1 U/hr increase, p = 0.02) independently predicted brain energy crisis. Cerebral microdialysis glucose was lower in nonsurvivors than in survivors (0.46 +/- 0.23 vs. 1.04 +/- 0.56 mmol/L, p0.05). Brain energy crisis was associated with increased mortality at hospital discharge (adjusted odds ratio 7.36, 95% CI 1.37-39.51, p = 0.02).In patients with severe brain injury, tight systemic glucose control is associated with reduced cerebral extracellular glucose availability and increased prevalence of brain energy crisis, which in turn correlates with increased mortality. Intensive insulin therapy may impair cerebral glucose metabolism after severe brain injury.

OBJECTIVE Hyperthermia can exacerbate outcome after traumatic brain injury (TBI). In this study, we examined the relationship between brain temperature (BT) and core body temperature and the relationship between BT and brain tissue oxygen (BtO2) to determine whether hyperthermia adversely affects BtO2. METHODS Seventy-two patients (mean age, 41 +/- 19 years) admitted to a Level I trauma center after TBI were retrospectively identified from a prospective observational database. Intracranial pressure (ICP), BT, and BtO2 were recorded continuously. Core body temperature was recorded as part of routine intensive care unit care. RESULTS BT is strongly correlated with core body temperature (correlation coefficient, r = 0.92) over a wide range. In addition, BT was correlated with body temperature during periods of normal ICP (IC P

Object. Nitric oxide (NO) metabolism may influence vasospasm after subarachnoid hemorrhage (SAH). It has been demonstrated in recent studies that erythrocytes carry NO for release in vessels, whereas transfused erythrocytes may lack stored NO. Several converging lines of evidence also indicate that blood transfusion may exacerbate poor outcomes in some critically ill patients. In this study the authors hypothesized that patients with SAH who received red blood cell (RBC) transfusions were at greater risk for vasospasm and poor outcome. Methods. The authors retrospectively reviewed a prospective observational database, including hospital records, computerized tomography (CT) scans, and pre- and postoperative four-vessel angiograms, in which the management methods used in 441 patients undergoing surgery for ruptured cerebral aneurysms were described. Two hundred seventy patients (61.2%) received an RBC transfusion during their hospital stay. After adjustment for Hunt and Hess grade, SAH grade on CT scans, delay between rupture and surgery, smoking status, and intraoperative aneurysm rupture, a worse outcome was more likely in patients who received intraoperative blood (odds ratio [OR] 2.44, confidence interval [CI] 1.32–4.52; 120 patients). Intraoperative RBC transfusion did not influence subsequent angiographically confirmed vasospasm (OR 0.92, CI 0.6–1.4). Worse outcome was observed in patients who received blood postoperatively (OR 1.81, CI 1.21–2.7), but not after adjustments were made for confounding variables (OR 1.48, CI 0.83–2.63). Angiographic vasospasm was observed in 217 patients and, after adjusting for confounding variables, was more frequent among patients who received postoperative RBC transfusion (OR 1.68, CI 1.02–2.75). Among patients in whom angiographically confirmed vasospasm developed there was a tendency to have received more blood than in those with no vasospasm; however, a clear dose-dependent response was not observed. Conclusions. Development of angiographically confirmed vasospasm after SAH is associated with postoperative RBC transfusion and worse outcome is associated with intraoperative RBC transfusion. Before blood is transfused, patients with SAH should be carefully assessed to determine if they are symptomatic because of anemia.

