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Zeineddine HA, Divito A, McBride DW, Pandit P, Capone S, Dawes BH, Chen CJ, Grotta JC, Blackburn SL. Subarachnoid Blood Clearance and Aneurysmal Subarachnoid Hemorrhage Outcomes: A Retrospective Review. Neurocrit Care 2023; 39:172-179. [PMID: 37100974 DOI: 10.1007/s12028-023-01729-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/03/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) continues to be a significant contributor to morbidity and mortality following aneurysmal subarachnoid hemorrhage (aSAH). Subarachnoid blood and its degradation products have been implicated in DCI, and faster blood clearance has been hypothesized to confer better outcomes. This study evaluates the relationship between blood volume and its clearance on DCI (primary outcome) and location at 30 days (secondary outcome) after aSAH. METHODS This is a retrospective review of adult patients presenting with aSAH. Hijdra sum scores (HSS) were assessed independently for each computed tomography (CT) scan of patients with available scans on post-bleed days 0-1 and 2-10. This cohort was used to evaluate the course of subarachnoid blood clearance (group 1). A subset of patients in the first cohort with available CT scans on both post-bleed days 0-1 and post-bleed days 3-4 composed the second cohort (group 2). This group was used to evaluate the association between initial subarachnoid blood (measured via HSS post-bleed days 0-1) and its clearance (measured via percentage reduction [HSS %Reduction] and absolute reduction [HSS-Abs-Reduction] in HSS between days 0-1 and 3-4) on outcomes. Univariable and multivariable logistic regression models were used to identify outcome predictors. RESULTS One hundred fifty-six patients were in group 1, and 72 patients were in group 2. In this cohort, HSS %Reduction was associated with decreased risk of DCI in univariate (odds ratio [OR] = 0.700 [0.527-0.923], p = 0.011) and multivariable (OR = 0.700 [0.527-0.923], p = 0.012) analyses. Higher HSS %Reduction was significantly more likely to have better outcomes at 30 days in the multivariable analysis (OR = 0.703 [0.507-0.980], p = 0.036). Initial subarachnoid blood volume was associated with outcome location at 30 days (OR = 1.331 [1.040-1.701], p = 0.023) but not DCI (OR = 0.945 [0.780-1.145], p = 0.567). CONCLUSIONS Early blood clearance after aSAH was associated with DCI (univariable and multivariable analyses) and outcome location at 30 days (multivariable analysis). Methods facilitating subarachnoid blood clearance warrant further investigation.
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Affiliation(s)
- Hussein A Zeineddine
- Department of Neurosurgery, University of Texas Health Science Center at Houston, University of Texas McGovern Medical School, Houston, TX, USA
| | - Anthony Divito
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Devin W McBride
- Department of Neurosurgery, University of Texas Health Science Center at Houston, University of Texas McGovern Medical School, Houston, TX, USA
| | - Peeyush Pandit
- Department of Neurosurgery, University of Texas Health Science Center at Houston, University of Texas McGovern Medical School, Houston, TX, USA
| | - Stephen Capone
- Department of Neurosurgery, University of Texas Health Science Center at Houston, University of Texas McGovern Medical School, Houston, TX, USA
| | - Bryden H Dawes
- Department of Neurosurgery, University of Texas Health Science Center at Houston, University of Texas McGovern Medical School, Houston, TX, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, University of Texas Health Science Center at Houston, University of Texas McGovern Medical School, Houston, TX, USA
| | - James C Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital-Texas Medical Center, Houston, TX, USA
| | - Spiros L Blackburn
- Department of Neurosurgery, University of Texas Health Science Center at Houston, University of Texas McGovern Medical School, Houston, TX, USA.
