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Case Report
Neurosurgery
A point-of-care evaluation after visual loss following paraclinoid aneurysm repair: the role of sonographic and pupillometer assessment
Giacomo Bertolini, Ernesto Migliorino, Diego Mazzatenta, Carlo Bortolotti, Raffaele Aspide
Received January 9, 2022  Accepted March 17, 2022  Published online July 5, 2022  
DOI: https://doi.org/10.4266/acc.2022.00045    [Epub ahead of print]
  • 2,025 View
  • 28 Download
AbstractAbstract PDF
Visual complications represent common deficits following surgical or endovascular repair of paraclinoid aneurysms. Different etiologies should be investigated to prevent devastating consequences. Herein we present a point-of-care evaluation to investigate sudden visual loss after coiling of a paraclinoid aneurysms. A 20-year-old male were admitted for a sudden headache. Head computed tomography showed a subarachnoid hemorrhage and subsequent angiography revealed a 9-mm left supraclinoid aneurysm of the internal carotid artery treated with endovascular coil embolization. Thirty minutes after intensive care unit admission the patient reported a left amaurosis. To exclude secondary etiologies an immediate evaluation with point-of-care devices (color-doppler and B-mode ultrasound and automated pupillometry) were performed. Sonographic evaluations were negative for ischemic/thrombotic events and neurologic pupil index within physiological ranges provide evidence of third cranial nerve responsiveness. The symptomatology resolved progressively over 120 minutes with low-dose steroid therapy, 30° head-of-bed elevation and blood pressure management. Visual deficits can occur after endovascular procedure and should be investigated. Suspected visual loss is a neurological emergency that deserve a prompt evaluation. Ultrasound and automated pupillometry have proved to be an effective, rapid, reliable and non-invasive combination for a clinical decision-making strategy in the management of post-procedural acute visual deficits.
Original Articles
Neurosurgery
The RAP Index during Intracranial Pressure Monitoring as a Clinical Guiding for Surgically Treated Aneurysmal Subarachnoid Hemorrhage: Consecutive Series of Single Surgeon
Sung-Chul Jin, Byung Sam Choi, Jung-Soo Kim
Acute Crit Care. 2019;34(1):71-78.   Published online February 28, 2019
DOI: https://doi.org/10.4266/acc.2019.00437
  • 6,436 View
  • 132 Download
  • 3 Web of Science
  • 3 Crossref
AbstractAbstract PDF
Background
It is well known that assessing the RAP index along with intracranial pressure (ICP) monitoring in traumatic brain injury patients is helpful. We will discuss the usefulness of this assessment tool as a clinical guide for surgically treated poor grade aneurysmal subarachnoid hemorrhage (SAH).
Methods
This retrospective study included 35 patients with aneurysmal SAH who presented with World Federation of Neurosurgical Societies (WFNS) grade V SAH and received surgical treatment from January 2013 to December 2018. Emergency surgical clipping, hematoma removal, extraventricular drainage, and if needed, wide decompressive craniectomy were combined as the proper surgical treatments. Outcomes were assessed based on in-hospital survival and the Glasgow outcome scale score at 14-day follow-up. We compared the mortality rate of two groups of seven patients: ICP monitoring only (n=5) and ICP monitoring combined with the RAP index (n=2).
Results
The in-hospital 14-day mortality rate by brain lesion was 48.5% (n=17). Seven patients had real-time ICP monitoring. Before 2018, three of five patients with poor WFNS grade who received real-time ICP monitoring only died. There were no deaths in the group of two patients receiving real-time ICP monitoring and the RAP index.
Conclusions
Our data indicate that combining the RAP index and ICP monitoring can be used as markers for critical intracranial physiological parameters in poor grade WFNS patients.

