Point-of-Care Testing in Neurosurgery

AbstractCoagulation disorders can have a major impact on the outcome of neurosurgical patients. The central nervous system is located within the closed space of the skull, and therefore, intracranial hemorrhage can lead to intracranial hypertension. Acute brain injury has been associated with alterations of various hemostatic parameters. Point-of-care (POC) techniques such as rotational thromboelastometry are able to identify markers of coagulopathy which are not reflected by standard assessment of hemostasis (e.g., hyperfibrinolysis). In patients with acute brain injury, POC test results have been associated with important outcome parameters such as mortality and need for neurosurgical intervention. POC devices have also been used to rapidly identify and quantify the effects of antithrombotic medication. In cases of life-threatening intracranial hemorrhage, this information can be valuable when deciding over administration of prohemostatic substances or immediate neurosurgical intervention. In elective neurosurgical procedures, POC devices can provide important information when unexpected bleeding occurs or in cases of prolonged operative time with subsequent blood loss. Initial experiences with POC devices in neurosurgical care have shown promising results but further studies are needed to characterize their full potential and limitations.

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Splanchnic ischemia and gut permeability after acute brain injury secondary to intracranial hemorrhage

Neurocritical Care ◽

10.1007/s12028-007-0026-8 ◽

2007 ◽

Vol 7 (1) ◽

pp. 40-44 ◽

Cited By ~ 7

Author(s):

Glenn Hernández ◽

Pablo Hasbun ◽

Nicolas Velasco ◽

Carol Wainstein ◽

Guillermo Bugedo ◽

...

Keyword(s):

Brain Injury ◽

Intracranial Hemorrhage ◽

Acute Brain Injury ◽

Gut Permeability ◽

Splanchnic Ischemia

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External retrospective validation of Brain Injury Guidelines criteria and modified guidelines for improved care value in the management of patients with low-risk neurotrauma

Journal of Neurosurgery ◽

10.3171/2019.6.jns19584 ◽

2020 ◽

Vol 133 (6) ◽

pp. 1880-1885 ◽

Cited By ~ 1

Author(s):

Miner Ross ◽

Priscilla S. Pang ◽

Ahmed M. Raslan ◽

Nathan R. Selden ◽

Justin S. Cetas

Keyword(s):

Brain Injury ◽

Trauma Center ◽

Injury Severity ◽

Radiographic Progression ◽

Medical Intervention ◽

Neurosurgical Procedures ◽

Radiographic Findings ◽

Level 1 ◽

Level 1 Trauma Center ◽

Neurosurgical Intervention

OBJECTIVEConventional management of patients with neurotrauma frequently consists of routine, repeat head CT at preordained intervals with ICU-level monitoring, regardless of injury severity. The Brain Injury Guidelines (BIG) are a classification tool for stratifying patients into injury severity and risk-of-progression categories based on presenting clinical and radiographic findings. In the present study, the authors aimed to validate BIG criteria at a single level 1 trauma center.METHODSPatients were classified according to BIG criteria and evaluated for subsequent radiographic progression or development of neurological decline. A 2-year retrospective cohort review of consecutive patients with neurotrauma (n = 590) was undertaken. The authors then developed a modified BIG algorithm for use at their institution and followed its implementation prospectively over 555 consecutive patients.RESULTSIn the retrospective analysis, no patient in the BIG 1 category (n = 88, 14.9%) demonstrated progression or neurological decline, and 7.5% of BIG 2 patients (n = 107, 18.1%) demonstrated mild radiographic progression without any decline or need for additional neurosurgical or medical intervention, whereas 15.4% of BIG 3 patients (n = 395, 66.9%) underwent additional neurosurgical procedures. In the prospective analysis, no BIG 1 (n = 105, 18.9%) or BIG 2 (n = 48, 8.6%) patients demonstrated a clinical decline or required any further neurosurgical intervention. By contrast, 12.9% of BIG 3 patients (n = 402, 72%) required immediate neurosurgical intervention, and a further 2.0% required delayed intervention based on clinical and/or radiographic evidence of injury progression.CONCLUSIONSApplication of the BIG criteria in a single large level 1 trauma center reliably sorted patients into appropriate risk categories that accurately guided ongoing management.

