Ventricular Drainage Research Articles

A Patient With Hypogammaglobulinemia and Bi-allelic Variants in the RNU4ATAC Gene

IntroductionThe RNU4ATAC gene codes for a small nuclear RNA involved in U12 minor intron splicing. Bi-allelic compound heterozygous pathogenic variants in the RNU4ATAC gene have been associated with Roifman Syndrome, which is an autosomal recessive disease manifesting with immunodeficiency, retinal dystrophy, developmental delay, poor growth, spondyloepiphyseal dysplasia and dysmorphic facial features. We present a case of a patient with similar characteristics seen in Roifman syndrome including impaired humoral immunity, short stature, developmental delay, osseous abnormalities and characteristic facial features found to have one likely pathogenic variant and one variant of uncertain significance (VUS) on the RNU4ATAC gene, raising the suspicion for Roifman syndrome. Case PresentationA 9-year-old male patient with a history of congenital hydrocephalus, seizure disorder, developmental delay, skeletal dysplasia, short stature and alopecia presented with headaches in the setting of EBV-meningitis requiring craniotomy and external ventricular drain placement. Prior infectious history was remarkable for four bacterial pneumonias, one sinusitis and recurrent otitis media infections in childhood. Initial evaluation of his immune system revealed decreased levels of IgG at 453 mg/dL (698–1560 mg/dL), IgM at 19 mg/dL (31–179 mg/dL), IgA at 36 mg/dL (63–236 mg/dL), and decreased CD19+ B-cells at 59/uL (200–600/uL), with suboptimal response to tetanus, pneumococcal-13, haemophilus influenzae and diphtheria vaccines. Although after receiving booster vaccinations, specific antibodies rose to protective levels, they began to drop within one year and IgG levels remained low, so he was started on immunoglobulin replacement, and has remained free of infections. Genetic evaluation revealed one de novo VUS and one maternally inherited likely pathogenic variant on the RNU4ATAC gene. Further VUS were detected in various genes with mode of inheritance and disease associations not consistent with our patient’s phenotype. DiscussionDisease-causing variants in compound heterozygosity have been associated with Roifman syndrome. The clinical similarities shared between this condition and our patient, including epiphyseal dysplasia, unique facial features, developmental delay and immunodeficiency characterized by hypogammaglobulinemia and impaired specific antibody response, raise the suspicion for Roifman syndrome. As broad testing failed to reveal any other possible etiologies, confirmation of clinical diagnosis may lead to future reclassification of the VUS into presumably pathogenic.

Antibiotic-impregnated external ventricular drainage for post-hemorrhagic hydrocephalus in premature infants

Antibiotic-impregnated external ventricular drainage for post-hemorrhagic hydrocephalus in premature infants

Analysis of Prognostic Factors in Patients with Hemorrhagic Moyamoya Disease

Background: Hemorrhagic Moyamoya disease (MMD) is a common subtype of MMD in adult patients, especially in East Asian countries. To our knowledge, current studies regarding factors affecting the prognosis in patients with hemorrhagic MMD is lacking. This study aimed to determine the potential prognostic factors for hemorrhagic MMD.Methods: This retrospective study reviewed patients with hemorrhagic MMD diagnosed at our hospital between June 2011 and June 2021. Patient outcome was measured at discharge using the extended Glasgow outcome scale (GOSE). Prognostic factors were assessed by multivariate logistic regression analysis.Results: Patients discharged with worst outcomes (GOSE 1 and 2) had significantly lower initial Glasgow coma scale (GCS) scores (5.9 ± 3.1 vs. 10.3 ± 3.7; P = 0.002) and were associated with more severe intraventricular hemorrhage (IVH) (P = 0.007), and IVH-related hydrocephalus requiring extraventricular drain (EVD) insertion was more common (n = 12 vs. n = 7; P = 0.001). The multivariate analysis showed that IVH-related hydrocephalus requiring EVD placement (OR 8.256, 95% CI 0.996–68.450; P = 0.016) and low initial GCS scores (OR 0.644; 95% CI 0.465–0.892; P = 0.008) were independent risk factors for unfavorable outcomes (GOSE 1–4) in patients with hemorrhagic MMD.Conclusion: This study analyzed several potential prognostic factors for patients with hemorrhagic MMD. Low initial GCS scores and IVH-related hydrocephalus requiring EVD insertion were related to unfavorable outcomes.

Benchmarking Hospital Practices and Policies on Intrahospital Neurocritical Care Transport: The Safe-Neuro-Transport Study.

