Ventricular Drainage Research Articles

Successful Treatment of MDRAcinetobacter baumannii Meningitis in a Young Adult Patient With Intraventricular and Intravenous Polymyxin B-Tigecycline Based Combinations: A Case Report.

Multiple drug resistance to Acinetobacter baumannii infection treatment is a great challenge for neuro-intensivists due to poor drug penetration through the blood-brain barrier (BBB). Fortunately, the intraventricular administration of polymyxin-B and tigecycline seems to be effective; there are few case reports demonstrating the effectiveness of such treatments. Here, we report the case of a 24-year-old male who presented with fever and neck rigidity after intracranial drainage following lung infection caused by MDR Acinetobacter baumannii. Due to the presence of turbid CSF, the administration of the intrathecal (ITH) route polymyxin-B and tigecycline is not possible. In this situation, the neuro-intensivist decided to start intraventricular tigecycline and polymyxin-B administration along with IV tigecycline and polymyxin-B via the intraventricular route, which was feasible because the patient had an external ventricular drain (EVD) due to obstructive hydrocephalus caused by the neurosurgeon after excision of the tumor.

The Value of Machine Learning Models in Predicting Factors Associated with the Need for Permanent Shunting in Patients with Intracerebral Hemorrhage Requiring Emergency Cerebrospinal Fluid Diversion

ObjectiveTo assess the efficacy of machine learning models (MLMs) in identifying factors associated with the need for permanent ventricular shunt placement in patients experiencing intracerebral hemorrhage (ICH) who require emergency cerebrospinal fluid (CSF) diversion. MethodsA retrospective review was performed on patients with ICH requiring urgent CSF diversion who were admitted to our facility between July 2009 and May 2023. A binary logistic regression analysis was carried out to determine independent predictors linked to the development of shunt-dependent hydrocephalus following ICH. Five different machine learning models—random forest (RF), support vector machine (SVM), k-nearest neighbor (k-NN), logistic regression (LR), and Adaptive Boosting (AdaBoost)—were utilized to predict the need for permanent shunting in those with spontaneous ICH necessitating emergency CSF diversion. Additionally, RF techniques were applied to identify the factors affecting the need for permanent ventricular shunt placement in these patients. ResultsA total of 578 patients were included in the analysis. Shunt-dependent hydrocephalus occurred in 121 individuals (20.9%). In the multivariate analysis, the Graeb Score, the length of time the external ventricular drain (EVD) was in place, and an elevated intracranial pressure (ICP) greater than 30 mm Hg were significant predictors for the need for permanent CSF diversion (p<0.05). All predictive models showed commendable performance, with RF achieving the highest accuracy (0.921), followed by SVM (0.906), k-NN (0.889), LR (0.881), and AdaBoost (0.823). RF also excelled over the other models in terms of sensitivity and specificity, with a sensitivity of 0.912 and specificity of 0.892. The area under the curve (AUC) values for RF, SVM, k-NN, LR, and AdaBoost were recorded at 0.903, 0.820, 0.804, 0.801, and 0.798, respectively. ConclusionThis research demonstrates that machine learning models can effectively predict the need for permanent CSF diversion in patients with ICH who underwent EVD placement for urgent CSF diversion, offering important prognostic insights that could facilitate early intervention and lead to potential cost reductions.

Abstract 110: Impact of Neuroimaging Markers on Clinical Outcomes in Cerebral Amyloid Angiopathy‐Related Intracerebral Hemorrhage