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Point-of-care detection of lactate in cerebrospinal fluid

Intensive Care Medicine Experimental ◽

10.1186/s40635-021-00385-9 ◽

2021 ◽

Vol 9 (1) ◽

Author(s):

C. Stephani ◽

A. H. K. Choi ◽

O. Moerer

Keyword(s):

Central Nervous System ◽

Cerebrospinal Fluid ◽

Nervous System ◽

Point Of Care ◽

Blood Gas ◽

Csf Drainage ◽

Increased Risk ◽

Neurosurgical Patients ◽

Csf Lactate ◽

The Central Nervous System

Abstract Purpose Measurements of cerebrospinal fluid (CSF) lactate can aid in detecting infections of the central nervous system and surrounding structures. Neurosurgical patients with temporary lumbar or ventricular CSF drainage harbor an increased risk for developing infections of the central nervous system, which require immediate therapeutic responses. Since blood gas analyzers enable rapid blood-lactate measurements, we were interested in finding out if we can reliably measure CSF-lactate by this point-of-care technique. Methods Neurosurgical patients on our intensive care unit (ICU) with either lumbar or external ventricular drainage due to a variety of reasons were included in this prospective observational study. Standard of care included measurements of leucocyte counts, total protein and lactate measurements in CSF by the neurochemical laboratory of our University Medical Center twice a week. With respect to this study, we additionally performed nearly daily measurements of cerebrospinal fluid by blood gas analyzers to determine the reliability of CSF-lactate measured by blood gas analyzers as compared to the standard measurements with a certified device. Results 62 patients were included in this study. We performed 514 CSF-lactate measurements with blood gas analyzers and compared 180 of these to the in-house standard CSF-lactate measurements. Both techniques correlated highly significantly (Pearson correlation index 0.94) even though lacking full concordance in a Bland–Altman plotting. Of particular importance, regular measurements enabled immediate detection of central infection in three patients who had developed meningitis during the course of their treatment. Conclusion Blood gas analyzers measure CSF-lactate with sufficient reliability and can help in the timely detection of a developing meningitis. In addition to and triggering established CSF diagnostics, CSF-lactate measurements by blood gas analyzers may improve surveillance of patients with CSF drainage. This study was retrospectively registered on April 20th 2020 in the German trial register. The trial registration number is DRKS00021466.

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Epidemiology of Mild Traumatic Brain Injury with Intracranial Hemorrhage: Focusing Predictive Models for Neurosurgical Intervention

World Neurosurgery ◽

10.1016/j.wneu.2017.07.130 ◽

2017 ◽

Vol 107 ◽

pp. 94-102 ◽

Cited By ~ 6

Author(s):

Alessandro Orlando ◽

A. Stewart Levy ◽

Matthew M. Carrick ◽

Allen Tanner ◽

Charles W. Mains ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Mild Traumatic Brain Injury ◽

Intracranial Hemorrhage ◽

Predictive Models ◽

Neurosurgical Intervention

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Neuroimaging of Traumatic Brain Injury

Medical Sciences ◽

10.3390/medsci7010002 ◽

2018 ◽

Vol 7 (1) ◽

pp. 2

Author(s):

David B. Douglas ◽

Tae Ro ◽

Thomas Toffoli ◽

Bennet Krawchuk ◽

Jonathan Muldermans ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Diffusion Tensor ◽

Secondary Injury ◽

Life Threatening ◽

Severe Tbi ◽

Head Computed Tomography ◽

And Diffusion ◽

Neurosurgical Intervention ◽

Neuroimaging Techniques

The purpose of this article is to review conventional and advanced neuroimaging techniques performed in the setting of traumatic brain injury (TBI). The primary goal for the treatment of patients with suspected TBI is to prevent secondary injury. In the setting of a moderate to severe TBI, the most appropriate initial neuroimaging examination is a noncontrast head computed tomography (CT), which can reveal life-threatening injuries and direct emergent neurosurgical intervention. We will focus much of the article on advanced neuroimaging techniques including perfusion imaging and diffusion tensor imaging and discuss their potentials and challenges. We believe that advanced neuroimaging techniques may improve the accuracy of diagnosis of TBI and improve management of TBI.

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Point-of-care Detection of Lactate in Cerebrospinal Fluid

10.21203/rs.3.rs-237709/v1 ◽

2021 ◽

Author(s):

Caspar Stephani ◽

Alexis H.K. Choi ◽

Onnen Mörer

Keyword(s):