An electronic survey was administered to multidisciplinary neurocritical care providers at 365 hospitals in 32 countries to describe intrahospital transport (IHT) practices of neurocritically ill patients at their institutions. The reported IHT practices were stratified by World Bank country income level. Variability between high-income (HIC) and low/middle-income (LMIC) groups, as well as variability between hospitals within countries, were expressed as counts/percentages and intracluster correlation coefficients (ICCs) with a 95% confidence interval (CI). A total of 246 hospitals (67% response rate; n = 103, 42% HIC and n = 143, 58% LMIC) participated. LMIC hospitals were less likely to report a portable CT scanner (RR 0.39, 95% CI [0.23; 0.67]), more likely to report a pre-IHT checklist (RR 2.18, 95% CI [1.53; 3.11]), and more likely to report that intensive care unit (ICU) physicians routinely participated in IHTs (RR 1.33, 95% CI [1.02; 1.72]). Between- and across-country variation were highest for pre-IHT external ventricular drain clamp tolerance (reported by 40% of the hospitals, ICC 0.22, 95% CI 0.00-0.46) and end-tidal carbon dioxide monitoring during IHT (reported by 29% of the hospitals, ICC 0.46, 95% CI 0.07-0.71). Brain tissue oxygenation monitoring during IHT was reported by only 9% of the participating hospitals. An IHT standard operating procedure (SOP)/hospital policy (HP) was reported by 37% (n = 90); HIC: 43% (n= 44) vs. LMIC: 32% (n = 46), p = 0.56. Amongst the IHT SOP/HPs reviewed (n = 13), 90% did not address the continuation of hemodynamic and neurophysiological monitoring during IHT. In conclusion, the development of a neurocritical-care-specific IHT SOP/HP as well as the alignment of practices related to the IHT of neurocritically ill patients are urgent unmet needs. Inconsistent standards related to neurophysiological monitoring during IHT warrant in-depth scrutiny across hospitals and suggest a need for international guidelines for neurocritical care IHT.

Persistent Hiccups Following Thalamic Hemorrhage (P2-5.014)

<h3>Objective:</h3> N/A <h3>Background:</h3> Persistent hiccups (lasting more than 48 hours) can cause physical and emotional distress. They can result in dehydration, exhaustion, malnutrition, insomnia, wound dehiscence, ventilatory desynchronization and hemodynamic changes. Hiccups are thought to be due to a complex reflex arc involving peripheral nerves and central structures such as the brainstem, temporal lobe, basal ganglia, hypothalamus and the spinal cord levels C3–5. Medullary strokes, for instance, have been reported to cause hiccups. We report a patient with a thalamic bleed who developed persistent hiccups. <h3>Design/Methods:</h3> N/A <h3>Results:</h3> A 56-year-old man was brought to the hospital in an unresponsive state. He was intubated for airway protection. CT brain showed a left thalamic hemorrhage with edema and mass effect on the 3^rd ventricle, intraventricular extension of hemorrhage and hydrocephalus. External ventricular drain was placed successfully with adequate drainage. One week after admission, patient developed persistent abdominal jerks. These jerks were occurring every 3–4 seconds and would last for hours with brief periods of remission. He was started on levetiracetam 1000 mg IV bid and then increased to 1500 mg IV BID without any improvement of symptoms. The patient was also placed on video EEG which did not reveal any epileptiform abnormality but did show an EMG artifact. His electrolytes including sodium, potassium and corrected calcium levels were normal. He did not have any evidence of pneumonia or other infections. It was determined that these jerks were likely hiccups. Metoclopramide 10 mg IV was tried without any benefit. He was then started on Baclofen 10 mg PO TID which resulted in a significant improvement in hiccups. <h3>Conclusions:</h3> Our case suggests that thalamic lesions might also lead to persistent hiccups. <b>Disclosure:</b> Dr. Nemade has nothing to disclose. Dr. Shivkumar has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Teva. Dr. Shivkumar has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Sunovion. Dr. Dhingra has nothing to disclose.

The Completion of a PGY-1 Neurology Bootcamp Leads to Increased Trainee Knowledge and Confidence in Neurologic Emergencies Management and Procedural Skills (P2-2.001)