Introduction/Purpose The recent update (version 2.0) to the Boston criteria for cerebral amyloid angiopathy (CAA) adds two additional neuroimaging markers to increase the sensitivity of CAA detection: multispot white matter hyperintensity (WMH) pattern and severe centrum semiovale enlarged perivascular spaces (CSO EPVS). While the presence of these novel non‐hemorrhagic markers, together with well‐established hemorrhagic markers such as lobar cerebral microbleeds (CMBs) and cortical superficial siderosis (cSS), increases the likelihood of underlying CAA in patients with intracerebral hemorrhage (ICH), it is unclear whether these markers have a prognostic impact on clinical outcomes. Materials/Methods Brain MRIs from a prospective database of consecutive non‐traumatic ICH patients admitted to a tertiary care center were reviewed for the presence of CMBs, cSS, multispot WMH pattern, and CSO EPVS. Patients who met the diagnostic criteria for CAA were selected for inclusion in this study. Clinical and neuroimaging predictors of an unfavorable discharge outcome (modified Rankin score ≥ 4) were assessed in univariate and multivariable models. Results Between 2003 and 2019, 1,791 patients were admitted with non‐traumatic ICH. Of the 1,297 (72%) patients who received a brain MRI, 645 (36%) were found to have CAA (mean age 74±11 years, 49% female). An unfavorable outcome was observed in 75% of patients. Lobar CMBs occurred in 326 (51%) patients, cSS occurred in 197 (31%), multispot WMH pattern occurred in 123 (19%), and severe CSO EPVS occurred in 156 (24%). In univariate analyses, age, hypertension, diabetes, ischemic stroke history, dementia, admission Glasgow Coma Scale (GCS) scores, intubation, external ventricular drain placement, hematoma evacuation, intraventricular extension, and cSS were associated with an unfavorable discharge outcome (all p &lt; 0.05). When entered into a multivariable model subjected to backward elimination, age (aOR 1.05, 95% CI 1.03‐1.08), hypertension (aOR 1.66, 95% CI 1.06‐2.62), dementia (aOR 8.40, 95% CI 1.97‐35.81), GCS score (aOR 0.85, 95% CI 0.75‐0.96), intubation (aOR 2.59, 95% CI 1.09‐6.15), intraventricular extension (aOR 1.75, 95% CI 1.67‐4.84), and cSS (aOR 1.75, 95% CI 1.07‐2.88) remained significantly associated with an unfavorable discharge outcome. Conclusion Although non‐hemorrhagic imaging markers are common in CAA patients with ICH, only the presence of cSS is significantly associated with unfavorable clinical outcomes.

Abstract 323: Lyme Neuroborreliosis Presenting with CNS Vasculitis, Subarachnoid Hemorrhage, and Rupture of a PICA Aneurysm: A Case Report

Background Lyme disease, caused by Borrelia burgdorferi, is a tick‐borne illness that commonly manifests as lymphocytic meningitis, cranial neuritis, and radiculoneuritis. Central nervous system (CNS) vasculitis is an exceedingly rare complication of Lyme neuroborreliosis (LNB), often presenting with stroke or transient ischemic attack, and less frequently with cerebral venous sinus thrombosis, intracerebral hemorrhage, or aneurysm. To date, the literature includes only one report of LNB‐associated CNS vasculitis presenting with subarachnoid hemorrhage (SAH) and rupture of a basilar aneurysm. Objective: We report an exceptionally rare case of LNB‐associated CNS vasculitis manifesting as SAH and a dysplastic posterior inferior cerebellar artery (PICA) aneurysm. Methods A 67‐year‐old male with a history of seizure disorder, migraine, and hypertension presented with the worst headache of his life. He subsequently experienced neurological decline, requiring intubation for airway protection. CT imaging revealed diffuse intraventricular hemorrhage with hydrocephalus involving the 3rd and 4th ventricles, along with SAH in the bilateral sylvian and interhemispheric fissures. The patient's Hunt and Hess grade was 4, and the Modified Fisher score was 4. An emergent external ventricular drain (EVD) was placed. A diagnostic cerebral angiogram (DSA) showed a severely dysplastic PICA with multiple areas of ectasia and a 3.5 times 1.5 mm saccular aneurysm, which was successfully treated with endovascular coiling. The hospital course was complicated by aspiration pneumonia and a urinary tract infection, managed with ceftriaxone. The patient also experienced recurrent high‐grade fevers, suspected to be of central origin, although cerebrospinal fluid (CSF) analysis was negative for infection. One month into hospitalization, neurological examination revealed bilateral ataxia, gait instability, and mild dysphasia. Follow‐up CTA demonstrated no residual flow in the left PICA aneurysm, and CT imaging showed resolution of the SAH. During rehabilitation, the patient's ataxia and gait instability worsened, and he developed horizontal nystagmus and diplopia. Additionally, a patchy red rash developed, which responded to dupilumab. A repeat DSA at 6 months revealed bilateral posterior cerebral artery (PCA) beading and stenosis with ectatic segments and reduced flow, consistent with PCA vasculitis. Further investigation disclosed a history of Lyme disease 8 years prior, characterized by fever, headache, and chills, and treated with doxycycline. Repeat CSF analysis showed a protein level of 74 mg/dL, a CSF Lyme index of 1.4, and the presence of 4 IgG bands. Initial CSF negativity was attributed to the partial course of ceftriaxone administered in hospital. The patient was ultimately diagnosed with LNB and treated with a 28‐day course of 2 g ceftriaxone. Infectious and rheumatologic workups were otherwise negative. Conclusion In cases of non‐traumatic SAH associated with CNS vasculitis or aneurysm, where infection and other secondary causes are considered, Lyme neuroborreliosis should also be evaluated as a potential underlying condition, especially in patients with a clinical history suggestive of prior Lyme disease.