Central Nervous System ◽

Cerebrospinal Fluid ◽

Nervous System ◽

Point Of Care ◽

Blood Gas ◽

Csf Drainage ◽

Increased Risk ◽

Neurosurgical Patients ◽

Csf Lactate ◽

The Central Nervous System

Abstract Purpose: Measurements of cerebrospinal fluid (CSF)-lactate can aid in detecting infections of the central nervous system and surrounding structures. Neurosurgical patients with temporary lumbar or ventricular CSF-drainage harbor an increased risk for developing infections of the central nervous system which require immediate therapeutic responses. Since blood-gas-analyzers enable rapid blood-lactate-measurements we were interested to find out if CSF-lactate may be reliably measured by this point-of-care technique. Methods: Neurosurgical patients on our intensive care unit (ICU) with either lumbar or external ventricular drainage due to a variety of reasons were included in this prospective observational study. Standard of care included measurements of leucocyte counts, total protein and lactate measurements in CSF by the neurochemical laboratory of our University Medical Center twice a week. With respect to this study we additionally performed nearly daily measurements of cerebrospinal-fluid by blood gas analyzers to determine the reliability of CSF-lactate measured by blood-gas-analyzers as compared to the standard measurements with a certified device. Results: 62 patients were included in this study. 514 CSF measurements were performed with blood-gas-analyzers. 180 of these could be compared to the in-house standard CSF-lactate measurements. Both techniques correlated highly significant (Pearson correlation index 0.94) even though lacking full concordance in a Bland-Altman-plotting. Of particular importance, regular measurements enabled immediate detection of central infection in 3 patients who had developed meningitis during the course of their treatment.Conclusion: CSF-lactate was reliably measured by blood-gas-analyzers and detected developing meningitis timely. In addition to and triggering established CSF-diagnostics, CSF-lactate measurements by blood-gas-analyzers may improve surveillance of central nervous infections in patients with CSF-drainage. This study was retrospectively registered on April 20th 2020 in the German trial register. The trial registration number is: DRKS00021466.

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Prothrombin Complex Concentrate for Warfarin-Associated Intracranial Bleeding in Neurosurgical Patients: A Single-Center Experience

Medicina ◽

10.3390/medicina54020022 ◽

2018 ◽

Vol 54 (2) ◽

pp. 22 ◽

Cited By ~ 2

Author(s):

Jomantė Mačiukaitienė ◽

Diana Bilskienė ◽

Arimantas Tamašauskas ◽

Adomas Bunevičius

Keyword(s):

Prothrombin Complex Concentrate ◽

International Normalized Ratio ◽

Intracranial Bleeding ◽

Neurosurgical Procedures ◽

Single Center Experience ◽

Number Of Patients ◽

Neurosurgical Patients ◽

Gcs Score ◽

Emergent Surgery ◽

Neurosurgical Intervention

Objective: The number of patients presenting with warfarin-associated intracranial bleeding and needing neurosurgical intervention is growing. Prothrombin complex concentrate (PCC) is commonly used for anti-coagulation reversal before emergent surgery. We present our experience with PCC use in patients presenting with coagulopathy and needing urgent craniotomy. Methods: We retrospectively identified all patients presenting with intracranial bleeding and coagulopathy due to warfarin use, requiring urgent neurosurgical procedures, from January, 2014 (implementation of 4-PCC therapy) until December, 2016. For coagulation reversal, all patients received 4-PCC (Octaplex) and vitamin K. Results: Thirty-five consecutive patients (17 men; median age 72 years) were administered 4-PCC before emergent neurosurgical procedures. The majority of patients presented with traumatic subdural hematoma (62%) and spontaneous intracerebral hemorrhage (32%). All patients were taking warfarin. Median international normalized ratio (INR) on admission was 2.94 (range: 1.20 to 8.60). Median 4-PCC dose was 2000 I.U. (range: 500 I.U. to 3000 I.U.). There was a statically significant decrease in INR (p < 0.01), PT (p < 0.01), and PTT (p = 0.02) after 4-PCC administration. Postoperative INR values were ≤3.00 in all patients, and seven (20%) patients had normal INR values. There were no 4-PCC related complications. Four (11%) patients developed subdural/epidural hematoma and 20 (57%) patients died. Mortality was associated with lower Glasgow coma scale (GCS) score. Conclusions: The 4-PCC facilitates INR reversal and surgery in patients presenting with warfarin-associated coagulopathy and intracranial bleeding requiring urgent neurosurgical intervention.

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Isolated subdural hematomas in mild traumatic brain injury. Part 1: the association between radiographic characteristics and neurosurgical intervention

Journal of Neurosurgery ◽

10.3171/2018.1.jns171884 ◽

2019 ◽

Vol 130 (5) ◽

pp. 1616-1625 ◽

Cited By ~ 1

Author(s):

Alessandro Orlando ◽

A. Stewart Levy ◽

Benjamin A. Rubin ◽

Allen Tanner ◽

Matthew M. Carrick ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Scale Score ◽

