Publications by authors named "Shaheryar Hafeez"

20 Publications

  • Page 1 of 1

Comparison of Amantadine, Modafinil, and Standard of Care in the Acute Treatment of Disorders of Consciousness After Severe Traumatic Brain Injury.

Clin Neuropharmacol 2022 Jan-Feb 01;45(1):1-6

Department of Pharmacotherapy and Pharmacy Services, University Health.

Objective: Traumatic brain injury (TBI) is a major cause of death and disability worldwide. