Tag Archives: SAH

Subarachnoid Hemorrhage and Ventriculitis

Clinical signs of ventriculitis are difficult to recognize in SAH patients who are sedated, who have recently undergone neurosurgery, or have a sterile inflammatory response in the CSF due to the SAH.  Clinical symptoms of SAH (headache, nuchal rigidity, AMS) closely resemble bacterial ventriculitis.

Suspect with:
  • new fever
    • Fever occurs in 40 % after SAH +/- infection
  • new nuchal rigidity

 

What to do?

Exclude other causes of infection

  1. physical examination
  2. blood / sputum / urinary cultures
  3. CXR

Exclude other causes of AMS (HCP and ischemia)

  • Neuroimaging with plain CT scan
Work-up:
  • Serum:  CRP WBC glucose
  • CSF analysis (cell count, GS / CS, glu / protein)
    • Interpretation of CSF WBC problematic; CSF RBC causes aseptic ventriculitis
    • CSF cell count  helpful but low sensitivity and specificity
      CSF RBC higher in CSF culture-negative bacterial ventriculitis
    • cell index for EVD-related ventriculitis with IVH (formula proposed, but not yet validated)
  • Blood cultures
  • CSF lactate, cytokine levels, and serum procalcitonin
    • Also disturbed after SAH
    • procalcitonin discriminates between SIRS and systemic infection but value for aseptic vs bacterial ventriculitis is limited
  • CSF PCR for bacterial pathogens – low sensitivity in EVD related bacterial ventriculitis and aseptic ventriculitis after surgery
Case definitions:
  1. Clincally suspected bacterial ventriculitis – empirical antibiotic treatment for bacterial ventriculitis, but negative CSF cultures
  2. Confirmed Bacterial ventriculitis – (+) CSF culture for bacteria; if staph epidermidis – needs 2 consecutive positive cultures to rule out contamination
Treatment:
  • No good discriminative tests, treatment initiated on first suspicion
  • Antibiotic regimen for bacterial ventriculitis
    •  ceftriaxone 2 g BID + vancomycin 2 g BID
    •  ceftazidime 2 g TID + vancomycin 2 g BID if external CSF catheter in place
  • Duration
    • culture negative – discontinue ABx (after 72h)
    • culture positive – 2 weeks

 

ORDERS:
  1. Physical Examination
  2. Assessment:
    • clinically suspected bacterial ventriculitis
    • confirmed bacterial ventriculitis
  3. Blood work:
    • CBC (WBC)
    • BMP (glucose)
    • Blood cultures x 2
    • CRP
    • Procalcitonin
  4. sputum cultures
  5. urinalysis with reflex to urine culture if (+)
  6. CXR
  7. Plain CT scan
  8. CSF studies
    • cell count
    • Gram stain and culture
    • CSF glucose
    • CSF protein
    • calculate cell index
    • CSF lactate
    • *CSF cytokine levels
    • *CSF PCR for bacterial pathogens
  9. Treatment x 2 weeks
    • ceftriaxone 2 g BID + vancomycin 2 g BID
    • ceftazidime 2 g TID + vancomycin 2 g BID if (+) EVD
    • discontinue within 72 hours if cultures are negative

 

Reference:

Hoogmoed, J. et al. “Clinical And Laboratory Characteristics For The Diagnosis Of Bacterial Ventriculitis After Aneurysmal Subarachnoid Hemorrhage”. Neurocritical Care (2016): 1-9.

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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

 

capture

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

 

 

1a.JPG

<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.

 

 

Treatment of Aneurysms

  • Clipping Most aneurysms
  • Coiling Most aneurysms
  • Flow diversion Large proximal ICA aneurysms, blister aneurysms
  • Flow diversion with adjunctive coiling Large and giant aneurysms with wide necks
  • Intrasaccular flow diversion Bifurcation aneurysms with neck ≥4 mm
  • Coiling with assistive stenting Wide-neck aneurysms and aneurysms with branch vessels near/incorporating aneurysm neck
  • Parent vessel sacrifice or branch vessel sacrifice with bypass Dissecting aneurysms, giant aneurysms with branch vessels incorporating aneurysm neck
  • Parent vessel sacrifice without bypass Distal PICA aneurysms, distal PCA aneurysms, distal mycotic aneurysms

 

Reference:

Walcott, Brian P. et al. “Blood Flow Diversion As A Primary Treatment Method For Ruptured Brain Aneurysms—Concerns, Controversy, And Future Directions”. Neurocritical Care (2016): pp 1-9.

FXa and “Universal” Reversal Agent Drug Targets

TWO REVERSAL AGENTS IN DEVELOPMENT:
  • Andexanet alfa = recombinant modified FXa decoy molecule
    • see previous blog
  • Ciraparantag = reverse many anticoagulants including the FXa inhibitors
    • developed by Perosphere
    • formerly known as “aripazine” or “PER977”
    • di-arginine piperazine
    • small (512 Da) synthetic molecule
    • binds to UFH, LMWH, fondaparinux, DOACs
    • inactivates anticoagulants via noncovalent hydrogen binding, blocks binding to target sites of FIIa and FXa
FXa and “Universal” Reversal Agent Drug Targets:
capture

Reference:

Milling, Truman J. and Scott Kaatz. “Preclinical And Clinical Data For Factor Xa And “Universal” Reversal Agents”. The American Journal of Emergency Medicine 34.11 (2016): 39-45.