Nicardipine infusion for blood pressure control in patients with subarachnoid hemorrhage.

INTRODUCTION: To evaluate the efficacy, tolerability, and safety of nicardipine infusion in controlling the elevated blood pressure after subarachnoid hemorrhage (SAH). METHODS: Nicardipine infusion was initiated if the individual pre-specified systolic blood pressure (SBP) level goal, mandated by the admitting neurosurgeon, was not met. Systolic and diastolic BPs were measured on admission, hourly during the infusion and 12 h before and after the infusion. RESULTS: Twenty-eight patients with SAH required 50 nicardipine infusions in order to achieve a mean SBP goal of 152 mmHg. The 3,112 extracted BP measurements showed that mean infusion SBP was significantly lower than admission and pre-infusion SBP (mean 146.5 vs. 177.1 and 155.6 mmHg, P < 0.001, respectively) and significantly higher than post-infusion SBP (146.5 vs. 142.6 mmHg, P = 0.002). Five infusions were stopped prematurely, because of hypotension (n = 3), emergent surgery (n = 1), and failure to reach the SBP goal (n = 1). Rebleeding was not observed in any patient. Nicardipine achieved SBP control in 59.9% of hourly infusion measurements, with a trend for higher proportion of success with higher SBP goals. CONCLUSION: In this study, nicardipine infusion was a safe and moderately effective treatment for BP control in patients with SAH. Although SBP during nicardipine infusion was higher than the pre-specified goal in a significant percentage of hourly observations, this may be due to the drug administration protocol and other factors such as analgesia and sedation.

The appointment of neurointensivists is financially beneficial to the employer.

BACKGROUND: Although the impact of a neurointensivist (NI) on patient outcomes has been examined in the past, the financial impact has not been estimated before. METHODS: We extracted the financial data from the Neuro-Intensive Care Unit (NICU) at Henry Ford Hospital during two 3-year periods, one before and one after the appointment of a NI. Net revenue (NR), total direct expenses (TDE), and contribution margin (CM) were compared between these two periods both for Henry Ford Hospital and the Henry Ford Medical Group. RESULTS: The average number of admissions increased by 24% during the period when the NI was present, the number of patient-days by 25% and the average length of stay by 2%. In the second period, when the NI was billing for critical care time spent in the NICU, as well as for procedures he performed, the mean yearly NR was $402,000, the TDE $317,000 and the NR/TDE 1.24 (>1.0 represents profitability). The combined mean NR (Henry Ford Hospital + Medical Group) increased by 54.6%, the combined TDE by 42.2% and the combined CM by 91.2% in the period when the NI was present. This is reflected in the combined mean CM per admission, which also increased by 56.4% in the after period. CONCLUSION: This study shows a significant financial benefit for the Henry Ford Health System during the period when a NI was present in the NICU.

Vancomycin-resistant enterococcal meningitis treated with intrathecal streptomycin.

Enterococcal meningitis is a rare complication of neurosurgical procedures. We present a patient who developed vancomycin-resistant enterococcal ventriculitis - meningitis after a brain tumor resection and ventriculoperitoneal shunt placement, treated successfully with intrathecal streptomycin through bilateral cerebrospinal fluid drainage catheters in addition to systemic antibiotics. This is the first report of such treatment for this resistant organism.

Free fatty acids in cerebrospinal fluids from patients with traumatic brain injury.

Free fatty acid (FFA) concentrations in cerebrospinal fluid (CSF) are recognized as markers of brain damage in animal studies. There is, however, relatively little information regarding FFA concentrations in human CSF in normal and pathological conditions. The present study examined FFA concentrations in CSF from 15 patients with traumatic brain injury (TBI) and compared the data with values obtained from 73 contemporary controls. Concentrations of specific FFAs from TBI patients, obtained within 48 h of the insult were significantly greater than those in the control group (arachidonic, docosahexaenoic and myristic, P<0.001; oleic, palmitic, P<0.01; linoleic, P<0.05). Higher concentrations of total polyunsaturated fatty acids (P<0.001) and of arachidonic, myristic and palmitic acids measured individually in CSF (P<0.01) obtained 1 week after the insult were associated with a worse outcome at the time of hospital discharge using the Glasgow Outcome Scale. This preliminary investigation suggests that CSF FFA concentrations may be useful as a predictive marker of outcome following TBI.

Chiari I malformation associated with thoracic epidural cord lesion: case report.

Many spinal cord lesions have been described previously, in association with Chiari I lesions. The authors report a unique case of a 29-year-old patient with a Chiari I malformation and an upper thoracic epidural lesion causing headaches, dysphagia and Brown-Sequard syndrome. The patient underwent a suboccipital decompression as well as a thoracic laminectomy and resection of the epidural lesion. Pathologic analysis revealed that the thoracic lesion was fibro-adipose tissue. A review of the literature failed to show any other similar cases. We discuss the possible etiologies of this case.

Free fatty acids in human cerebrospinal fluid following subarachnoid hemorrhage and their potential role in vasospasm: a preliminary observation.

OBJECT: The mechanisms leading to vasospasm following subarachnoid hemorrhage (SAH) remain unclear. Accumulation in cerebrospinal fluid (CSF) of free fatty acids (FFAs) may play a role in the development of vasospasm; however, in no previous study have concentrations of FFAs in CSF been examined after SAH. METHODS: We collected samples of CSF from 20 patients with SAH (18 cases of aneurysmal SAH and two cases of spontaneous cryptogenic SAH) and used a high-performance liquid chromatography assay to determine the FFA concentrations in these samples. We then compared these findings with FFA concentrations in the CSF of control patients. All FFA concentrations measured 24 hours after SAH were significantly greater than control concentrations (p < 0.01 for palmitic acid and < 0.001 for all other FFAs). All measured FFAs remained elevated for the first 48 hours after SAH (p < 0.05 for linoleic acid, p < 0.01 for palmitic acid, and p < 0.001 for the other FFAs). After 7 days, a second elevation in all FFAs was observed (p < 0.05 for linoleic acid, p < 0.01 for palmitic acid, and p < 0.001 for the other FFAs). Samples of CSF collected within 48 hours after SAH from patients in whom angiography and clinical examination confirmed the development of vasospasm after SAH were found to have significantly higher concentrations of arachidonic, linoleic, and palmitic acids than samples collected from patients in whom vasospasm did not develop (p < 0.05). CONCLUSIONS: Following SAH, all FFAs are initially elevated. A secondary elevation occurs between 8 and 10 days after SAH. This study provides preliminary evidence of FFA elevation following SAH and of a potential role for FFAs in SAH-induced vasospasm. A prospective study is warranted to determine if CSF concentrations of FFAs are predictive of vasospasm.

Neurotrauma: the role of CT angiogram.

Cerebrovascular injuries can occur in blunt or penetrating head and neck trauma. A high index of suspicion based on mechanism of injury and clinical assessment warrants screening for intracranial and extracranial vascular lesions. Conventional angiogram has been and remains the gold standard for diagnosis of these injuries, but computerized tomography angiography offers a fast, noninvasive method of imaging for neurotrauma patients. Advantages and disadvantages of each modality are discussed.