The Alchemist A Graphic Novel



Cilostazol for DCI Prevention

Cilostazol is a phosphodiesterase III inhibitor which increases cAMP and leads to reversible inhibition of platelet aggregation, vasodilation and inhibition of vascular smooth muscle cell proliferation.  A systematic review was recently published in the Journal of Neurology on the effect of cilostazol on the incidence of delayed cerebral ischemia in subarachnoid hemorrhage (Department of Neurosurgery, West China Hospital).

The meta-analysis included seven studies, all of which were done in Japan:  three were randomized controlled studies, 3 were retrospective studies and one was a prospective study.  Most studies used cilostazol at 200mg per day for 14 days.


Forest plots for the outcomes provided below:

A. Severe angiographic vasospasm

forest plot 1

B. Symptomatic vasospasm

forest plot 2

C. New cerebral infarction

forest plot 3

D. Poor outcome

forest plot 4

E.  Mortality

forest plot 5

Adverse effects related to cilostazol administration in the studies include diarrhea, transaminitis, tachycardia, headaches, hemorrhagic and cardiac events.

The meta-analysis concluded that cilostazol effectively reduced the incidence of severe angiographic vasospasm, symptomatic vasospasm, new cerebral infarction and poor outcome in patients with aneurysmal subarachnoid hemorrhage, but does not reduce mortality significantly.

It is important to note that all of the studies included in the meta-analysis were from one country (Japan), which precludes the generalization of the results to the general population.  Also, none of the patients in the studies received nimodipine, which has not been approved for SAH treatment in Japan.  Whether or not the co-administration of nimodipine would add to or nullify the benefits seen with cilostazol requires further investigation.

Take home message:  should not change current practice, needs further research.



Shan, T., Zhang, T., Qian, W., Ma, L., Li, H., You, C. and Xie, X. (2019). Effectiveness and feasibility of cilostazol in patients with aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. Journal of Neurology. (2019). UpToDate. [online] Available at: [Accessed 6 Apr. 2019].

Neuron Specific Enolase (NSE)

NSE is an enzyme in humans encoded by the ENO2 gene. It is a phosphopyruvate hydratase. This enzyme is found in mature neurons and cells of neuronal origin, and is released after neuronal damage.

NSE has been studied as a marker for brain injury. Serum levels have been shown to be elevated in patients with stroke, correlates with the infarct volume and the degree of neurologic deficit. However, increase in serum NSE after brain injury occur late and lack sensitity and specificity.


  • Sensitivity 53%
  • Specificity 64%



Enolase 2. (2019). Retrieved from

González-García, S., González-Quevedo, A., Peña-Sánchez, M., Menéndez-Saínz, C., Fernández-Carriera, R., & Arteche-Prior, M. et al. (2012). Serum neuron-specific enolase and S100 calcium binding protein B biomarker levels do not improve diagnosis of acute stroke. The Journal Of The Royal College Of Physicians Of Edinburgh, 42(3), 199-204. doi: 10.4997/jrcpe.2012.302

UpToDate. (2019). Retrieved from

West Haven Criteria for Altered Mental Status in Hepatic Encephalopathy

West Haven criteria for altered mental status in hepatic encephalopathy

Grade 0 Minimal hepatic encephalopathy, lack of detectable changes in personality or behavior; no asterixis.

Grade 1 Trivial lack of awareness, shortened attention span, sleep disturbance, altered mood, and slowing the ability to perform mental tasks; asterixis may be present.

Grade 2 Lethargy or apathy, disorientation to time, amnesia of recent events, impaired simple computations, inappropriate behavior, and slurred speech; asterixis is present.

Grade 3 Somnolence, confusion, disorientation to place, bizarre behavior, clonus, nystagmus, and positive Babinski sign; asterixis usually absent.

Grade 4 Coma, lack of verbal, eye, and oral response to stimuli.


Emergency Management in Neurocritical Care: Chapter 17 Metabolic Encephalopathies, by Edward Manno

Straight Catheterization Protocol



straight cath protocol (proposal)



Lenox Hill Hospital CAUTI Team.

Medication Administration Times

  • Daily:  standard at 12 noon except for
    • antihypertensives, arrhythmics, diuretics, thyroid meds, steroids – 06:00
    • warfarin – 22:00
  • every 24 hours – times scheduled with first administration
  • BID or q12h  – 06:00, 18:00
  • TID or q8h    – 06:00, 14:00, 22:00
  • QID or q6h    – 00:00, 06:00, 12:00, 18:00
  • At bedtime    – 22:00



LHH Pharmacy handouts

Heparin Prophylaxis

  • Adult patients >50Kg – 5000 units SQ q8h
  • Adult patients <50Kg – 5000 units SQ q12h
  • Adult patients BMI>35 – 7500 units SQ q8h




LHH Pharmacy handouts.