<h3>Objective:</h3> To evaluate the impact of an end-of-the-year, post-graduate year 1 (PGY-1) simulation-based neurology bootcamp on trainee knowledge, self-confidence, and skill independence regarding acute neurologic emergencies management and bedside procedural skills. <h3>Background:</h3> The post-graduate year 2 (PGY-2) neurology resident is often the first line of triage for evaluation of acute neurologic deterioration on the inpatient neurology service, requiring autonomy and responsibility. We implemented and evaluated a bootcamp prior to this critical training period. <h3>Design/Methods:</h3> In this prospective cohort study, 14 rising PGY-2 neurology residents attended a two-day bootcamp with a simulation-based curriculum led by neurology faculty practicing cerebrovascular, critical care, and inpatient neurology medicine. Pre- and postbootcamp, trainees completed multiple-choice knowledge assessments and via Likert scales, self-reported confidence in managing neurologic emergencies. Faculty observed and rated trainee ability to independently perform five neurologic procedures (lumbar puncture, external ventricular drain [EVD] management, botulinum toxin injection for migraine, digital fundoscopy, and pupillometry), with residents additionally reporting their own perceived degree of independence. <h3>Results:</h3> Proportion of trainees demonstrating independence per faculty rating significantly increased for all five procedural skills post-bootcamp (for all, p &lt; .05). Trainee self-reported independence of EVD management, pupillometry, and fundoscopy skills also increased postbootcamp (for all, p &lt; .05), with &lt; 25% of trainees reporting total independence pre-bootcamp to 50%, 86%, and 79% post-bootcamp, respectively. Knowledge assessment scores increased from a pre-bootcamp mean of 54% of questions correct to mean 70% correct (p = 0.002), driven by increases in vascular neurologic emergency and procedural knowledge. On a 5-point Likert scale, trainee self-reported confidence in emergency management increased from median 2.5 (a little confident) to median 4 (fairly confident) (p &lt; .001) <h3>Conclusions:</h3> A simulation-based, two-day bootcamp with focus on acute cerebrovascular neurologic emergencies and neurologic procedural skills showed significant improvements in trainee knowledge along with faculty-observed and self-reported confidence and independence. <b>Disclosure:</b> An immediate family member of Dr. Swetlik has received personal compensation for serving as an employee of Pfizer. Dr. Buletko has nothing to disclose. Dr. Marquardt has nothing to disclose. Dr. Higgins has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Organon. Ms. Hassett has nothing to disclose.

An Unusual Case of Posterior Fossa Predominant Posterior Reversible Encephalopathy Syndrome (PRES) Leading to Acute Hydrocephalus (P10-7.002)

<h3>Objective:</h3> To discuss acute hydrocephalus as an unusual complication of Posterior Reversible Encephalopathy Syndrome. <h3>Background:</h3> Posterior Reversible Encephalopathy Syndrome (PRES) is a well-recognized clinical and radiologic syndrome typically characterized by parieto-occipital vasogenic edema along with neurological symptoms, that improves after management or withdrawal of offending factor, in most cases being acute uncontrolled hypertension. However, clinical presentation and radiological findings are variable and may encompass different cerebral structures. Although pathophysiology is not well established, failure of sympathetic autoregulation in the vertebrobasilar system is thought to be related. This failure leads to breakdown of the blood-brain barrier, hence the vasogenic-type edema appreciated on imaging. Acute obstructive hydrocephalus is a rare and potentially fatal complication of PRES. <h3>Design/Methods:</h3> A 56-year-old Caucasian female who presented due to encephalopathy, headache and falls in the setting of hypertensive emergency. CT (Computed Tomography) head showed hypodense pons, midbrain, cerebellum, and bilateral thalami with effacement of the fourth ventricle, ventriculomegaly in the lateral and 3rd ventricles with associated trans-ependymal edema. Due to initial concern of posterior fossa mass leading to acute hydrocephalus, neurosurgery was consulted, and extra ventricular drain (EVD) was placed for emergent CSF diversion. <h3>Results:</h3> MRI Brain with and without contrast showed no evidence of acute ischemia or enhancing lesions. Severe edema was redemonstrated within the pons, midbrain, bilateral thalami, and cerebellum. Susceptibility weighted imaging showed microhemorrhages confined to the brainstem. The patient’s clinical exam improved after blood pressure management and EVD placement. Repeat head CT showed decreased cerebral edema and improvement of fourth ventricle obstruction. Based on presentation of hypertensive encephalopathy with posterior circulation vasogenic edema that improved with blood pressure management, PRES diagnosis was made. <h3>Conclusions:</h3> Posterior fossa predominant PRES is an uncommon presentation that if overlooked may lead to life threatening complications. Early recognition of clinical manifestations and radiological findings may lead to favorable outcomes. <b>Disclosure:</b> Dr. Morales-Nunez has nothing to disclose. Dr. Baez-Lugo has nothing to disclose. Dr. Yalcin has nothing to disclose. Dr. Shah has nothing to disclose. Dr. Garcia has nothing to disclose. Dr. Nichols has nothing to disclose.