Background The Fisher grade (FG) is widely used to predict cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH). We revisited the grading scale to determine its validity in the era of modern management. Methods We retrospectively reviewed the records of 134 patients with SAH. The amount and distribution of subarachnoid blood on admission computed tomography (CT) scan was quantified according to the FG and compared with development of symptomatic vasospasm. Results We reviewed 134 patients (median age, 54) who presented with aneurysmal SAH. Six (5%) were FG 1, 34 (25%) were FG 2, 25 (19%) were FG 3, and 69 (51%) were FG 4. Symptomatic vasospasm developed in no (0%) FG 1, 8 (24%) FG 2, 7 (28 %) FG 3, and 13 (19%) FG 4 patients (28 of 134 total patients; 21%). Development of symptomatic vasospasm was not associated with admission FG, Hunt and Hess grade, age, sex, or location of blood on presenting CT scan. Elevated transcranial Doppler blood flow velocity was associated with blood in the basal cisterns ( P = .0047), lateral ventricles ( P = .026), or blood in any ventricle ( P = .04). Postoperative angiograms were obtained in 57 patients; moderate to severe vasospasm was observed in 5 (15%) FG 2, 6 (24%) FG 3, and 14 (20%) FG 4 patients. Twenty patients (71%) with symptomatic vasospasm had moderate or severe angiographic vasospasm. Angiographic vasospasm was associated with intraventricular blood ( P = .054) but not with FG. Conclusions Symptomatic vasospasm occurred in 21% of cases. The FG correlated with symptomatic vasospasm in only half the patients. A new predictive CT grading scale for vasospasm may be necessary.

Swallowing difficulties and dysphonia may occur in patients undergoing anterior cervical discectomy and fusion. The etiology and incidence of these abnormalities, however, are not well defined. In view of this, we performed a prospective, objective analysis of swallowing function and vocal cord approximation in patients undergoing anterior cervical discectomy and fusion. Twenty-three consecutive patients (22 male and one female, mean age 59 years) undergoing anterior cervical discectomy and fusion had standardized modified barium swallow study and videolaryngoendoscopy performed preoperatively and again at 1 week and 1 month postoperatively. Eleven patients (48%) had radiographic evidence of preoperative swallowing abnormalities. The majority of these patients had myelopathic rather than radicular findings (p = 0.03). None, however, had symptoms of swallowing dysfunction. Among these patients, one had worse function postoperatively, three had improvement, and function remained unchanged in seven. The preoperative swallowing assessment was normal in 12 patients (52%). Postoperative radiographic swallowing abnormalities were demonstrated in eight of these patients (67%). Preoperative vocal cord movement was normal in all patients. Postoperatively, vocal cord paresis was detected in two patients. The paresis was transient in one and permanent in the other. Age, previous medical history, operation duration, and spinal level decompressed were not significantly associated with the incidence of swallowing dysfunction. There was, however, a tendency for patients undergoing multilevel surgery to demonstrate an increased incidence of swallowing abnormalities on postoperative radiographic studies. In addition, soft tissue swelling was more frequent in patients whose swallowing function was worse postoperatively (p = 0.007). Postoperative voice and swallowing dysfunction are common complications of anterior cervical discectomy and fusion, although in the majority of patients these abnormalities are not symptomatic. Patients undergoing multilevel procedures are at an increased risk for these complications, in part because of soft tissue swelling in the neck.

Objective. Lumbar discectomy is a common elective surgical procedure but many patients still experience postoperative back pain which may delay hospital discharge. We therefore evaluated the efficacy of a parenteral non-steroidal antiinflammatory agent, ketorolac, for the management of post-surgical pain. Methods. Fifty three patients undergoing lumbar discectomy at a Medical School affiliated Veterans Administration hospital were randomly assigned to receive either: 1) 30 mg intramuscular ketorolac upon surgical closure and every 6 hours for 36 hours and narcotic analgesics as needed (PRN); or 2) only narcotic analgesics as needed. A blinded observer recorded the average, minimum and maximum postoperative pain intensity using a Numeric Pain Intensity Scale; total postoperative narcotic consumption, complications, length of hospitalization (from surgery to discharge) and outcome at 6 weeks. Results. The patients who received ketorolac reported significantly lower average (p

To evaluate the nutritional status of HIV-1 seropositive patients with regards to laboratory parameters; the correlation between nutrient intake and actual values of nutrients, as well as the relationship between malnutrition and disease progression.A cross sectional study.The Immunology Clinic at the Pelonomi Hospital in Bloemfontein, South Africa.90 HIV/AIDS patients in different stages of disease were recruited consecutively from January to May 1995. Sixteen patients were followed up in 1997.The patients were divided into three groups according to their CD4+ T-cell counts, and blood levels of protein, albumin, cholesterol, ferritin, vitamin B12, magnesium, and phosphorus, as well as several micronutrients including vitamin E, vitamin C, beta-carotene and retinol which were determined using standard methods. These values were compared with the normal reference values used in the laboratory, and we tried to correlate these parameters with disease stage, as well as recorded nutrient intake in a subgroup of 35 patients.Abnormal values for several parameters, including plasma-retinol and serum-protein were found, but no correlation between more advanced disease and micronutrient deficiencies could be demonstrated.HIV/AIDS patients from this population are deficient in several micronutrients, and for some patients this is mirrored by a low intake. Multivitamin/anti-oxidant supplementation of HIV/AIDS patients should be considered, as this could lead to improved immune function in these patients.

INTRODUCTION: Cerebral angiography performed after aneurysm surgery can identify causes of morbidity and mortality that may be corrected. The risks and benefits of angiography that is performed after aneurysm surgery, however, have not been clearly defined. We therefore reviewed our experience with postoperative angiography to determine its dangers and benefits. METHODS: During 10 years, 543 consecutive patients received treatment for cerebral aneurysms. A retrospective analysis of 597 diagnostic angiograms obtained after aneurysm surgery for 494 of these patients was performed. RESULTS: Catheter-induced vessel spasm and dissection, occurring most frequently in the internal carotid artery, were observed in seven (1.2%) and six (1%) studies, respectively. No angiography-associated strokes were identified. No association between age, smoking, hypertension, blood pressure, atherosclerosis, or severe vasospasm and angiographic complications was observed. Aneurysm remnants were identified in 36 (5.7%) of the 637 aneurysms that were surgically treated. Atherosclerosis (P < 0.01) or multiple clip applications (P < 0.01) were significantly associated with aneurysm remnants. Angiographic vessel occlusion was observed in 28 (5.7%) patients and resulted in stroke in 14 of these patients. Vessel occlusion was significantly associated with increasing aneurysm size (P < 0.001), atherosclerosis (P < 0.001), temporary clips (P < 0.001), multiple clips (P = 0.03), multiple clip applications (P = 0.001), and a new postoperative neurological deficit (P = 0.002). Severe vasospasm and newly identified aneurysms were observed in 51 and 16 patients, respectively. CONCLUSION: Angiography after aneurysm surgery is safe and can be routinely performed. Angiography after aneurysm surgery should be particularly considered for patients with large aneurysms or cerebrovascular atherosclerosis and for those who develop new postoperative neurological deficits.

✓ To determine the relationship between clinical grade on admission and treatment cost after aneurysm rupture, the authors retrospectively examined the length of hospital stay (LOS) and total hospitalization costs (excluding professional fees) for 543 patients admitted for aneurysm surgery between 1983 and 1993. The overall median LOS was 18 days, with a range of 1 to 165 days. Increased median LOS correlated with Hunt and Hess Grades 0 to IV on admission (p< 0.001). Median LOS for Grade V patients was reduced, in part, because of early mortality. Increased treatment cost also correlated with worse admission clinical grade (p < 0.001). A significant proportion of total expenditures occurred early in the hospitalization for patients in all clinical grades. Identification of additional factors affecting the cost of aneurysm treatment is indicated to complement treatment outcome studies.

The authors report their experience with 25 patients (mean age, 44.3 +/- 12.1 years) with an intracerebral hematoma (ICH) from a ruptured aneurysm who were emergently operated on without angiography. Instead, preoperative high-resolution infusion computed tomography (CT) scans were used to identify the aneurysm causing the hemorrhage. In all patients, the preoperative Glasgow Coma Scale score was5 and brain stem compression was evident. ICH was present in the frontal or temporal lobe and was often associated with intraventricular hemorrhage (n = 17) and significant (1 cm) midline shift (n = 18). Infusion CT scans correctly identified the aneurysm in all patients (middle cerebral artery, 18; posterior communicating artery, 2; carotid bifurcation, 3; anterior communicating artery, 2). Partial evacuation of the hematoma guided by infusion CT scan was usually required first to clip the aneurysm definitively using standard microvascular techniques. Intraoperative rupture occurred twice, and temporary clips were used on four occasions. Lobectomy (n = 8), decompressive craniotomy (n = 15), and ventriculostomy (n = 8) were required to control cerebral swelling. All patients underwent postoperative angiography to confirm aneurysm obliteration. Eleven unruptured aneurysms were subsequently identified. Nine had been predicted by infusion scan. Twelve patients survived, eight of whom were only moderately disabled and were independent at 6-months' follow-up. Of the 13 patients who died, all except one died within 4 days of admission. The authors conclude that although angiographic verification before aneurysm surgery is preferable, in the moribund patient with intracerebral hemorrhage, infusion CT scanning provides sufficient information concerning vascular anatomy to allow rational emergency craniotomy and aneurysm clipping.

