S. Andrew Josephson, Vanja C. Douglas, Michael T. Lawton, Joey D. English, Wade S. Smith and Nerissa U. Ko
Neurointensivists are specialists trained to manage all aspects of the intensive care unit (ICU) stay of neurologically ill patients. No study to date has examined the role of neurointensivists specifically in subarachnoid hemorrhage (SAH) management. This study examined the use of a team-based neurointensivist co-management approach.
The authors reviewed all cases involving patients with SAH admitted to the neurosurgical service during a period of more than 4 years. A comparison was made between those patients admitted before and those admitted after the initiation of a mandatory neurointensivist co-management strategy. The primary outcome examined was length of ICU stay. Secondary outcomes included in-hospital mortality, ventriculoperitoneal shunt placement, and other complications such as fever, antibiotic use, pressor utilization, and ventilator-associated pneumonia.
A total of 512 patients were included, 216 prior to and 296 after the initiation of neurointensivist comanagement. Length of ICU stay was significantly decreased after the initiation of neurointensivist co-management (mean 12.4 vs 10.9 days, p = 0.02), even after adjusting for demographic characteristics and admission Hunt and Hess grade. The percentage of patients requiring a ventriculoperitoneal shunt significantly decreased after initiation of the co-management approach (23.0 vs 11.5%, p = 0.001), but in-house mortality was unaffected.
Initiation of a strategy of routine involvement of a neurointensivist, charged with managing all aspects of the patients' care, resulted in a significantly reduced length of ICU stay for neurosurgical SAH patients. This team-based approach, using neurointensivists to manage neurosurgical SAH patients, merits further study as a successful model of care.
Sunil A. Sheth, Daniel Hausrath, Adam L. Numis, Michael T. Lawton and S. Andrew Josephson
Intraoperative rerupture during open surgical clipping of cerebral aneurysms in subarachnoid hemorrhage (SAH) is a relatively frequent and potentially catastrophic occurrence. Patients who suffer rerupture have been shown to have worse outcomes at discharge compared with those who do not have rerupture. Perioperative injury likely plays a large part in the clinical worsening of these patients. However, due to the increased vessel manipulation and repeat exposure to acute hemorrhage, it is possible that secondary injury from increased incidence of vasospasm also contributes. Identifying an increased rate of vasospasm in these patients would justify early aggressive treatment with measures to prevent delayed cerebral ischemia. The authors investigated whether patients who suffer intraoperative rerupture during surgical treatment of ruptured cerebral aneurysms are at increased risk of developing vasospasm.
Five hundred consecutive patients treated with open surgical clipping for SAH were reviewed, and clinical and imaging data were collected. Angiographic vasospasm was defined as vessel narrowing believed to be consistent with vasospasm on angiography. Symptomatic vasospasm was defined as angiographic vasospasm in the setting of a clinical change attributable to vasospasm. Rates of angiographic and symptomatic vasospasm among patients with and without intraoperative rerupture were compared.
There were no significant differences between the groups with and without rupture with respect to age, sex, modified Fisher grade, history of hypertension, or smoking. The group with intraoperative rupture had more patients with Hunt and Hess Grade I. Angiographic vasospasm was noted in 279 (66%) of the 425 patients without rerupture compared with 49 (65%) of the 75 patients with rerupture (p = 1.0, Fisher's exact test). Symptomatic vasospasm was noted in 154 (36%) of the 425 patients without rerupture, compared with 31 (41%) of the 75 patients with rerupture (p = 0.44, Fisher's exact test). In multivariate analysis, higher modified Fisher grade was significantly predictive of vasospasm, whereas older age and male sex were protective.
This study found no significant influence of intraoperative rerupture during open surgical clipping on the rate of angiographic or symptomatic vasospasm. Brief exposure to acute hemorrhage and vessel manipulation associated with rerupture events did not affect the rate of vasospasm. Risk of vasospasm was related to increased modified Fisher grade, and inversely related to age and male sex. These results do not justify early, targeted vasospasm therapy in patients with intraoperative rerupture.