Mobilization of Patients with External Ventriculostomy Drains: Pros and Cons

The effects of prolonged immobilization in the critical patient have been well described. Patients on mechanical ventilation and patients receiving extracorporeal membrane oxygenation therapy have been presented as evidence of the feasibility of implementation of early mobilization protocols. Prolonged immobilization of critically ill patients has been associated with intensive care unit-acquired weakness syndrome, increased mortality, at the cognitive level, impact on quality, and cost increase among other considerations. Early mobilization emphasizes strategies to stimulate motor, sensory, and proprioceptive levels in the context of critically ill patients. Early mobility intervention in critically ill patients begins in the first days of stay in the unit and requires a scheduled combination of passive and active activities. The presence of an external ventriculostomy device is not a contraindication for mobilization.[1] [2] It helps as above with the progression and improvement in the outcome. The dislodgement and risk of fracture of external ventricular drainage (EVD) are major concerns. Here, we briefly go over the technical aspect of EVD placement and how to safely mobilize the patient.

Characterizing the Use of Intrathecal Nicardipine for Post Traumatic Cerebral Vasospasm (P13-7.005)

<h3>Objective:</h3> Characterizing the use of intrathecal nicardipine for post traumatic cerebral vasospasm and treatment-related complications. <h3>Background:</h3> Post traumatic cerebral vasospasm (PTV) is a significant cause of secondary neurologic injury after traumatic brain injury (TBI) and is associated with worse outcomes. There is limited data to guide treatment of PTV. Intrathecal nicardipine (ITn) was shown to improve outcomes and reduce delayed cerebral ischemia in non-traumatic subarachnoid hemorrhage (SAH) patients, but traumatic mechanisms were not well studied. In this retrospective study, we characterize the use of ITn for PTV at a high-volume trauma center. <h3>Design/Methods:</h3> We reviewed all TBI admissions at a high-volume trauma center over a 10-year period. Patients ≥18 years of age requiring external ventricular drain (EVD) placement were included. We collected data regarding injury severity, length of stay, rationale, and timing for initiation of ITn, dosing, frequency and treatment-related complications. <h3>Results:</h3> Seven patients with severe TBI received ITn for radiographic vasospasm (VSP) on surveillance imaging. The average duration of treatment was 6 days. ITn was stopped given radiographic improvement (4), pre-defined decision for 48 hours of treatment (1), after DSA revealed no VSP (1) or identification of ventriculitis (1). Three patients had delayed cerebral ischemia on imaging; however, these were noted before the initiation of ITn. Two patients developed ventriculitis and one patient had brief, elevated intracranial pressure spikes with ITn. <h3>Conclusions:</h3> ITn is rarely used for PTV in this high-volume center. When ordered, it is done for radiographic VSP with variations in practice patterns for dosing, duration and weaning. Given the possible benefit of ITn in non-traumatic SAH patients and otherwise limited treatment options for PTV, understanding ITn use and outcomes in PTV is warranted. <b>Disclosure:</b> Dr. Sigman has nothing to disclose. Dr. Chester has nothing to disclose. Dr. Sciarretta has nothing to disclose. The institution of Dr. Ratcliff has received research support from Nico Corporation. The institution of Dr. Ratcliff has received research support from Sense . Ofer Sadan has received intellectual property interests from a discovery or technology relating to health care.

Validation of a Non-Invasive Method Using Mechanical Extensometer for the Estimation of Intracranial Compliance Using Repeated Measures Agreement Analysis (P11-7.001)

<h3>Objective:</h3> To validate a non-invasive intracranial (ICP) waveform monitoring device against the gold standard invasive ICP monitoring device for comparison of three methodologies calculating estimated intracranial compliance. <h3>Background:</h3> Cerebral compliance is the brain’s ability to accommodate volumes increases without an increase in pressure. Several methods utilize surrogate cerebral compliance estimations, but these require invasive ICP monitoring. For this study, intracranial compliance was calculated by transcranial doppler (TCD), as well as ICP waveform analysis (P1:P2 ratio, Time to Peak [TTP]). <h3>Design/Methods:</h3> Adult brain-injured patients were monitored with both invasive (extraventricular drain) and noninvasive (mechanical extensometer). TCD and ICP waveform analysis was performed by ICM+ and Brain4Care analytics. To examine agreement, a linear mixed-effects model accounted for repeated measurements to compute the concordance correlation coefficient (CCC), total deviation index (TDI), and coefficient of individual agreement (CIA). TCD values were log-transformed to mitigate non-normality. A coverage probability plot (CPP) was computed for the percent of observations within different cut points for each method. Computations were performed in R. All tests were two-sided and statistical significance was established at 0.05. <h3>Results:</h3> 21 patients were monitored for median 36 minutes (IQR 27–42). Agreement statistics for TCD, P2/P1 ratio, and TTP were as follows: TTP: [CCC 0.33; CIA 0.25; TDI, 95% agreement 0.24 units], P2:P1: [CCC 0.42; CIA 0.05; TDI, 95% agreement 1.05], and log(TCD): [CCC: 0.50; CIA: 0.04; TDI, 95% agreement 2.94]. Although the CCC was highest for log(TCD) values, TTP and P2:1 ratio had better agreement with TDI and CIA analysis. This was further supported by the CPP, which showed TTP had the highest percent of cases within various cutoff difference values. <h3>Conclusions:</h3> Non-invasive and invasive evaluations of estimated intracranial compliance reveals discordance between the three methodologies. ICP waveform derived measurements may be a better estimate of compliance compared to TCD-derived methods; however, prospective validation studies are required. <b>Disclosure:</b> An immediate family member of Dr. Williams has stock in Jazz Pharmaceuticals. Dr. Uysal has nothing to disclose. Nicholas Thompson has nothing to disclose. Ms. Hassett has nothing to disclose. Dr. Gomes has nothing to disclose.

Delayed malignant cerebellar posterior reversible encephalopathy syndrome secondary to (CLAG-M) and venetoclax regimen. (P12-13.006)

<h3>Objective:</h3> PRES (posterior reversible encephalopathy syndrome) is a heterogenous syndrome caused by multiple factors. Cerebellar PRES is commonly seen with autoimmune disease and rarely with chemotherapy. <h3>Background:</h3> Isolated cerebellar malignant posterior reversible encephalopathy syndrome (PRES) is rare. We report a case of delayed malignant cerebellar PRES triggered by cladribine, cytarabine, granulocyte colony-stimulating factor, mitoxantrone (CLAG-M) and venetoclax regimen. <h3>Design/Methods:</h3> A 73-year-old male presented with history of relapse after allogeneic stem cell transplantation for refractory myelodysplastic syndrome on maintenance tacrolimus. He was admitted for salvage therapy with (CLAG-M) + venetoclax regimen. Day 16^th post salvage therapy he developed acute onset altered mental status and headache followed by fever and hypotension. Brain MRI revealed posterior bilateral cerebellar, vermian edema with tiny petechial hemorrhages, ventriculomegaly, transependymal edema and mass effect on fourth ventricular effacement. Despite external ventricular drain placement, hyperosmolar therapy and steroids, day 19^th the patient suffered devastating neurological injury and family opted for hospice care. Of note, maintenance tacrolimus was held prior to admission and was started 4 days prior to onset of neurological symptoms with sub-therapeutic levels. <h3>Results:</h3> NA <h3>Conclusions:</h3> The potential role of (CLAG-M) and venetoclax regimen in the pathogenesis of PRES needs to be considered. Cerebellar PRES is rare and can be complicated by early hydrocephalus and 4^th ventricle compression. Although PRES is usually benign, prompt recognition of indicators of the malignant phenotype and aggressive management is crucial. <b>Disclosure:</b> Dr. Snehal has nothing to disclose. Dr. Mathew has nothing to disclose.

A Modern Artillery to put off the Electric Storm of the Brain–A case report of aborting seizure with brivaracetam 2-minute intravenous bolus in a patient with a compromised airway. (P8-7.004)

<h3>Objective:</h3> A case report of successful seizure treatment using bolus administration of intravenous brivaracetam over 2 minutes in a patient with compromised airway. <h3>Background:</h3> As time is brain, it is paramount to rapidly treat seizures and status epilepticus to avoid permanent neuronal injuries. Benzodiazepines are the recommended first-line antiepileptic medications, but with initial and repetitive dosing, airway compromise can occur even before seizure resolution. Alternative fast-acting antiepileptics that can minimize this effect could lead to better outcomes and decreased ICU stays. <h3>Design/Methods:</h3> N/A <h3>Results:</h3> Our patient is a 47-year-old male with a history of developmental delay and chronic ventriculomegaly was successfully extubated after external ventricular drain weaning. While his mentation improved, he had ongoing difficulties clearing secretions requiring a heated high-flow nasal cannula and repeated nebulizer treatments. The following day, the patient acutely had a seizure, manifesting as obtundation, whole body rigidity, and left lateral forced gaze deviation. Given ongoing respiration issues, lorazepam was held, and he was given a 2-minute bolus of intravenous brivaracetam 100mg instead. Post administration, patient’s mentation improved with the resolution of the gaze deviation. Continuous video electroencephalogram did not show any electrographic seizures. Patient was continued on brivaracetam 100 mg twice daily. <h3>Conclusions:</h3> Brivaracetam with high lipophilicity of 1.04 and T-max of less than 5 minutes can be given intravenously as a rapid 2-minute bolus. While there are no high-quality studies substantiating the efficacy of brivaracetam as a first-line medication, its pharmacokinetic/pharmacodynamic properties could make it a reasonable alternative to benzodiazepines as the first-line anti seizures medication, especially in pre-existing tenuous airways to avoid further compromise and reduce ICU and hospital length of stay. The benefits of its fast onset of action and efficacy may mitigate the major barriers of ready accessibility and cost. <b>Disclosure:</b> Dr. Tang has nothing to disclose. Prathyankara Premkumar has nothing to disclose.

Pulmonary Hypertension and Patent Foramen Ovale: A Rare Risk Factor for Stroke (P12-5.022)

<h3>Objective:</h3> To illustrate the importance of a comprehensive and individualized stroke evaluation in young patients with pulmonary hypertension presenting with ischemic stroke. <h3>Background:</h3> Approximately 45% of strokes in the United States are cryptogenic. A common etiology of cryptogenic stroke is a paradoxical embolism through a patent foramen ovale (PFO). Additionally, pulmonary artery hypertension (PAH) is independently associated with 1.5 times higher odds of stroke. It is unclear the compounded risk of stroke in patients with both a PFO and PAH. <h3>Design/Methods:</h3> Case Report and Literature Review. <h3>Results:</h3> A 35-year-old woman with history of PAH presented with vertigo, nausea and headache. Her neurological assessment revealed left-sided dysmetria and truncal ataxia. Brain MRI demonstrated a large left superior cerebellar non-hemorrhagic infarct with partial effacement of the fourth ventricle. She was not a candidate for reperfusion therapy. She required external ventricular drainage. Transthoracic echocardiogram (TTE) showed a dilated right ventricle with reduced systolic function but was otherwise unrevealing. Bilateral lower extremity duplex ultrasound showed no evidence of deep vein thrombosis. The patient was seen in our outpatient multidisciplinary cryptogenic stroke clinic, where repeat TTE with agitated saline injection showed evidence of a PFO. Due to severe pulmonary hypertension, PFO closure was contraindicated, due to potential for worsening right heart function. The patient was started on apixaban for secondary stroke prevention without recurrence of embolic events. <h3>Conclusions:</h3> This unique case report highlights the importance of PFO screening in patients with PAH. Patients with PAH have an increased incidence of stroke, the mechanisms of which are not well understood. In this case, PFO was identified in a patient with severe PAH in our outpatient clinic. Right-to-left shunting in this setting may increase risk of paradoxical embolism. A multidisciplinary approach to cryptogenic stroke patients may facilitate identification of rare mechanisms of stroke as well as improve and personalize secondary stroke prevention. <b>Disclosure:</b> Mr. Arkin has nothing to disclose. Dr. Then has nothing to disclose. An immediate family member of Dr. Ragupathi has received personal compensation for serving as an employee of Merck.

Effect of Early External Ventricular Drainage on Perihemorrhagic Edema and Functional Outcome in Patients with Intraventricular Hemorrhage

External ventricular drainage (EVD) is the most common neurosurgical procedure that allows drainage of cerebrospinal fluid and intraventricular blood. A specific time threshold for insertion of an EVD catheter in patients with spontaneous intracerebral hemorrhage and intraventricular hemorrhage has not been established. This study aimed to evaluate the association ofearly EVD with functional outcome in patients with intracerebral hemorrhage and intraventricular hemorrhage. Propensity score matching was used to account for baseline imbalances. Modified Rankin Scale score at 3 and 6 months, mortality rates at 3 and 6 months, postoperative complications, time course of edema evolution, and peak perihemorrhagic edema (PHE) were compared in patients who received early EVD versus routine EVD. The rate of favorable outcome at 3 months was higher in the early EVD group compared with the routine EVD group. There were no differences between groups in modified Rankin Scale score at 6 months or mortality rates at 3 and 6 months. Absolute peak PHE and relative PHE volumes were significantly less in the early EVD group compared with the routine EVD group. The incidence of postoperative infections was lower in the early EVD group compared with the routine EVD group. Early EVD was associated with improved functional outcome at 3 months, reduced PHE, and lower rate of infection in intracerebral hemorrhage and intraventricular hemorrhage. However, survival at 3 and 6 months and functional outcome at 6 months were not improved.

Safety and efficacy of peripheral nerve blocks to treat refractory headaches after aneurysmal subarachnoid hemorrhage - A pilot observational study.

