Monthly Archives: December 2016

Composition of PCC

A handy table:  composition of common prothrombin complex concentrates

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References:

Frontera, Jennifer A. et al. “Guideline For Reversal Of Antithrombotics In Intracranial Hemorrhage”. Neurocritical Care 24.1 (2015): 6-46.

Kiwon Lee, NeuroICU Book

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EVD Bundle (Placement)

Elements of EVD infection control protocol for EVD placement.

  1. wide clipping of head – enough to fit a medium-sized Tegaderm
  2. apply chlorhexidine-alcohol – first skin prep
  3. full draping followed by second chlorhexidine-alcohol skin preparation with the surgeon wearing gown, gloves, cap, and mask and full barrier precautions used throughout
  4. minocycline/rifampin antibiotic-impregnated EVD catheter tunneled 3 to 5 cm; secured with curvilinear line of surgical staples
  5. apply benzoin tincture to skin broadly and fully dry
  6. apply biopatch over exit site (not wrapping around catheter)
  7. apply medium-sized transparent dressing film
  8. secure borders of transparent dressing film and catheter with adhesive strips

 

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<click here for MS Powerpoint File>

 

Reference:

Flint, Alexander C. et al. “A Simple Protocol To Prevent External Ventricular Drain Infections”. Neurosurgery 72.6 (2013): 993-999. Web.

I-TRACH Score to Predict Risk of Prolonged Mechanical Ventilation

  • Intubation in ICU (hospitalized in ICU for >24 hours prior to intubation)
  • Tachycardia (HR > 110)
  • Renal dysfunction (BUN > 25)
  • Acidemia (pH < 7.25)
  • Creatinine (>2.0)
  • decreased HCO3(<20)

*Threshold of 4 or more good Sp and Sn in predicting prolonged mechaniascal ventilation

Note: This study excluded neurological patients and therefore cannot be applied in the NSICU setting.

 

Reference:

Clark, P. A., R. C. Inocencio, and C. J. Lettieri. “I-TRACH: Validating A Tool For Predicting Prolonged Mechanical Ventilation”. Journal of Intensive Care Medicine (2016): pages 1-7.

Data Sheet for Aneurysm Stent/Coil

  • Age:
  • Gender:
  • Rupture status
    • Ruptured
    • Unruptured
  • Aneurysm size
    • Small
    • Large
    • Giant
  • Dome volume:
  • Neck size:
  • Aspect ratio:
  • Aneurysm location
    • Anterior circulation
      • Cavernous ICA
      • Ophthalmic
      • Superior hypophyseal
      • Posterior communicating
      • Anterior choroidal
      • ICA other
      • ICA bifurcation
      • Anterior communicating
      • Pericallosal
      • ACA other
      • MCA
    • Posterior circulation
      • Vertebral
      • PICA
      • Basilar trunk
      • SCA
      • Basilar tip
      • PCA
    • Procedure assistance
      • Stand-alone
      • Balloon
      • Stent
    • Coil type
      • Galaxy
      • GDC
      • Hydrocoil
      • Matrix
      • Orbit
      • Penumbra
      • Target
      • Trufill
      • Unknown
      • Multiple coil types
    • Stent data
      • Enterprise
      • Liberty
      • Neuroform
      • Multiple stents

 

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aneurysm-data-collection-form

Reference:

Mascitelli, Justin R et al. “An Update To The Raymond–Roy Occlusion Classification Of Intracranial Aneurysms Treated With Coil Embolization”. Journal of NeuroInterventional Surgery 7.7 (2014): 496-502. Web. 11 Dec. 2016.

Modified Raymond–Roy Classification

  • Class I: complete obliteration12.jpg
  • Class II: residual neck
  • Class IIIa: residual aneurysm with contrast within coil interstices
  • Class IIIb: residual aneurysm with contrast along aneurysm wall

3.jpg4.jpg

 

 

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<click here to access MS ppt file>

 

 

References:

Hospital, Massachusetts. “Endovascular Procedures To Prevent Ruptured Brain Aneurysms”. Massachusetts General Hospital. N.p., 2016. Web. 11 Dec. 2016.

Mascitelli, Justin R et al. “An Update To The Raymond–Roy Occlusion Classification Of Intracranial Aneurysms Treated With Coil Embolization”. Journal of NeuroInterventional Surgery 7.7 (2014): 496-502.

 

Antiplatelets for Stent-Coil Techniques

  • ASA (325 mg daily) and clopidogrel (75 mg daily) x 5 days prior to procedure
  • platelet aggregometry 1–2 days before procedure
  • further loading of aspirin and/or clopidogrel PRN
  • unanticipated stenting
    • load with IV or IA abciximab intraprocedurally
    • then load and maintain on ASA and clopidogrel
  • systemic heparinization prior to guide catheter introduction, target activated clotting time 2–2.5 greater than baseline

 

Reference:

Spiotta, Alejandro M et al. “Comparison Of Techniques For Stent Assisted Coil Embolization Of Aneurysms”. Journal of NeuroInterventional Surgery 4.5 (2011): 339-344.

 

Stent-Assisted Coiling Techniques

  1. ‘jailing’ of microcatheter
    • stent deployed after the aneurysm is catheterized but before coil deployment
    • microcatheter pinned between intima and stent, coils are kept within the aneurysm and outside of vessel lumen
    • A.jpg
  2. ‘coil through’
    • stent fully deployed across aneurysm neck
    • aneurysm catheterized through the tines of the stent
    • b
  3. ‘coil stent’
    • unassisted coil embolization to completion followed by stent deployment
    • capitalizes on biologic benefit of vascular remodeling or to constrain a prolapsed coil loop
    • C.jpg
  4. ‘balloon stent’
    • stent placement after completion of balloon assisted embolization
    • D.jpg
  5. other techniques
    • coiling with ‘Y stent’ configuration for basilar tip aneurysms
    • depositing single or multiple stents for flow diversion for blister dorsal carotid wall aneurysms

 

FINAL RESULT OF ALL STENT-ASSISTED COILING:

E.jpg

 

 

Reference:

Spiotta, Alejandro M et al. “Comparison Of Techniques For Stent Assisted Coil Embolization Of Aneurysms”. Journal of NeuroInterventional Surgery 4.5 (2011): 339-344.