Neurosurgery in Australia's Top End: the lifesaving advantages of developing sustainable neurosurgical care in rural and remote regions.

The authors' goal was to perform a retrospective audit of all emergency cranial neurosurgery performed at the Royal Darwin Hospital in the first 5 years of the unit and to compile their data in a similar fashion to an earlier study titled "Emergency Neurosurgery in Darwin: Still the Generalist Surgeons' Responsibility," which was published in 2015. All emergency cranial neurosurgery performed by a neurosurgeon between 2017 and 2021 was identified. Data were extracted from the National Critical Care and Trauma Response Centre database. Statistical analyses were descriptive logistic regression performed using Stata version 15.1 software to examine factors associated with death. A total of 320 patients (42% Indigenous) underwent 427 emergency neurosurgeries. There were 35 emergency neurosurgeries in 2017 and 82 in 2021. The most common procedure performed was insertion of an external ventricular drain, followed by craniotomy and removal of intracranial hematoma. Mortality was 7.5% overall and 8.4% among patients with trauma. Only age proved to be a statistically significant independent risk factor for death (t = -2.95, p < 0.0041; OR 1.06, p = 0.02). Location, sex, injury severity, and presenting Glasgow Coma Scale score were not associated with death. Indigenous and non-Indigenous patients had similar outcomes. The data illustrate the importance of developing small but sustainable neurosurgical units in rural and remote areas. A dedicated neurosurgical unit at the Royal Darwin Hospital has led to an increase in the amount and variety of emergency neurosurgery performed in Darwin. Interstate transfers have reduced. This has tangible lifesaving and economic advantages.

Hair-sparing approach versus traditional hair clipping for cerebral spinal fluid shunt procedures: a retrospective comparative study.

Cerebral spinal fluid (CSF) diversion methods, including ventriculoperitoneal (VP) shunts, are the standard treatment for hydrocephalus. Hair clipping (HC) has been a routine neurosurgical practice of the great majority of neurosurgeons, due to the perception that this will either decrease the risk of shunt infection or allow for a faster, unimpeded opening and closing of the skin. The benefits of not cutting or clipping hair in terms of normalizing appearance and self-esteem are obvious. The purpose of this study was to assess whether the rate of shunt infection would differ between pediatric patients receiving operation via the hair-sparing (HS) approach versus HC. A retrospective single-institution study comparing HS versus HC was conducted on pediatric patients undergoing long-term CSF shunt procedures at the Montreal Children's Hospital between August 2014 and April 2021. The primary outcome measure was shunt infection at 90 days and at long-term follow-up. Inclusion criteria were having at least 18 months of follow-up after long-term CSF shunt procedures, including insertions or revisions of VP shunts, ventriculoatrial shunts, cystoperitoneal shunts, subdural-peritoneal shunts, ventriculosubgaleal shunts, and ventriculosubgaleal reservoirs. Excluded procedures were those involving external ventricular drains, externalized shunts, Omaya reservoirs, endoscopic third ventriculostomies, and lumbar shunts. There were 434 CSF shunt procedures performed in 226 unique patients; 155 (35.71%) procedures were done using the HS approach versus 279 (64.29%) procedures via HC. At 90 days postoperatively, the infection rate was 1.29% in the HS group and 2.87% in the HC group, with an absolute risk difference of 1.58% (95% CI -1.07% to 4.23%, p = 0.24). At long-term follow-up (mean follow-up: 752 days and 716 days for the HS and HC groups, respectively), the rate of shunt infection remained at 1.29% for the HS group (no new infections) but rose to 4.66% for the HC group, with an absolute risk difference of 3.37% (95% CI 0.33%-6.41%, p = 0.03). Performing CSF shunt procedures without cutting or clipping any hair has a very low risk of shunt infection, and certainly does not appear to increase the risk of infection (or malfunction) versus the hair removal approach. It is a safe alternative and should be considered due to its esthetic and psychological benefits regarding normalization of appearance and ease of resuming a normal life following shunt surgery.

Abstract 456: Utilizing Cangrelor, a potent antiplatelet medication, within the scope of External ventricular drainage devices

Abstract 456: Utilizing Cangrelor, a potent antiplatelet medication, within the scope of External ventricular drainage devices

Relationship between NLR (Neutrophil/Lymphocyte ratio) value and clinical outcome in patients with external ventricular drainage due to intraventricular hemorrhage.

