SESSION TYPE: Neuro Critical CarePRESENTED ON: Tuesday, October 23, 2012 at 04:30 PM - 05:45 PM

PURPOSE:

To evaluate the impact and safety of tPA for ischemic stroke (IS) in patients 80 years old (yo) and older.

METHODS:

: We retrospectively reviewed charts of patients greater than 80 yo who received tPA for IS from June 2006-February 2012. Demographics and clinical data included age, gender, Charles-Deyo comorbidity index(CCI), blood pressure(BP), blood sugar(BS), platelet count(PLT), and NIHH, MSS, and HAT scores at the time of tPA administration. Outcomes included Modified Rankin scale(MRS) on discharge, intracranial hemorrhage(ICH), ICU/hospital length of stay(LOS), mortality, and disposition. T-test, Chi-square, Cochran-Armitage Trend Test, and AUC were employed to analyze the data using SAS9.3(Cary, NC).

RESULTS:

58 patients greater than 80 yo received tPA for IS during this period. Most patients were female(75%), Caucasian(49%), had few co-morbidities (CCI=1.8), and good functional status(MRS=1.8). Time to administration of tPA, BP, and PLT, were within guideline recommendations. 27%(n=16) of patients developed ICH. There were no differences in demographics, NIHH score, PLT, BS, or BP between patients with ICH and no-ICH. However, there was a trend towards increased risk of ICH with longer time to t-PA administration (124min vs.154min;p=0.057). MRS on discharge, ICU/hospital LOS, and mortality were not different between the two groups. MSS score, but not HAT score, was significantly higher in the ICH group when compared to no-ICH(2.6 vs.2.2;p=0.0204,AUC0.67). Moreover, patients with a higher MSS(≥3) were at higher risk of ICH(45%) when compared to scores of 2 (21%) or 1 (0%) (p=0.02,Cochran-Armitage test).

CONCLUSIONS:

In our study, patients older than 80 yo who received tPA for IS had a higher incidence of ICH and overall mortality when compared to what is described in the literature. Moreover, their MSS score could possibly be a good predictor for ICH.

CLINICAL IMPLICATIONS:

MSS score could possibly be a good predictor for ICH in octogenarians; nonetheless, a larger population is needed to further evaluate this score as a tool for tPA administration for IS in patients greater than 80 yo.DISCLOSURE: The following authors have nothing to disclose: Farzin Rahmanou, Edison Gavilanes, Anirban Basu, Chris Cheng, Susan Denn, Edward Chai, Melvin Hochman, Cristina GutierrezNo Product/Research Disclosure InformationNew York Hospital of Queens, Flushing, NY.

SESSION TYPE: Critical Care Student/Resident Case Report Posters IPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION:

Propofol infusion syndrome (PRIS) is marked by metabolic acidosis, cardiac dysfunction and rhabdomyolysis. Along with volume expansion, usage of continuous renal replacement therapy (CRRT) has been shown to be advantageous in patients with rhabdomyolysis and oliguric renal failure. We discuss a case in which two continuous veno-venous hemofiltration (CVVH) pumps were applied in a patient with severe PRIS.

CASE PRESENTATION:

A 19 year old female sustained severe head trauma after a motor vehicle accident. Her subsequent intracranial hypertension was managed medically including infusion of propofol at 80-100mcg/kg/min. On hospital day four she developed hypotension and intractable intracranial hypertension. She underwent a left decompressive hemicraniectomy. After surgery she became oliguric with a myoglobinemia of 40,000ng/ml. Her propofol was discontinued due to the concern for PRIS. She was started on CVVH with ultrafiltration of 6L/hr and 50 kDa pore size filter. Her myoglobin levels decreased. She subsequently developed abdominal compartment syndrome and underwent decompressive laparotomy. She intermittently required catecholamine infusion. Two days later serum myoglobin climbed above 100,000 ng/ml, despite her initial improvement and being free from propofol for five days. A second CVVH pump was started with a total ultrafiltration approaching 14L/hr. At the peak of her CVVH treatment, analysis of the ultrafiltrate revealed removal of 2.6gm of myoglobin per day. She required 16 days of CVVH treatment before her myoglobin levels normalized. A muscle biopsy done at the time of her initial laparotomy revealed a necrotizing myopathy making PRIS the most likely cause. Her renal function returned and she was discharged to rehabilitation.

