LHH Department of Neurosurgery Guideline. <pdf attached>
LHH Department of Neurosurgery Guideline. <pdf attached>
Table. Predictive grading systems for procedural risk in the endovascular treatment of brain AVMs.
Buffalo score best predicts procedural risks, although predictive value is modest (AUC ~0.7).
Pulli, B., Stapleton, C., Walcott, B., Koch, M., Raymond, S., & Leslie-Mazwi, T. et al. (2019). Comparison of predictive grading systems for procedural risk in endovascular treatment of brain arteriovenous malformations: analysis of 104 consecutive patients. Journal Of Neurosurgery, 1-9. doi: 10.3171/2019.4.jns19266
DVT Chemoprophylaxis Guideline Recommendations (summary) from the Neurocritical Care Society (published in 2016).
We recommend the use of IPC and/or GCS for VTE prophylaxis over no prophylaxis beginning at the time of hospital admission. (Strong recommendation and high-quality evidence)
We suggest using prophylactic doses of subcutaneous UFH or LMWH to prevent VTE in patients with stable hematomas and no ongoing coagulopathy beginning within 48 h of hospital admission. (Weak recommendation and low-quality evidence)
We suggest continuing mechanical VTE prophylaxis with IPCs in patients started on pharmacologic prophylaxis. (Weak recommendation low-quality evidence)
ANEURYSMAL SUBARACHNOID HEMORRHAGE
We recommend VTE prophylaxis with UFH in all patients with aSAH (Strong recommendation and high-quality evidence) except in those with unsecured ruptured aneurysms expected to undergo surgery. (Strong recommendation and low-quality evidence)
We recommend initiating IPCs as VTE prophylaxis as soon as patients with aSAH are admitted to the hospital. (Strong recommendation and moderate-quality evidence)
We recommend VTE prophylaxis with UFH at least 24 h after an aneurysm has been secured by surgical approach or by coiling. (Strong recommendation and moderate-quality evidence)
TRAUMATIC BRAIN INJURY
We recommend VTE prophylaxis with either LMWH or UFH upon hospitalization for patients with brain tumors who are at low risk for major bleeding and who lack signs of hemorrhagic conversion. (Strong recommendation and moderate-quality evidence).
SPINAL CORD INJURY
COMPLICATED SPINAL SURGERY
ELECTIVE INTRACRANIAL / INTRA-ARTERIAL PROCEDURES
INTRACRANIAL ENDOVASCULAR PROCEDURES
Nyquist, P., Bautista, C., Jichici, D., Burns, J., Chhangani, S., DeFilippis, M., Goldenberg, F., Kim, K., Liu-DeRyke, X., Mack, W. and Meyer, K. (2015). Prophylaxis of Venous Thrombosis in Neurocritical Care Patients: An Evidence-Based Guideline: A Statement for Healthcare Professionals from the Neurocritical Care Society. Neurocritical Care, 24(1), pp.47-60.
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
B. Symptomatic vasospasm
C. New cerebral infarction
D. Poor outcome
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.
Uptodate.com. (2019). UpToDate. [online] Available at: https://www.uptodate.com/contents/cilostazol-drug-information?sectionName=Adult&topicId=8872&search=cilostazol&usage_type=panel&anchor=F151445&source=panel_search_result&selectedTitle=1~36&kp_tab=drug_general&display_rank=1#F151413 [Accessed 6 Apr. 2019].
In cerebral salt-wasting (CSW), natriuretic factor is produced in response to a central insult. Natriuretic factor decreases sodium transport in proximal renal tubule which leads to urinary loss of sodium (and water) and depletion of extracellular volume. Hypovolemia then triggers secretion of ADH, renin and aldosterone, which provides a negative feedback to decrease secretion of natriuretic factor.
Differentiating CSW from syndrome of inappropriate antidiuretic hormone (SIADH) is problematic, laboratory work-up (urine and plasma sodium levels and urine and plasma osmolarity) is similar in both conditions. CSW patients are usually volume depleted while SIADH patients are euvolemic. The traditional approach of examining patient clinically to to determine volume status is inaccurate.
An interesting paper published in 2014 suggested a new algorithm to differentiate SIADH from CSW based on the effect of sodium correction on the fractional excretion of urate (FEUa). FEurate is calculate using the folllowing formula:
Normal FEUa = 4-11%, SIADH & CSW FEUa = >11%. FEUa determines the percent excertion of the filtered load of urate at the glomerulus.
In SIADH, FEUa normalizes after correction of hyponatremia (see graph below):
whereas in CSW, FEUa remains elevated >11% after correction of hyponatremia. The reason is probably because natriuretic factor also decreases urate transport in the proximal tubule.
Based on this finding, the paper suggests a new algorithm for determining the etiology of hyponatremia that omits reliance of UNa (and also plasma renin, aldosterone, atrial or brain antriuretic peptide, BUN/creatinine ratio).
Based on this algorithm, a patient with hyponatremia should undergo correction of sodium by any means (water restriction or isotonic / hypertonic saline). Observing whether FEUa normalizes or remains increased would differentiate SIADH from CSW syndrome.