Intraventricular hemorrhages (IVH) are common pathologies in neurosurgery practice and are associated with the worst clinical outcome among all intracranial hemorrhages. Blood in the ventricles is thought to worsen the clinical condition by triggering inflammatory processes. In recent years, NLR value is a frequently used inflammatory parameter, and there are many publications reporting that a high NLR value is an important marker in predicting the severity of inflammation. Our study aimed to evaluate the effect of NLR values at admission on the clinical outcome of patients undergoing EVD due to IVH in our clinic. In our study, age and gender data, admission Glasgow Coma Scale (GCS), NLR value at the time of admission and clinical status at discharge of 36 patients, who underwent EVD following IVH in our hospital neurosurgery clinic between 2019 and 2024, were examined. Of the 36 cases in our study, 16 were female and 20 were male. For all cases, the mean age was 61.88, and the mean GCS values at admission were calculated as 8.5. In the laboratory of our hospital, the normal NLR range was determined as 0.78-3.53, and the mean NLR values at admission were evaluated as 16.57. When the clinical outcomes of the cases were examined, it was seen that 30 cases ended with exitus after intensive care follow-up, and 6 cases were discharged with good clinical outcomes (GCS:15). The mean NLR value was calculated as 18.00 for the patients who ended with exitus and 8.12 for the patients discharged with good clinical outcomes. NLR, which has been used to determine the severity of inflammation in recent years, has been reported to be a marker that can predict clinical outcomes of many diseases. In our study, NLR was observed to be high at admission in all cases, but it was significantly higher in the cases ending with exitus than in the cases not ending with exitus. As a result, it is thought that NLR value is a parameter that can be used to predict the clinical course in IVH patients undergoing EVD.

Abstract 148: TCD Monitoring during Intrathecal Nicardipine Use in Aneurysmal Subarachnoid Hemorrhage Induced Vasospasm

Introduction/Purpose Subarachnoid hemorrhage secondary to a ruptured cerebral aneurysm can be a devastating disease process with high rates of morbidity and mortality. For those who survive the initial hemorrhage, secondary delayed cerebral ischemia is the highest cause of further neurologic injury. The current standard of care is regular transcranial doppler (TCD) monitoring to evaluate for cerebral vasospasm and common interventions include intraarterial pharmacologic vasodilation with verapamil or nicardipine and balloon or stent‐assisted angioplasty in refractory cases. Intraventricular nicardipine (IVN) can also be used as rescue therapy for patients with treatment‐refractory cerebral vasospasm, and has been shown to decrease the rates of escalation to more invasive rescue interventions such as angioplasty and decrease the incidence of delayed cerebral ischemia. Methods We present a case of aneurysmal subarachnoid hemorrhage induced vasospasm who had drastic improvement in TCD mean velocities and subsequent good clinical outcome after receiving courses of IVN without developing intraventricular infectious complications. Results A 53‐year‐old female presented with “worst headache of her life.” CT Brain showed basal cistern subarachnoid hemorrhage with interventricular hemorrhage in the 4 th ventricle. Emergent diagnostic cerebral angiogram (DCA) showed a right posterior communicating artery aneurysm (6.68 mm x 2.52 mm x 2.80 mm) with a neck of 2.25 mm and patient underwent successful trans‐arterial coil embolization with small residual neck (Raymond Roy class II). Patient was admitted to neurosurgical intensive care unit for continued management and initially placed on oral nimodipine but did not remain on this therapy due to hypotension and vasopressor requirement. Initial MRI brain showed scattered embolic and watershed infarcts with MRA brain showing concern for severe vasospasm involving the middle segment arteries of the bilateral anterior circulation. TCD monitoring showed concern for progressive worsening velocities more so in posterior circulation, and follow‐up DCA showed multifocal stenosis consistent with vasospasm. Following intraarterial verapamil infusion, there was mild improvement in the non‐flow limiting moderate stenosis within the right middle cerebral, left anterior cerebral, and basilar arteries. Given patient inability to remain on oral nimodipine for systemic blood pressure goals, intraventricular nicardipine 4mg q8h was started for approximately a 3‐day course. Repeat TCD mean velocities after just two doses of IVN showed drastic reduction and improvement. Two days later, a repeat DCA was negative for vasospasm. Approximately two days after IVN treatment was stopped, patient once more had TCD velocities with multifocal definite vasospasm, and a repeat 3‐day course of IVN was initiated with complete resolution of vasospasm. The patient was unable to tolerate external ventricular drainage clamp trials and ventriculo‐peritoneal shunt was placed without complications. She was ultimately discharged to inpatient rehabilitation in good condition with some residual aphasia and weakness. Conclusion In cases of aneurysmal subarachnoid hemorrhage induced vasospasm, intraventricular nicardipine can be an effective potential treatment option that has been shown to reduce the incidence of delayed cerebral ischemia. IVN can be especially considered in patients with refractory vasospasm who cannot otherwise tolerate oral nimodipine or repeated endovascular therapies.