DISCUSSION:

This case represents rhabdomyolysis in the setting of PRIS, its severity marked by the persistence of the myoglobinemia despite aggressive hemofiltration. Due to the continuous distribution of myoglobin from the muscle to the circulation, continuous filtration is likely to be of benefit in the setting of rhabdomyolysis with renal failure.

CONCLUSIONS:

In this case using very high ultrafiltrate volumes created the daily clearance of myoglobin which was necessary to resolve the myoglobinemia. Though this level of myoglobin clearance has been previously demonstrated with the use of a larger pore size filter, this high volume therapy allowed for aggressive clearance without the need for albumin replacement.1) Naka. T et al. "Myoglobin clearance by super high-flux hemofiltration in a case of severe rhabdomyolysis: a case report" Critical care (2005): R90-95.2) Casserly, B et al. "Propofol Infusion Syndrome: An unusual cause of renal failure" American Journal of Kidney Diseases 44.6 (2004): E98-E101.DISCLOSURE: The following authors have nothing to disclose: Blaine Kenaa, Laurie Punch, Deborah Stein, Thomas ScaleaNo Product/Research Disclosure InformationUniversity of Maryland, Baltimore, MD.

Thrombosis of the cerebral veins and sinuses is an unusual but important cause of increased intracranial pressure and stroke, especially in the young and middle aged. Pregnant women, especially during the puerperium, and individuals with thrombophilia are a special risk group. What makes the diagnosis difficult is the vast range of symptoms including: headache, nausea, vomiting, blurry vision, reduction of consciousness, aphasia and motor and sensory disturbances. We present four cases which reflect the diverse clinical presentation of the disease. Key words: cerebral sinus thrombosis, raised intracranial pressure, stroke, anti-coagulation. Correspondence: Olafur Sveinsson, olafur.sveinsson@karolinska.se Key words: cerebral sinus thrombosis, raised intracranial pressure, stroke, anti-coagulation. Correspondence: Olafur Sveinsson, olafur.sveinsson@karolinska.se.

Cysticercosis is a tropical disease caused by infection with the larval stage of the pork tapeworm, Taenia solium. Humans and pigs acquire cysticercosis by ingesting T. solium eggs shed in the feces of humans with taeniasis (i.e., infected with an adult intestinal tapeworm). Cerebral cysticercosis occurs when the cysts of T. solium develop within the central nervous system, and it is the primary cause of illness in T. solium infection. Currently, cerebral cysticercosis is endemic worldwide, and it is a leading cause of adult-onset epilepsy in developing countries. However, it is now increasingly detected in developed countries due to the immigration of T. solium carriers from the endemic areas. The antiparasitic treatment of cerebral cysticercosis remains controversial till now. In China, except a few cases who conform to the contraindicated criteria of antiparasitic therapy, most cerebral cysticercosis patients with symptoms and signs are given etiological treatment. This paper reviews the antiparasitic therapy of cerebral cysticercosis in China during the past several decades. Praziquantel treatment with different regimens has been used, and various efficacies are achieved. In the early stage, unsatisfactory therapeutic efficacy was achieved due to small doses and short treatment courses. Afterwards, the therapeutic efficacy became increasingly remarkable in both adults and children with the increases in dosage and courses. Albendazole also presents activity against cysticercosis with slow and moderate action, and it has been widely used in the treatment of the infection. The comparison between praziquantel and albendazole treatments showed that the immediate and short-term effects of albendazole treatment were better than those of praziquantel treatment, but similar mid- and long-term efficacies were observed following albendazole and praziquantel treatments. The combination of albendazole and praziquantel treatments can increase the therapeutic efficacy, and now, from the massive clinical practices, most of Chinese clinical specialists propose the combination therapy of albendazole and praziquantel for cerebral cysticercosis with simultaneous administration of steroids, especially in the first course. In addition, administration of praziquantel at a high dose can become a diagnostic treatment for suspected cerebral cysticercosis and serve as a supplement of the currently available diagnostic methods, such as diagnoses based on the clinical features, immunology, CT and MRI imaging, etc., in some atypical cerebral cysticercosis patients. Praziquantel and albendazole treatments have some adverse reactions, and to control these adverse effects, all the cerebral cysticercosis patients should be treated in hospital. According to the type of cerebral cysticercosis, especially for intracranial hypertension type and meningocephalitis type, the dosages of anti-cysticercus drugs need to follow a gradually increasing pattern. During the period of anti-cysticercosis treatments, steroids and/or dehydrating agents need be administered which can alleviate the intracranial hypertension and so on. Traditional Chinese medicines have been also used in the treatment of cerebral cysticercosis and achieve satisfactory outcomes. However, the compound prescription of traditional Chinese medicines is very complex, and the effective components are not fully clear. Some cerebral cysticercosis patients with very high intracranial tension could not receive antiparasitic treatment immediately, and surgical treatment is required. Chinese surgeons also achieve some successful experiences, but not all the cysticercus can be removed completely during the surgery. Therefore, antiparasitic drugs are still needed after the operation. The rehabilitative treatment is supplementary in the therapy of cerebral cysticercosis. In China, the rehabilitative treatment of cerebral cysticercosis is still at the initial stage. These lessons and experiences in China can be shared with medical staff and researchers from other countries where the disease is endemic.