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Slowey C, Divito A, Goeddel L. Additional Outcomes and Limitations in the Treatment of Acute Unstable Chest Wall Injuries. JAMA Surg 2023:2802381. [PMID: 36884233 DOI: 10.1001/jamasurg.2022.8169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Affiliation(s)
- Charlie Slowey
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Anthony Divito
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Lee Goeddel
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland
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Schwengel DA, Divito A, Burgess N, Yaache M, Greenberg RS, Walsh G, Toy S. Influx! A game-based learning tool for in-hospital interprofessional disaster preparedness and response. Br J Anaesth 2021; 128:e213-e215. [PMID: 34924176 DOI: 10.1016/j.bja.2021.11.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 11/01/2021] [Accepted: 11/23/2021] [Indexed: 11/02/2022] Open
Affiliation(s)
- Deborah A Schwengel
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Anthony Divito
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Noelle Burgess
- Institute of Cell Engineering, Neurology, Art as Applied to Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mira Yaache
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert S Greenberg
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Greg Walsh
- Digital Whimsy Lab, University of Baltimore, Baltimore, MD, USA
| | - Serkan Toy
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Divito A, Kerr K, Wilkerson C, Shepard S, Choi A, Kitagawa RS. Use of Anticoagulation Agents After Traumatic Intracranial Hemorrhage. World Neurosurg 2018; 123:e25-e30. [PMID: 30528524 DOI: 10.1016/j.wneu.2018.10.173] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 10/24/2018] [Accepted: 10/26/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Anticoagulant therapy (ACT) after traumatic intracranial hemorrhage may lead to progression of hemorrhage, but in the presence of thromboembolic events, the clinician must decide if the benefits outweigh the risks. Currently, no data exist to guide therapy in the acute setting. METHODS We retrospectively identified all patients admitted to our institution with traumatic intracranial hemorrhage that received intravenous heparin, full-dose enoxaparin, or warfarin during their initial hospitalization over a 3-year period. We reviewed their demographics, hospital course, clinical indication and timing for initiation of ACT, and complications. RESULTS A total of 112 patients were identified. The median age and Glasgow Coma Scale score of these patients was 50.5 years and 9.5, respectively. Twenty-two patients required neurosurgical procedures for their presenting injury, including intracranial pressure monitors and/or open surgeries. Fifty-four patients had deep vein thrombosis or pulmonary embolism prior to initiation, and the remaining 20 patients had preexisting conditions or other indications for initiating ACT. The median time from injury to starting ACT was 8 days. Immediate complications occurred in 6 patients; however, none of these patients required a neurosurgical intervention. Delayed complications included progression of acute to chronic subdural hematoma that required intervention in 2 patients. One patient died from delayed hemorrhage. CONCLUSIONS For this patient population, the risk of immediate and delayed intracranial hemorrhages from initiating ACT therapy in intracranial injury must be weighed against the morbidity of delaying treatment. Although further studies are needed, our review provides the first rates of complications for this patient population.
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Affiliation(s)
- Anthony Divito
- Vivian L. Smith Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Keith Kerr
- Vivian L. Smith Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Christopher Wilkerson
- Vivian L. Smith Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Scott Shepard
- Vivian L. Smith Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Alex Choi
- Vivian L. Smith Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Ryan S Kitagawa
- Vivian L. Smith Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA.
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Divito A, Keller JT, Hagen M, Zuccarello M. Vestibular schwannoma or tanycytic ependymoma: Immunohistologic staining reveals. Surg Neurol Int 2014; 5:158. [PMID: 25506503 PMCID: PMC4253034 DOI: 10.4103/2152-7806.144595] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 09/05/2014] [Indexed: 11/04/2022] Open
Abstract
Background: The cerebellopontine angle (CPA) is a common location for primary tumors, most often vestibular schwannomas, and also meningiomas, dermoids, and a host of other neoplasms. Our case report illustrates how radiologic and histopathologic presentations of an unusual variant of ependymal neoplasm can be diagnostically challenging and how accurate diagnosis can affect treatment protocols. Case History: Our patient had a CPA mass that was a variant of ependymoma known as tanycytic ependymoma that mimicked vestibular schwannoma radiologically and during intraoperative pathologic examination. Diagnosis as a World Health Organization (WHO) grade II tanycytic ependymoma was supported by its appearance on evaluation of the permanent sections, its diffuse immunoreactivity for glial fibrillary acidic protein (GFAP), and the perinuclear dot-and-ring-like staining for epithelial membrane antigen (EMA). Conclusions: Our patient's CPA mass initially believed to be a vestibular schwannoma on preoperative evaluation, surgical appearance, and intraoperative pathologic consultation was then correctly diagnosed as a WHO grade II tanycytic ependymoma on permanent histologic sections with the assistance of immunohistochemical stains, including EMA. After this definitive diagnosis, our patient's adjuvant treatment was adjusted. Earlier diagnosis could have provided guidance for goals of resection and prompt initiation of adjuvant treatment.
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Affiliation(s)
- Anthony Divito
- Department of Neurosurgery, University of Cincinnati (UC) College of Medicine, Cincinnati, OH, USA
| | - Jeffrey T Keller
- Department of Neurosurgery, University of Cincinnati (UC) College of Medicine, Cincinnati, OH, USA ; Comprehensive Stroke Center at UC Neuroscience Institute, OH, USA ; Mayfield Clinic, Cincinnati, OH, USA
| | - Matthew Hagen
- Department of Pathology and Laboratory Medicine, University of Cincinnati (UC) College of Medicine, Cincinnati, OH, USA
| | - Mario Zuccarello
- Department of Neurosurgery, University of Cincinnati (UC) College of Medicine, Cincinnati, OH, USA ; Comprehensive Stroke Center at UC Neuroscience Institute, OH, USA ; Mayfield Clinic, Cincinnati, OH, USA
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