Single Institution Experience with Lumbar Drainage and Subarachnoid Hemorrhage

Abstract Introduction In our article, we evaluate the effect of lumbar drainage on delayed cerebral ischemia and requirements for permanent cerebrospinal fluid diversion in patients with aneurysmal subarachnoid hemorrhage. Methods We performed a retrospective cohort study from 2014 to 2023 at the University of Arkansas for Medical Sciences (UAMS) examining factors associated with patients (n = 150) who had aneurysmal subarachnoid hemorrhage and a lumbar drain placed. The main outcomes examined were incidence of delayed cerebral ischemia, need for permanent cerebrospinal fluid diversion, and neurologic outcomes at discharge that were compared to currently published standards. Results We failed to appreciate a reduced occurrence of delayed cerebral ischemia (37.3% with the current literature supporting rates of 20–30%); however, we did find a low rate of requiring permanent cerebrospinal fluid diversion (12% compared to 10–20% in the current literature) with overall good neurologic outcomes at discharge (∼69% of patients had a Glasgow Outcome Scale [GOS] of 4–5 at discharge). Patients with GOS ≥ 4 at discharge were noted to be more likely to have more days or lumbar drainage and less likely to be older than 65 years, have had an external ventricular drain placed, and have experienced delayed cerebral ischemia. Conclusion Lumbar drainage is a potentially useful adjunct in the management of secondary neurologic injury in subarachnoid hemorrhage.

Cerebrospinal fluid red blood cells and total protein are associated with clinical outcome in spontaneous subarachnoid hemorrhage.

Prognostication in patients with spontaneous subarachnoid hemorrhage (SAH) can be challenging. The aim of this study was to assess whether cerebrospinal fluid (CSF) red blood cell (RBC) count and total protein (TP) concentration are associated with SAH prognosis. Patients with SAH treated at the neurological intensive care unit (ICU) in Innsbruck were included in this real-world, observational study. Longitudinal CSF samples were collected as part of routine diagnostics. RBC count and CSF TP at the time of admission (RBCfirst, TPfirst), in Week 1 (RBCDays1-7, TPDays1-7), Week 2 (RBCDays8-14, TPDays8-14), and Week 3 or thereafter (RBCDay>14, TPDay>14), the highest detected value (RBChighest, TPhighest), as well as the RBC count adjusted for disease duration (RBCadjusted) were assessed. Primary outcomes were good functional outcome after 3 months, defined as modified Rankin scale score ≤2 and ICU survival. A total of 183 SAH patients with a female predominance (69%), a median (interquartile range [IQR]) age of 60 (50-70) years and median (IQR) Hunt and Hess score of 4 (3-5) were included. Multivariable analyses revealed that lower values of RBCfirst, RBCadjusted, RBChighest, TPfirst and TPhighest were associated with good functional outcome and hospital survival. Lower TP concentrations in Weeks 1, 2 and 3 were associated with good functional outcome, and in Weeks 1 and 2 with ICU survival. Early RBC measurements (Week 1) were associated with good functional outcome and ICU survival. Low CSF RBC counts and TP concentrations were associated with good functional outcome and ICU survival in a real-world cohort of SAH patients requiring external ventricular drainage.

Commentary: An Improvised External Ventricular Drain Fixation Technique to Avoid Pullout-Related Complications in a Low-Resource Setting: A Descriptive Cross-Sectional Study in a Single Center of Nepal.

Commentary: An Improvised External Ventricular Drain Fixation Technique to Avoid Pullout-Related Complications in a Low-Resource Setting: A Descriptive Cross-Sectional Study in a Single Center of Nepal.

Are variations in ventricular catheter placement related to design of the catheter? A single-center cohort study.

The use of intracranial catheters is a common procedure used for neurosurgical patients with a variety of pathologies. Despite its frequency of use, shunt failure and revision have been reported to be a common problem. Given that depth of insertion can significantly affect the catheter tip position, a single institution retrospective chart review was performed to examine the accuracy of shunt and external ventricular drain (EVD) placement. Computed tomography (CT) images of the head following shunt or ventriculostomy insertion were analyzed to determine the delta between the final length of the intracranial catheter and the intended depth described in the operative notes. We found that there was a statistically significant difference in the accuracy of placement when comparing EVDs to shunts. The most used EVDs at our institution are marked with a solid black line in increments spaced 2 cm apart. The most used ventricular shunt catheter has a marking at 5 cm and 10 cm from the tip of the catheter. We believe that the visual confirmation that is afforded by metric unit markings on the EVD allows for better final placement of the catheter at the outer table of the calvarium. The addition of regular millimeter metric unit markings by the manufacturer is imperative in decreasing the chances of error in the insertion of ventricular catheters and preventing potential neurovascular injury to the surrounding structures.