Mild Traumatic Brain Injury ◽

Intervention Group ◽

Stepwise Logistic Regression ◽

Neurosurgical Procedures ◽

Acute Hemorrhage ◽

Subdural Hematomas ◽

Neurosurgical Intervention

OBJECTIVEIsolated subdural hematomas (iSDHs) are one of the most common intracranial hemorrhage (ICH) types in the population with mild traumatic brain injury (mTBI; Glasgow Coma Scale score 13–15), account for 66%–75% of all neurosurgical procedures, and have one of the highest neurosurgical intervention rates. The objective of this study was to examine how quantitative hemorrhage characteristics of iSDHs in patients with mTBI at admission are associated with subsequent neurosurgical intervention.METHODSThis was a 3.5-year, retrospective observational cohort study at a Level I trauma center. All adult trauma patients with mTBI and iSDHs were included in the study. Maximum length and thickness (in mm) of acute SDHs, the presence of acute-on-chronic SDH, mass effect, and other hemorrhage-related variables were double–data entered; discrepant results were adjudicated after a maximum of 4 reviews. Patients with coagulopathy, skull fractures, no acute hemorrhage, a non-SDH ICH, or who did not undergo imaging on admission were excluded. The primary outcome was neurosurgical intervention (craniotomy, burr hole, catheter drainage of SDH, placement of intracranial pressure monitor, shunt, or ventriculostomy). Multivariate stepwise logistic regression was used to identify significant covariates and to assess interactions.RESULTSA total of 176 patients were included in our study: 28 patients did and 148 patients did not receive a neurosurgical intervention. Increasing head Abbreviated Injury Scale score was significantly associated with neurosurgical interventions. There was a strong correlation between the first 3 reviews on maximum hemorrhage length (R2 = 0.82) and maximum hemorrhage thickness (R2 = 0.80). The neurosurgical intervention group had a mean maximum SDH length and thickness that were 61 mm longer and 13 mm thicker than those of the nonneurosurgical intervention group (p < 0.001 for both). After adjusting for the presence of an acute-on-chronic hemorrhage, for every 1-mm increase in the thickness of an iSDH, the odds of a neurosurgical intervention increase by 32% (95% CI 1.16–1.50). There were no interventions for any SDH with a maximum thickness ≤ 5 mm on initial presenting scan.CONCLUSIONSThis is the first study to quantify the odds of a neurosurgical intervention based on hemorrhage characteristics in patients with an iSDH and mTBI. Once validated in a second population, these data can be used to better inform patients and families of the risk of future neurosurgical intervention, and to evaluate the necessity of interhospital transfers.

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Prevalence of Hyponatremia in Neurosurgical Patients in South India – An Institution-Based Observational Study

Journal of Evidence Based Medicine and Healthcare ◽

10.18410/jebmh/2021/585 ◽

2021 ◽

Vol 8 (34) ◽

pp. 3217-3223

Author(s):

Surumi Makkat Mukkil Sheikh ◽

Neetha Thattaparambil Chandran ◽

Asish Karthik ◽

Irfana Hameed ◽

Sunanda Chulliparambil

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Observational Study ◽

Treatment Modalities ◽

Neurosurgical Procedures ◽

Intracranial Tumour ◽

Close Monitoring ◽

Electrolyte Abnormality ◽

Preoperative Serum ◽

Neurosurgical Patients

BACKGROUND Hyponatremia is the most frequently encountered electrolyte abnormality in hospitalized patients, especially those with neurological injury. Acute onset hyponatremia is common in patients with any type of cerebral insult including traumatic brain injury (TBI), subarachnoid haemorrhage (SAH) and brain tumours. Also seen as a complication of intracranial procedures, contributing to increased morbidity and mortality. Early diagnosis and effective management can reduce mortality associated with this condition. This study was done to estimate the prevalence of hyponatremia in neurosurgical patients in our institution. METHODS This is an observational study that analysed the adult patients admitted to the neuro intensive care unit (ICU) after having undergone the neurosurgical procedure from January 2019 to July 2019. A structured questionnaire was used for data collection. The prevalence of hyponatremia was calculated with preoperative serum sodium levels in the study population. RESULTS In this study with 61 patients undergoing neurosurgical procedures, the prevalence of hyponatremia was 34.4 %. The majority of patients for surgery comes between 41 to 50 years. 57.4 % cases were with traumatic brain injury, 11.5 % cases were with sub arachnoid haemorrhage and 31.1 % were with intracranial tumour. 26 % of hyponatremia patients belonged to mild grade while 8 % to moderate grade. 62.5 % of patients above 70 years, 44.4 % of patients between 51 to 60 years and 40 % of patients between 61 and 70 years presented with mild hyponatremia. 37.5 % of patients above 70 years and 10 % of patients between 61 and 70 years presented with moderate hyponatremia. CONCLUSIONS Our study showed an increased prevalence of hyponatremia in neurosurgical patients which demand effective approaches for an accurate and timely diagnosis of this electrolyte disorder. Hyponatremia frequently occurs in patients with TBI, SAH and intracranial tumours. It is also essential to differentiate between syndrome of inappropriate antidiuretic hormone (SIADH) and cerebral salt wasting syndrome (CSW) as the treatment modalities are entirely different for these two entities. Early detection, close monitoring, etiological evaluation and prompt treatment based on aetiology can reduce the complications and improve patient’s outcomes. KEYWORDS Electrolyte Abnormality; Brain Injury, Morbidity

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