This article reviews the growing epidemic of West Nile virus (WNV), clinical manifestations of the 2 primary groups of WNV, diagnostic tests, critical nursing management, risk factors, and prevention of WNV. Critical care nursing management is based on symptom management and supportive therapy for neuroinvasive disease complications. Nursing management for complications such as altered level of consciousness, mechanical ventilator respiratory support, high fever, cerebral edema, increased intracranial pressure, seizures, and neuropsychiatric issues is outlined. Preventive measures for WNV, such as surveillance programs, personal protective measures, source reduction, mosquito programs, and vaccine development, are discussed.

INTRODUCTION:

Posterior reversible encephalopathy syndrome (PRES) is a largely reversible disease with long-term favorable outcome. A minority of patients, however, may develop progressive cerebral edema and ischemia resulting in severe disability or death. We report a case of severe intracranial hypertension associated with PRES that was successfully treated according to intracranial pressure (ICP)- and cerebral perfusion pressure (CPP)-driven therapy.

METHODS:

Case report.

RESULTS:

A 42-year-old woman underwent bilateral lung transplantation for severe bronchiectasis. Her immunosuppressive regimen consisted of azathioprine, prednisone, and tacrolimus. She acutely developed an aggressive form of PRES that rapidly resulted in severe refractory intracranial hypertension despite discontinuation of potentially causative medications and adequate supportive therapy. Accordingly, second-tier therapies, including barbiturate infusion, were instituted and immunosuppression was switched to anti-thymocyte globulin followed by mycophenolate mofetil. Within 10 h of barbiturate administration, ICP dropped to 20 mmHg. Thiopental was administered for two days and then rapidly tapered because of severe urosepsis. Six months after discharge from the intensive care unit the patient returned to near-normal life, her only complaint being short-term amnesia.

CONCLUSIONS:

The decision to undertake ICP monitoring in medical conditions in which no clear recommendations exist greatly relies on physicians' judgment. This case suggests that ICP monitoring may be considered in the setting of acute PRES among selected patients, when severe intracranial hypertension is suspected, provided that a multidisciplinary team of neurocritical care specialists is readily available.

Patients who undergo placement of a drug-eluting coronary artery stent are prescribed dual antiplatelet therapy for one year. Early cessation of this therapy is a risk factor for a major adverse cardiac event, especially in high-risk patients. The perioperative physician team must evaluate the risk of surgical bleeding relative to the thrombotic risk during the perioperative period in patients taking dual antiplatelet therapy who must undergo intracranial neurosurgery. A 67 year old woman presented with right-sided hearing loss. Neurologic examination was significant for early papilledema and decreased hearing in the right ear. Magnetic resonance imaging showed a > 5 cm contrast-enhancing mass within her right-middle fossa with surrounding vasogenic edema and midline shift. Additional medical history was significant for diabetes, hypertension, and placement of a drug-eluting stent for coronary artery disease three months before her initial presentation. Medications included aspirin and clopidogrel. She underwent embolization of the middle meningeal arterial supply to the meningioma, then was admitted to the hospital for perioperative management of her antiplatelet therapy and telemetry monitoring. Her clopidogrel was stopped and aspirin continued perioperatively. An intravenous infusion of the antiplatelet drug, eptifibatide, replaced clopidogrel and was continued until 8 hours prior to surgical incision. During resection of the meningioma, no unusual surgical bleeding was noted. The patient was discharged on postoperative day 3 with satisfactory recovery.