Headache after aneurysmal subarachnoid hemorrhage (HASH) is common, severe, and often refractory to conventional treatments. Current treatment standards include medications including opioids, until the pain is mitigated. Peripheral nerve blocks (PNBs) may be an effective therapeutic option for HASH. We conducted a small before-and-after study of PNBs to determine safety, feasibility, and efficacy in treatment of HASH. We conducted a pilot before-and-after observational study and collected data for 5 patients in a retrospective control group and 5 patients in a prospective intervention PNB group over a 12-month period. All patients received a standard treatment of medications including acetaminophen, magnesium, gabapentin, dexamethasone and anti-spasmodics or anti-emetics as needed. Patients in the intervention group received bilateral greater occipital, lesser occipital, and supraorbital PNBs in addition to medications. The primary outcome was pain severity, measured by Numeric pain rating scale (NPRS). All patients were followed for 1 week following enrollment. The mean ages in the PNB group and control group were 58.6 and 57.4, respectively. One patient in the control group developed radiographic vasospasm. Three patients in both groups had radiographic hydrocephalus and IVH, requiring external ventricular drain (EVD) placement. The PNB group had an average reduction in mean raw pain score of 2.76 (4.68, 1.92 p = 0.024), and relative pain score by 0.26 (0.48, 0.22 p = 0.026), compared to the control group. The reduction occurred immediately after PNB administration. PNB can be a safe, feasible and effective treatment modality for HASH. Further investigations with a larger sample size are warranted.

Feasibility of Prompt Lumbar Drainage in Patients with Aneurysmal Subarachnoid Hemorrhage

Numerous studies have shown that continuous lumbar drainage (LD) reduces spontaneous subarachnoid hemorrhage (SAH)-related complications, decreasing the incidence of cerebral vasospasm, delayed cerebral ischemia , and hydrocephalus in patients treated with coiling or clipping, but performing LD before securing the aneurysm is still controversial. Our hospital has been implementing prompt LD for several years, and we present the results in this paper. Between January 2014 and December 2020, a total of 438 patients with SAH were included in this retrospective study. The indication for prompt LD was aneurysmal SAH of modified Fisher grade III or higher without dense intraventricular hemorrhage with obstructive hydrocephalus requiring extraventricular drainage or large intracranial hemorrhage requiring immediate decompression. Prompt LD was performed for 229 patients with SAH, and the control group included 209 patients. We compared in-hospital mortality and vasospasm or hydrocephalus occurrence and procedure-related complications between the two groups. The in-hospital mortality rate was 7.4% for patients with prompt LD and 14.4% for patients without LD, and the difference was significant (P= 0.019). Vasospasm occurred in 10% of patients with prompt LD and 16.7% of controls (P= 0.039). Hydrocephalus requiring extraventricular drainage occurred in 10.9% of the LD group and 28.7% of the control group (P < 0.001). Rebleeding occurrence was 3.1% in the prompt LD group and 5.7% in the non-LD group (P= 0.168). Cerebrospinal fluid infection occurred in 0.4% of the prompt LD group and 1.4% of controls(P= 0.272). Prompt LD is a feasible option for treating patients with selective aneurysmal SAH.

Prediction of delayed cerebral ischemia after cerebral aneurysm rupture using explainable machine learning approach.

Aneurysmal subarachnoid hemorrhage results in significant mortality and disability, which is worsened by the development of delayed cerebral ischemia. Tests to identify patients with delayed cerebral ischemia prospectively are of high interest. We created a machine learning system based on clinical variables to predict delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage patients. We also determined which variables have the most impact on delayed cerebral ischemia prediction using SHapley Additive exPlanations method. 500 aneurysmal subarachnoid hemorrhage patients were identified and 369 met inclusion criteria: 70 patients developed delayed cerebral ischemia (delayed cerebral ischemia+) and 299 did not (delayed cerebral ischemia-). The algorithm was trained based upon age, sex, hypertension (HTN), diabetes, hyperlipidemia, congestive heart failure, coronary artery disease, smoking history, family history of aneurysm, Fisher Grade, Hunt and Hess score, and external ventricular drain placement. Random Forest was selected for this project, and prediction outcome of the algorithm was delayed cerebral ischemia+. SHapley Additive exPlanations was used to visualize each feature's contribution to the model prediction. The Random Forest machine learning algorithm predicted delayed cerebral ischemia: accuracy 80.65% (95% CI: 72.62-88.68), area under the curve 0.780 (95% CI: 0.696-0.864), sensitivity 12.5% (95% CI: -3.7 to 28.7), specificity 94.81% (95% CI: 89.85-99.77), PPV 33.3% (95% CI: -4.39 to 71.05), and NPV 84.1% (95% CI: 76.38-91.82). SHapley Additive exPlanations value demonstrated Age, external ventricular drain placement, Fisher Grade, and Hunt and Hess score, and HTN had the highest predictive values for delayed cerebral ischemia. Lower age, absence of hypertension, higher Hunt and Hess score, higher Fisher Grade, and external ventricular drain placement increased risk of delayed cerebral ischemia. Machine learning models based upon clinical variables predict delayed cerebral ischemia with high specificity and good accuracy.