Citations

Citations to this article as recorded by  
  • Multimodal Neurologic Monitoring in Children With Acute Brain Injury
    Jennifer C. Laws, Lori C. Jordan, Lindsay M. Pagano, John C. Wellons, Michael S. Wolf
    Pediatric Neurology.2022; 129: 62.     CrossRef
  • Intracranial pressure: current perspectives on physiology and monitoring
    Gregory W. J. Hawryluk, Giuseppe Citerio, Peter Hutchinson, Angelos Kolias, Geert Meyfroidt, Chiara Robba, Nino Stocchetti, Randall Chesnut
    Intensive Care Medicine.2022; 48(10): 1471.     CrossRef
  • The application value of CT radiomics features in predicting pressure amplitude correlation index in patients with severe traumatic brain injury
    Jiaqi Liu, Yingchi Shan, Guoyi Gao
    Frontiers in Neurology.2022;[Epub]     CrossRef
Neurosurgery
Acute Cholecystitis as a Cause of Fever in Aneurysmal Subarachnoid Hemorrhage
Na Rae Yang, Kyung Sook Hong, Eui Kyo Seo
Korean J Crit Care Med. 2017;32(2):190-196.   Published online May 31, 2017
DOI: https://doi.org/10.4266/kjccm.2016.00857
  • 5,630 View
  • 87 Download
  • 2 Web of Science
  • 3 Crossref
AbstractAbstract PDF
Background
Fever is a very common complication that has been related to poor outcomes after aneurysmal subarachnoid hemorrhage (aSAH). The incidence of acalculous cholecystitis is reportedly 0.5%–5% in critically ill patients, and cerebrovascular disease is a risk factor for acute cholecystitis (AC). However, abdominal evaluations are not typically performed for febrile patients who have recently undergone aSAH surgeries. In this study, we discuss our experiences with febrile aSAH patients who were eventually diagnosed with AC.
Methods
We retrospectively reviewed 192 consecutive patients who underwent aSAH from January 2009 to December 2012. We evaluated their characteristics, vital signs, laboratory findings, radiologic images, and pathological data from hospitalization. We defined fever as a body temperature of >38.3°C, according to the Society of Critical Care Medicine guidelines. We categorized the causes of fever and compared them between patients with and without AC.
Results
Of the 192 enrolled patients, two had a history of cholecystectomy, and eight (4.2%) were eventually diagnosed with AC. Among them, six patients had undergone laparoscopic cholecystectomy. In their pathological findings, two patients showed findings consistent with coexistent chronic cholecystitis, and two showed necrotic changes to the gall bladder. Patients with AC tended to have higher white blood cell counts, aspartame aminotransferase levels, and C-reactive protein levels than patients with fevers from other causes. Predictors of AC in the aSAH group were diabetes mellitus (odds ratio [OR], 8.758; P = 0.033) and the initial consecutive fasting time (OR, 1.325; P = 0.024).
Conclusions
AC may cause fever in patients with aSAH. When patients with aSAH have a fever, diabetes mellitus and a long fasting time, AC should be suspected. A high degree of suspicion and a thorough abdominal examination of febrile aSAH patients allow for prompt diagnosis and treatment of this condition. Additionally, physicians should attempt to decrease the fasting time in aSAH patients.