Maesaka, J., Imbriano, L., Mattana, J., Gallagher, D., Bade, N. and Sharif, S. (2014). Differentiating SIADH from Cerebral/Renal Salt Wasting: Failure of the Volume Approach and Need for a New Approach to Hyponatremia. Journal of Clinical Medicine, 3(4), pp.1373-1385.
CRITICAL CARE CODES:
Document and explain why patient is critically ill. Critically ill indicates “a high probability of imminent or life-threatening deterioration in the patient’s condition.” Decision making and treatment must include an indication that the patient’s condition met that definition as well as considerations and plans to prevent life-threatening deterioration or organ system failure.
Code 99291 covers the initial 30 to 74 minutes on that day. Code 99292 covers the additional 30-minute time increments. Use 99292 when time totals 75 minutes or more. When using 99292, documentation should show why time was needed beyond the first hour.
Below is a list of the commonly encountered neurologic disorders that often justify use of critical care codes
Total time for critical care services include:
Total time for critical care services does not include:
Procedures bundled into CPT codes 99291 and 99292 that do not require separate coding include the following:
ADDITIONAL CODES FOR PROCEDURES:
Procedures that may be coded separately include:
When performing these other procedures, use modifier 25 with the critical care codes to indicate that procedures and evaluation and management were performed on the same day.
Lumbar puncture has three different CPT codes. The three CPT codes are:
Neurodiagnostic and monitoring procedures for EMG, nerve conduction studies, and EEG may be coded separately.
The following monitoring and emergency procedures also are among those commonly coded separately in the critical care unit:
ADVANCE CARE PLANNING:
Two CPT codes allow for coding of the time spent in discussions and preparation of advance care plans. These codes cannot be used by the same physician on the same day he or she uses CPT code 99291. Examples of written advance directives include healthy care proxy, durable power of attorney for health care, living will and MOLST. The two CPT codes for time spent in discussion and preparation of these forms are:
Prolonged services are not used with the primary codes 99291 and 99292. Subsequent day hospital management is coded as 99233, base time for this code is 35 minutes. When time spent exceeds base time by more than 30 minutes, physician may add a prolonged service code:
Telemedicine is coded using the standard CPT codes plus a modifier. In January 2017, the modifier of choice changed from GT to 95. Modifier 95 identifies a “synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system.”
CPT specifies two codes for telehealth critical care:
When providing telehealth, use Place of Service 02, which is a new place of service code as of January 2017.
Patients covered by Medicare Part B are eligible for remote critical care only if they are hospitalized in a rural area. Medicare uses different codes for remote critical care. Medicare also makes an exception by covering certain teleconsultations for acute stroke within 4.5 hours of symptom onset. The critical care telehealth codes for patients with Medicare are included in the Healthcare Common Procedure Coding System:
INTERPROFESSIONAL TELEPHONE CONSULTATIONS:
A neurointensivist might provide a telephone consultation directly with a physician who is caring for a patient at a remote hospital. These circumstances include urgent situations where a timely face-to-face service with the consultant may not be feasible. The codes may not be used if the consultant has or will see the patient within 14 days. This code is not to arrange for transfer of care. The time for the service may include review of records and images if the time consulting with the primary physician is more than half of the documented time. The code may be used only once per week for the same patient by the same physician.
The CPT codes for interprofessional telephone/Internet consultations are as follows:
All CPT codes listed above are copyrighted. CPT © 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Nuwer, M. and Vespa, P. (2018). Neurocritical Care Coding for Neurologists. CONTINUUM: Lifelong Learning in Neurology, 24(6), pp.1800-1809.
This score is used for patients with intracerebral hemorrhages with intraventricular extension, and is not appropriate for pure intraventricular hemorrhages.
In this score, each lateral ventricle is graded as:
3rd and 4th ventricles receive a score of:
Hydrocephalus was coded as
The formula for calculating the IVH score is as follows:
Or simplified: 3(RV+LV) + III + IV + 3(H)
Once the IVH score has been computed, the IVH volume can be calculated using the following formula:
To make things simpler, here is a table showing the calculated IVH volume based on the IVH score.
Here are two examples of IVH scores calculated for you:
How to use the IVH Score?
With the IVH score, cutoff of 40 mL indicates poor outcome and 60 mL, mortality.
With the ICH score, cutoff is 25 mL and 30 mL respectively.
The total volume of hemorrhage can be calculated by adding the ICH volume (using the ABC/2 formula) and the IVH volume (using the ICH score). Total volume predicts outcome better than ICH volume alone.
NOTE: Be wary of using ICH score and IVH score to withdraw care. Early limitation of care in ICH / IVH is a self-fulfilling prophecy which is, of course, associated with mortality.
Hallevi, H., Dar, N., Barreto, A., Morales, M., Martin-Schild, S., Abraham, A., Walker, K., Gonzales, N., Illoh, K., Grotta, J. and Savitz, S. (2009). The IVH Score: A novel tool for estimating intraventricular hemorrhage volume: Clinical and research implications*. Critical Care Medicine, 37(3), pp.969-e1.