Non-invasive assessment of intracranial pressure through the eyes: current developments, limitations, and future directions.

Detecting and monitoring elevated intracranial pressure (ICP) is crucial in managing various neurologic and neuro-ophthalmic conditions, where early detection is essential to prevent complications such as seizures and stroke. Although traditional methods such as lumbar puncture, intraparenchymal and intraventricular cannulation, and external ventricular drainage are effective, they are invasive and carry risks of infection and brain hemorrhage. This has prompted the development of non-invasive techniques. Given that direct, non-invasive access to the brain is limited, a significant portion of research has focused on utilizing the eyes, which uniquely provide direct access to their internal structure and offer a cost-effective tool for non-invasive ICP assessment. This review explores the existing non-invasive ocular techniques for assessing chronically elevated ICP. Additionally, to provide a comprehensive perspective on the current landscape, invasive techniques are also examined. The discussion extends to the limitations inherent to each technique and the prospective pathways for future advancements in the field.

Unveiling Therapeutic Challenges: A Unique Case of Intracranial Myroides odoratimimus Infection Following Hemorrhagic Stroke.

Intracranial infections post-neurosurgical procedure pose substantial morbidity and mortality risks. Myroides odoratimimus, an opportunistic gram-negative pathogen, represents a real challenge because of limited clinical experience. This article details the second reported case of intracranial M. odoratimimus infection associated with external ventricular drains in an immunocompetent adult. Treatment involved a 21-day course of intravenous antibiotherapy using meropenem and vancomycin. This case underscores the complexity of managing rare complications, providing insights into therapeutic strategies for this challenging condition.

Neurosurgical Procedures in Patients Requiring Extracorporeal Membrane Oxygenation.

Extracorporeal membrane oxygenation (ECMO) is often withheld in patients with significant neurologic injury or recent neurosurgical intervention due to perceived futility. Studies of neurosurgical interventions before or during ECMO are limited to case reports or single-center series, limiting generalizability, and outcomes in this population are unknown. We therefore sought to report the outcomes of ECMO patients with acute neurosurgical interventions at four high-volume ECMO and comprehensive stroke centers. Retrospective case series. Four academic tertiary referral hospitals in the United States. Adults (n = 24) having undergone neurosurgical procedures before or during ECMO. None. We retrospectively reviewed adults at four institutions who had undergone neurosurgical procedures immediately before or during ECMO from 2015 to 2023. The primary outcome was survival to hospital discharge. Secondary outcomes included favorable neurologic outcome (Cerebral Performance Category 1 or 2) and neurosurgical complications. Twenty-four of 2957 ECMO patients (0.8%) were included. Primary indications for neurosurgical intervention included traumatic brain (n = 8) or spinal (n = 3) injury, spontaneous intracranial hemorrhage (n = 6), and acute ischemic stroke (n = 5). Procedures included extraventricular drain (EVD) and/or intracranial pressure monitor placement (n = 10), craniectomy/craniotomy (n = 5), endovascular thrombectomy (n = 4), and spinal surgery (n = 3). Fifteen patients (63%) survived to hospital discharge, of whom 12 (80%) were discharged with favorable neurologic outcomes. Survival to discharge was similar for venoarterial and venovenous ECMO patients (8/12 vs. 7/12; p = 0.67) and those who had neurosurgery before vs. during ECMO (8/13 vs. 7/11; p = 0.92). One patient (4%) experienced a neurosurgical complication, a nonlethal tract hemorrhage from EVD placement. Survival to discharge was similar for neurosurgical and nonneurosurgical ECMO patients at participating institutions (63% vs. 57%; p = 0.58). Patients with acute neurologic injury can feasibly undergo neurosurgery during ECMO or can undergo ECMO after recent neurosurgery. Larger studies are needed to fully understand risks for bleeding and other procedure-related complications.

Bleeding complications related to external ventricular drainage placement in patients with ruptured intracranial aneurysms: a single-center study.