Citations

Citations to this article as recorded by  
  • Rare or Overlooked Cases of Acute Acalculous Cholecystitis in Young Patients with Central Nervous System Lesion
    Seong-Hun Kim, Min-Gyu Lim, Jun-Sang Han, Chang-Hwan Ahn, Tae-Du Jung
    Healthcare.2023; 11(10): 1378.     CrossRef
  • Acute cholecystitis as a rare and overlooked complication in stroke patients
    Myung Chul Yoo, Seung Don Yoo, Jinmann Chon, Young Rok Han, Seung Ah Lee
    Medicine.2019; 98(9): e14492.     CrossRef
  • Acute Acalculous Cholecystitis in Neurological Patients; Clinical Review, Risk Factors, and Possible Mechanism
    See Won Um, Hak Cheol Ko, Seung Hwan Lee, Hee Sup Shin, Jun Seok Koh
    Journal of Neurointensive Care.2019; 2(2): 77.     CrossRef
Case Report
Neurosurgery
Delayed Traumatic Subarachnoid Hemorrhage in a Polytraumatized Patient with Disseminated Intravascular Coagulation
Jiwoong Oh, Wonyeon Lee, Ji Young Jang, Pilyoung Jung, Sohyun Kim, Jongyeon Kim, Jinsu Pyen, Kum Whang, Sungmin Cho
Korean J Crit Care Med. 2015;30(4):336-342.   Published online November 30, 2015
DOI: https://doi.org/10.4266/kjccm.2015.30.4.336
  • 9,088 View
  • 137 Download
  • 1 Crossref
AbstractAbstract PDF
The precise mechanism involved in DIC and delayed traumatic subarachnoid hemorrhage (DT-SAH) remains unclear in multipletrauma patients. Hereby, we describe a polytraumatized patient with DIC who died due to DT-SAH. A 75-year-old female patient was admitted to our Emergency Department complaining of abdominal pain and drowsiness after a pedestrian accident. Her initial brain computerized tomography (CT) finding was negative for intracranial injury. However, her abdominal CT scan revealed a collection of retroperitoneal hematomas from internal iliac artery bleeding after a compressive pelvic fracture. This event eventually resulted in shock and DIC. An immediate angiographic embolization of the bleeding artery was performed along with transfusion and antithrombin III. Her vital signs were stabilized without neurological change. Fourteen hours after admission, she suddenly became comatose, and her follow-up brain CT scan revealed a dense DT-SAH along the basal cisterns with acute hydrocephalus. This event rapidly prompted brain CT angiography and digital subtraction angiography, which both confirmed the absence of any cerebrovascular abnormality. Despite emergency extraventricular drainage to reverse the hydrocephalus, the patient died three days after the trauma. This paper presents an unusual case of DT-SAH in a polytraumatized patient with DIC.

Citations

Citations to this article as recorded by  
  • Is initial optic nerve sheath diameter prognostic of specific head injury in emergency departments?
    Bedriye Müge Sönmez, Emirhan Temel, Murat Doğan İşcanlı, Fevzi Yılmaz, Uğur Gülöksüz, Selçuk Parlak, Özhan Merzuk Uçkun
    Journal of the National Medical Association.2019; 111(2): 210.     CrossRef
Original Article
A Retrospective Study about Characteristics of Out-of-hospital Cardiac Arrest Caused by Non-traumatic Subarachnoid Hemorrhage
Min Seob Sim, Ki Dong Sung, Mun Ju Kang, Ji Ung Na, Tae Gun Shin, Ik Joon Jo, Hyoung Gon Song, Keun Jeong Song, Yeon Kwon Jeong
Korean J Crit Care Med. 2011;26(3):151-156.
DOI: https://doi.org/10.4266/kjccm.2011.26.3.151
  • 2,317 View
  • 27 Download
AbstractAbstract PDF
BACKGROUND
Subarachnoid hemorrhage is a fatal disease relatively common in the East Asian population. It can lead to cardiac arrest in several pathologic processes. We attempted to elucidate the characteristics of out-of-hospital cardiac arrest caused by non-traumatic subarachnoid hemorrhage.
METHODS
We conducted a retrospective, observational study in which patients who had visited Samsung medical center emergency room for out-of-hospital cardiac arrest from January, 1999 to December 2008 were enrolled. A total of 218 OHCA patients who had achieved ROSC were investigated by review of medical charts. Excluding those who had worn trauma, we analyzed 22 patients who had been diagnosed for SAH by brain non-contrast CT scan.
RESULTS
Median age of aneurysmal SAH-induced OHCA patients was 61 (IQR 54-67) years. Fourteen patients (64%) were female and 15 patients (68%) were witnessed. Besides, 7 patients (32%) had complained of headache before collapse. We also found 11 patients (50%) had been diagnosed with hypertension previously. All of them showed unshockable rhythm (asystole 60%, PEA 40%) initially. Their median duration of ACLS was 10 minutes. Majority of patients died within 24 hours and survivors showed poor neurologic outcome.
CONCLUSIONS
Subarachnoid hemorrhage is a relatively uncommon cause of cardiac arrest, and the outcome of OHCA induced by SAH is very poor. However, emergency physicians have to consider the possibility of SAH when trying to determine the cause of arrest, especially when treating patients who have the characteristics described above.

ACC : Acute and Critical Care