The skull-brain complex is typically modeled as an integrated structure, similar to a fluid-filled shell. Under dynamic loads, the interaction of the skull and the underlying brain, cerebrospinal fluid, and other tissue produces the pressure and strain histories that are the basis for many theories meant to describe the genesis of traumatic brain injury. In addition, local bone strains are of interest for predicting skull fracture in blunt trauma. However, the role of skull flexure in the intracranial pressure response to blunt trauma is complex. Since the relative time scales for pressure and flexural wave transmission across the skull are not easily separated, it is difficult to separate out the relative roles of the mechanical components in this system. This study uses a finite element model of the head, which is validated for pressure transmission to the brain, to assess the influence of skull table flexural stiffness on pressure in the brain and on strain within the skull. In a Human Head Finite Element Model, the skull component was modified by attaching shell elements to the inner and outer surfaces of the existing solid elements that modeled the skull. The shell elements were given the properties of bone, and the existing solid elements were decreased so that the overall stiffness along the surface of the skull was unchanged, but the skull table bending stiffness increased by a factor of 2.4. Blunt impact loads were applied to the frontal bone centrally, using LS-Dyna. The intracranial pressure predictions and the strain predictions in the skull were compared for models with and without surface shell elements, showing that the pressures in the mid-anterior and mid-posterior of the brain were very similar, but the strains in the skull under the loads and adjacent to the loads were decreased 15% with stiffer flexural properties. Pressure equilibration to nearly hydrostatic distributions occurred, indicating that the important frequency components for typical impact loading are lower than frequencies based on pressure wave propagation across the skull. This indicates that skull flexure has a local effect on intracranial pressures but that the integrated effect of a dome-like structure under load is a significant part of load transfer in the skull in blunt trauma.

Acute liver failure is uncommon but not a rare complication of liver injury. It can happen after ingestion of acetaminophen and exposure to toxins and hepatitis viruses. The defining clinical symptoms are coagulopathy and encephalopathy occurring within days or weeks of the primary insult in patients without preexisting liver injury. Acute liver failure is often complicated by multiorgan failure and sepsis. The most life-threatening complications are sepsis, multiorgan failure, and brain edema. The clinical signs of increased intracranial pressure (ICP) are nonspecific except for neurologic deficits in impending brain stem herniation. Computed tomography of the brain is not sensitive enough in gauging intracranial hypertension or ruling out brain edema. Intracranial pressure monitoring, transcranial Doppler, and jugular venous oximetry provide valuable information for monitoring ICP and guiding therapeutic measures in patients with encephalopathy grade III or IV. Osmotic therapy using hypertonic saline and mannitol, therapeutic hypothermia, and propofol sedation are shown to improve ICPs and stabilize the patient for liver transplantation. In this article, diagnosis and management of hepatic encephalopathy and cerebral edema in patients with acute liver failure are reviewed.

To analyse the epidemiological characteristics, clinical symptoms, radiological aspects, treatments, and outcomes of primary central nervous system (CNS) hydatidosis and compare our results with those observed for secondary intracranial hydatidosis. Patients and Methods: We retrospectively reviewed 21 cases of primary CNS hydatid cysts operated on at the First Affiliated Hospital of Xinjiang Medical University between 1996 and 2010.Of the 21 primary cases, the vast majority were intracranial hydatidosis patients (20 cases, 95·24%). Only one patient had spinal hydatidosis. Unlike previously published reports, we found that intracranial hydatid cysts were more common in adults (80·96%) than in children (19·04%), with a slight male predominance (M/F = 1·1). All symptoms, including vomiting, nausea, and focal neurological signs, resulted from the increased intracranial pressure, which was closely associated with the cyst location. For the spinal hydatidosis patient, the primary symptom of back pain was indicative of spinal cord compression syndrome. All cysts in the 21 primary cases were pathologically similar. The recurrence percentage was 28% over 12 years. Two patients with multiple intracranial hydatid cysts died due to foramen magnum herniation.Despite imaging and therapeutic advances, CNS hydatidosis remains difficult to treat, and severe complications and the high incidence of recurrence result in unsatisfactory outcomes.