Does preventive external ventricular drainage benefit patients with mild ventricular hemorrhage?

External ventricular drainage (EVD) is the routine intraventricular hemorrhage (IVH) treatment. Neurological deterioration and symptomatic hydrocephalus are often the default indications for EVD insertion. However, the outcome of preventive EVD is unclear in patients with mild IVH. This study aimed to determine whether EVD is beneficial in patients with mild IVH. This study aimed to determine whether EVD is beneficial in patients with mild IVH. Data from IVH patients treated conservatively or with EVD at two hospitals from January 2017 to December 2022 were analyzed retrospectively. Patients with a Glasgow Coma Scale (GCS) score of 12-14 and a modified Graeb score (mGS) ≥ 5 at admission were included. The primary outcome was poor functional status, defined as a modified Rankin Scale (mRS) score of 3-6 at 90days. Secondary outcomes included the distribution of mRS score categories, the resolution time of intraventricular blood clots, and complications. Forty-nine patients were enrolled in the study: 21 patients in the EVD group, 28 in the non-EVD group, and 13 in the EVD group who received urokinase injections. ICH volume was an independent predictor of poor functional status. Currently, no evidence supports that preventive EVD benefits patients with mild IVH.

A pilot study for evaluating the feasibility of using alpha-defensin to support the diagnosis of ventriculitis

ObjectivesNosocomial ventriculitis is a difficult infectious condition to diagnose given that typical cerebral spinal fluid (CSF) parameters, commonly used in the diagnosis of meningitis, lack sensitivity and specificity in nosocomial ventriculitis. Consequently, novel diagnostics are needed to aid in diagnosing this condition. Herein a pilot study using alpha-defensins (α-defensins) to diagnose ventriculitis is discussed. MethodsFrom May 01, 2022, to December 30, 2022, ten patients with culture-proven external ventricular drain (EVD)-associated ventriculitis and ten patients without EVD-associated ventriculitis had CSF preserved. Levels of α-defensins were compared between the two cohorts with enzyme-linked immunosorbent assay. ResultsThere was a statistically significant (P ˂0.0001) higher level of CSF α-defensins in the ventriculitis cohort compared to the non-ventriculitis cohort. The levels of α-defensins were not affected by blood in CSF or bacterial virulence. Patients with other infectious conditions had increased levels of α-defensins but these levels were still statistically significantly (P ˂0.001) less than those seen in the ventriculitis cohort. ConclusionThis pilot study shows that α-defensins have promise as a biomarker to aid in the diagnosis of ventriculitis. If larger studies support the findings here, this biomarker can help improve diagnostic accuracy and decrease unwarranted empirical broad-spectrum antibiotic use in suspected EVD-associated ventriculitis.

Obstructive Hydrocephalus Due to Posterior Fossa Tumors in Adults: A Comparative Analysis of 3 Surgical Techniques

The main treatments for hydrocephalus due to posterior fossa tumors are tumor resection with or without an external ventricular drain, ventriculoperitoneal shunt (VPS), and endoscopic third ventriculostomy. Although preoperative cerebrospinal fluid diversion by any of these techniques improves clinical outcomes, evidence comparing the efficacy of these techniques is scarce. Therefore, we aimed to retrospectively evaluate each treatment modality. This single-center study analyzed 55 patients. Treatments were classified as successful (hydrocephalus resolution with a single surgical event) or failed and compared with a χ2 test. Kaplan-Meier curves and log-rank tests were employed. A Cox proportional hazard model was used to determine relevant covariates predicting outcomes. Mean patient age was 36.3 years, 43.4% of patients were men, and 50.9% of patients presented with uncompensated intracranial hypertension. Mean tumor volume was 33.4 cm3, and extent of resection was 90.85%. Tumor resection with or without an external ventricular drain was successful in 58.82% of cases, VPS was successful in 100%, and endoscopic third ventriculostomy was successful in 76.19% (P= 0.014). Mean follow-up time was 15.12 months. Log-rank test found statistically significant differences between survival curves of treatments (P= 0.016) favoring the VPS group. Postoperative surgical site hematoma was a significant covariate in the Cox model (hazard ratio= 17; 95% confidence ratio, 2.301-81.872; P= 0.004). This study favored VPS as the most reliable treatment of hydrocephalus due to posterior fossa tumors in adult patient; however, several factors influence clinical outcomes. We proposed an algorithm based on our findings and other authors' findings to facilitate the decision-making process.