S. Andrew Josephson, Alexander M. Papanastassiou, Mitchel S. Berger, Nicholas M. Barbaro, Michael W. McDermott, Joan F. Hilton, Bruce L. Miller and Michael D. Geschwind
Obtaining brain biopsy specimens is often the diagnostic test of last resort for patients with unexplained neurological conditions, particularly those with a rapidly deteriorating neurological course. The goals of this analysis were to determine the diagnostic sensitivity of brain biopsy specimens in these types of patients and retrospectively identify features of these disorders that may have enabled an earlier diagnosis, which may prevent the need for diagnostic brain biopsy procedures in the future.
The authors reviewed the case records of all brain biopsy procedures that had been performed at a single tertiary care institution between January 1993 and April 2002 in 171 patients. Patients with HIV or nonlymphomatous brain tumors were excluded from this analysis because the utility of brain biopsy specimens for these conditions has been determined from previous studies. A subgroup analysis of this cohort was performed in the 64 patients who had comprehensive medical records and a clinical syndrome involving a progressively deteriorating neurological condition of less than 1 year in duration.
The overall sensitivity of brain biopsy procedures for diagnostic purposes in the cohort was 65% (111 of 171 patients). The two most common diagnoses in the subgroup with rapidly deteriorating neurological conditions were primary central nervous system (CNS) B-cell lymphoma in 20.3% (13 patients) and Creutzfeldt–Jakob disease in 15.6% (10 patients), followed by viral encephalitis in 14.1% (nine patients) and CNS vasculitis in 9.4% (six patients). Clinical symptoms and laboratory data were compared among the diagnostic groups.
These results will help guide the evaluation of patients with neurological conditions that are difficult to diagnose and will provide a foundation for further prospective studies.
Praveen V. Mummaneni, John F. Burke, Andrew K. Chan, Julie Ann Sosa, Errol P. Lobo, Valli P. Mummaneni, Sheila Antrum, Sigurd H. Berven, Michael S. Conte, Sarah B. Doernberg, Andrew N. Goldberg, Christopher P. Hess, Steven W. Hetts, S. Andrew Josephson, Maureen P. Kohi, C. Benjamin Ma, Vaikom S. Mahadevan, Annette M. Molinaro, Andrew H. Murr, Sirisha Narayana, John P. Roberts, Marshall L. Stoller, Philip V. Theodosopoulos, Thomas P. Vail, Sandra Wienholz, Michael A. Gropper, Adrienne Green and Mitchel S. Berger
During the COVID-19 pandemic, quaternary-care facilities continue to provide care for patients in need of urgent and emergent invasive procedures. Perioperative protocols are needed to streamline care for these patients notwithstanding capacity and resource constraints.
A multidisciplinary panel was assembled at the University of California, San Francisco, with 26 leaders across 10 academic departments, including 7 department chairpersons, the chief medical officer, the chief operating officer, infection control officers, nursing leaders, and resident house staff champions. An epidemiologist, an ethicist, and a statistician were also consulted. A modified two-round, blinded Delphi method based on 18 agree/disagree statements was used to build consensus. Significant disagreement for each statement was tested using a one-sided exact binomial test against an expected outcome of 95% consensus using a significance threshold of p < 0.05. Final triage protocols were developed with unblinded group-level discussion.
Overall, 15 of 18 statements achieved consensus in the first round of the Delphi method; the 3 statements with significant disagreement (p < 0.01) were modified and iteratively resubmitted to the expert panel to achieve consensus. Consensus-based protocols were developed using unblinded multidisciplinary panel discussions. The final algorithms 1) quantified outbreak level, 2) triaged patients based on acuity, 3) provided a checklist for urgent/emergent invasive procedures, and 4) created a novel scoring system for the allocation of personal protective equipment. In particular, the authors modified the American College of Surgeons three-tiered triage system to incorporate more urgent cases, as are often encountered in neurosurgery and spine surgery.
Urgent and emergent invasive procedures need to be performed during the COVID-19 pandemic. The consensus-based protocols in this study may assist healthcare providers to optimize perioperative care during the pandemic.