Acute aneurysmal rupture can be treated with endovascular therapy or surgical clipping. For patients with concurrent acute hydrocephalus, the placement of an external ventricular drainage (EVD) is required. This study aims to investigate the impact of pre-treatment EVD placement on rebleeding in ruptured aneurysms and to examine the influence of dual antiplatelet therapy and the sequencing of dual antiplatelet therapy with EVD placement on EVD-related hematomas. We reviewed the clinical data of 83 patients with ruptured aneurysms who underwent EVD placement from a total of 606 aneurysm patients consecutively admitted between January 2018 and January 2023. The analysis focused on the impact of pre-treatment EVD placement on aneurysmal rebleeding and the effect of dual antiplatelet therapy and its sequencing with EVD placement on EVD-related hematomas. Among the 503 patients with ruptured aneurysms, 83 required EVD placement. EVD was placed before aneurysm treatment in 63 patients and after treatment in 20 patients. The number of aneurysmal rebleeding cases in the pre-treatment EVD group and non-EVD group was 1 (1.6%) and 20 (4.8%), respectively (p = 0.406). 31 patients (37.3%) underwent stent-assisted embolization or flow diversion requiring dual antiplatelet therapy, while 52 patients (62.7%) underwent simple embolization or surgical clipping without antiplatelet therapy. EVD-related hematomas occurred in 14 patients (16.9%), with 10 cases (32.3%) in those receiving dual antiplatelet therapy and 4 cases (7.7%) in those not receiving antiplatelet therapy (p = 0.01). Among 16 patients who had EVD placed before dual antiplatelet therapy, 4 (25%) developed EVD-related hematomas. Of the 15 patients who had EVD placed after dual antiplatelet therapy, 6 (40%) developed EVD-related hematomas (p = 0.458). In patients with aneurysmal subarachnoid hemorrhage (aSAH) and acute hydrocephalus, the placement of EVD before aneurysm treatment does not increase the risk of rebleeding. However, dual antiplatelet therapy increases the risk of EVD-related hematoma, and the sequence of EVD placement relative to dual antiplatelet therapy does not appear to significantly affect the outcome of EVD-related hematoma.

Utility of cell index in the diagnosis of healthcare-associated ventriculitis and meningitis: an analytical cross-sectional study

BackgroundThe diagnosis of healthcare-associated ventriculitis and meningitis (HCAVM) can be complex because multiple factors confound the interpretation of cerebrospinal fluid (CSF) tests. The cell index (CI) may help in the diagnosis of HCAVM. It does not incur additional medical cost and it avoids delays from the turnaround time of CSF cultures. It is derived by calculating the ratio of CSF white blood cell (WBC) and red blood cell (RBC) divided by the ratio of peripheral WBC and RBC. This study aimed to evaluate the diagnostic utility of this parameter.MethodsAn analytic, observational, cross-sectional study was conducted at the University of the Philippines – Philippine General Hospital. All admitted pediatric and adult patients from 2015 to 2022 who underwent external ventricular drain (EVD) insertion for hydrocephalus secondary to intracranial hemorrhage (ICH), acute ischemic stroke, intracranial neoplasms, traumatic brain injury, or congenital hydrocephalus were screened. Records of patients fulfilling the inclusion criteria were then reviewed.ResultsA total of 363 patients underwent EVD insertion from 2015 to 2022. Of these, 161 were included in the study. Two-thirds (66.5%) were adults ≥ 19 years old whereas the remaining were pediatric patients 1 to < 19 years old. There were no patients < 12 months old as they fulfilled at least one exclusion criteria. Forty-nine of them were later confirmed to have HCAVM based on the CDC/NHSN criteria. A CI cut-off of ≥ 1.21 gave a maximum sensitivity of 30.6% and specificity of 86.4%. Receiver operating characteristic area under the curve (AUC-ROC) analysis was 0.585. Subgroup analysis by age showed sensitivity of 52.9% in the pediatric age group and 3.13% in adults. Subgroup analysis by neurologic indication showed sensitivity of 27.6% for ICH and 35.0% for neoplasms. Subsequent AUC-ROC analyses, however, showed that CI failed to adequately diagnose HCAVM in these subgroups.ConclusionsIn our population of neurologic patients who underwent EVD insertion, the cell index is not a reliable parameter in the diagnosis of HCAVM.

Intrathecal Nicardipine as Treatment for Severe Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage: A Retrospective Clinical Study.