Thirty-three patients with low grade gliomas were evaluated with preoperative computed tomography (CT), magnetic resonance (MR) and intraoperative ultrasound (IOUS). Six patients had undergone previous surgical exploration. Tumor borders were marked with cortical letters and corresponding depths calculated. Resection of tumor corresponded to these ultrasound dimensions. The histology of biopsy specimens from tumor and ultrasound determined margins was studied on formalin fixed permanent sections using hematoxylin and eosin (HE) and immunocytochemistry (GFAP). Tumors were all seen on preoperative MR studies and most commonly showed a decreased T1 and increased T2 signal. Seven tumors showed variable enhancement with gadolinium. On CT two tumors were not seen, twenty-three tumors were hypodense and eight hyperdense. Three tumors showed variable CT contrast enhancement. All tumors were hyperechoic on ultrasound. Twenty-five (75%) tumors were well defined with distinct margins compared to adjacent brain. Eight tumors had poorly defined borders on ultrasound; five (62%) of these lesions had previously undergone surgery. Eight tumors invaded functional brain identified by stimulation mapping techniques (e.g., speech cortex), thus limiting the resection. Five resections were limited because of involvement of important anatomical structures (e.g., corpus callosum). Of the remaining 20 tumors, seventeen (85%) had ultrasound defined margins that were histologically free of solid tumor (normal brain or sparse atypical cells only). Low grade gliomas are readily identified and their margins well defined by intraoperative ultrasound regardless of preoperative imaging patterns. The results suggest that IOUS may enhance intraoperative delineation and extent of resection for low grade gliomas.

Background Many physicians do not routinely inquire about intimate partner violence. Purpose This qualitative study explores the process of academic detailing as an intervention to change physician behavior with regard to intimate partner violence (IPV) identification and documentation. Method A non-physician academic detailer provided a seven-session modular curriculum over a two-and-a-half month period. The detailer noted written details of each training session. Audiotapes of training sessions and semi-structured exit interviews with each physician were recorded and transcribed. Transcriptions were qualitatively and thematically coded and analyzed using Atlas ti®. Results All three study physicians reported increased clarity with regard to the scope of their responsibility to their patients experiencing IPV. They also reported increased levels of comfort in the effective identification and appropriate documentation of IPV and the provision of ongoing support to the patient, including referrals to specialized community services. Conclusion Academic detailing, if presented by a supportive and knowledgeable academic detailer, shows promise to improve physician attitudes and practices with regards to patients in violent relationships.

The clinical success of angioplasty for symptomatic vasospasm following subarachnoid hemorrhage (SAH) depends on early intervention and can best be achieved after the aneurysm is occluded. However, patients presenting with unsecured ruptured aneurysms and established clinical vasospasm offer a dilemma for the surgeon. The authors describe the cases of five such patients who underwent acute clipping of aneurysms followed by immediate postoperative angioplasty between 1988 and 1992. All were referred at least 5 days after SAH. Severe vasospasm compatible with the clinical presentation was confirmed by angiography. The patients met the department's criteria for angioplasty but, because of unclipped aneurysms, were first taken patients met the department's criteria for angioplasty but, because of unclipped aneurysms, were first taken to the operating room for a craniotomy and aneurysm obliteration. Angiography was repeated immediately after surgery. Arterial narrowing had progressed during surgery in two patients. In all patients, postoperative mechanical dilatation was achieved with the use of a silicone microballoon. Following angioplasty, transcranial Doppler ultrasound flow velocities and single-photon emission computerized tomography evaluation indicated improved cerebral perfusion compared to preoperative determinations. Four patients improved clinically and made a good recovery. In this subgroup of patients presenting with proven symptomatic vasospasm and an unclipped but ruptured aneurysm, urgent surgical obliteration of the aneurysm followed by immediate postoperative angioplasty may be a safe and reasonable means to improve outcome.