Introduction Vasospasm and delayed cerebral ischemia (DCI) are complications of aneurysmal subarachnoid hemorrhage (aSAH) and contribute up to 23% of the disability and deaths from aSAH. The use of intrathecal nicardipine (ITN) as a possible treatment for DCI has been explored with mixed results. We present a retrospective series comparing standard post-aSAH care to standard care plus ITNtherapy. The primary objective of this study was to assess for any difference in functional outcome in terms of modified Rankin scale (mRS) scorebetween the standard therapy group and ITN group at discharge and one month after discharge. Methods The Institutional Review Board (IRB) approval was obtained for a retrospective chart review of patients with aSAH who were treated at the University of Mississippi Medical Center between January 2012 and June 2019. The inclusion criteria included sufficient available medical documentation, aSAH with documentation of an intracranial aneurysm, and age ≥ 18. The exclusion criteria included non-aSAH, patients with insufficient medical records, and mycotic aneurysms. The decision to treat with ITN was based on the individual practice of a single neuro-intensivist in collaboration with the neurosurgical staff. Results A total of 385 patients were included in the study with 31 patients receiving ITN. Those within the nicardipine group presented with significantly worse Hunt and Hess grades and experienced significantly worse cerebral vasospasm, higher transcranial Doppler (TCD) velocities, higher rates of DCI, and higher rates of hydrocephalus. When controlling for placement of an external ventricular drain, the patients in the ITN group experienced higher rates of ventriculitis (10.0% vs. 2.0%, p < 0.05). There was no significant difference between the two groups in the intensive care unit (ICU) stay, hospital stay, mRS at discharge, or mRS at one-month follow-up. Conclusion In our series, ITN therapy did not significantly alter outcomes in terms of mRS at discharge or at one month after discharge. However, there was a significant increase in ventriculitis among patients who received this therapy.

6791 Pituitary Apoplexy as Presentation of Atypical Teratoid/Rhabdoid Tumor

Abstract Disclosure: S.I. Babli: None. H. Alkubedan: None. N.M. Ali: None. R. Alqawahmed: None. M.M. Elhassan: None. Introduction: Pituitary apoplexy occurs in a pituitary adenoma; it migh occur in other less common types of tumors. The atypical teratoid/rhabdoid tumor (ATRT) is a very aggressive malignant tumor of the central nervous system and has a poor prognosis. It is rare to occur in adult and in the sellar region. Clinical Case: 32 years old male presented to ER with 4 days history of fever, headache and vomiting. He was conscious but confused. Vital signs Temperature 39 C, BP 120/80, HR 110 beats/min and Saturation of 95 %, Possibility of meningoencephalitis was raised, patient Brain CT showed Sellar and suprasellar mass with compression over the optic chiasma and invasion to the left cavernous sinus. Patient suddenly developed Generalize tonic-clonic convulsion and hypotension. He received IV midazolam, intubated and was started on noradrenaline and hydrocortisone, he was admitted to ICU as a case of meningoencephalitis and started on Ceftriaxone, Vancomycin and Acyclovir. Cerebrospinal fluid analysis showed RBC 175/cumm, WBC 20/cumm with 20% polymorph and 80% mononuclear cells, Protein 1.38 g/l (0.24-0.49) glucose 7.9 mmol/l with plasma glucose of 10 mmol/l. Repeated Brain CT showed Sellar and suprasellar mass with compression over the optic chiasma and invasion to the left cavernous sinus and with minimal heterogenicity and increased density suggestive of hemorrhagic components. Endocrine history revealed weight gain but no history to suggest acromegaly, Cushing’s syndrome or hypogonadism . Examinations: Patient was intubated and sedated BP 90/60 on Maximum inotropic support. Left oculomotor nerve palsy, Bilateral papilledema, he was having acanthosis nigricans with no signs of acromegaly, CS or hypogonadism. Laboratory finding: WBC17 with neutrophilia, Hgb 14.7 g/dl plt 360 Na 140 mmol/l, creatnin 180 mmol/, FT4 6.2 pmol/l, TSH 0.015, PROLACTINE 22, IGF1 29 ng/ml (41-246) Free testosterone index 2.13 (33-106), LH 0.5, FSH 0.3 .Patient had TTS and histopathology showed: SMARCB1 deficient malignant neoplasm, consistent with sellar atypical teratoid rhabdoid tumor. Post OP, patient had Ventilator associated pneumonia and recurrent attacks of seizures despite multiple antiepileptic medications. Patient was evaluated by medical and radiation oncologists but due to his general condition the treatment was postpone. One month after TSS, he developed intractable seizure new Brain CT showed interventricular haemorrhage with hydrocephalus and marked enlargement of hyperdense pituitary lesion which suggests haemorrhage. External ventricular drain was inserted but patient arrested and died. Conclusions: ATRT of the CNS usually affects young children. In the literature review performed in adults, only nine cases have occurred in the sellar or suprasellar region. Survival is variable in the different cases reported in the literature, with a mean of 26 months. Presentation: 6/2/2024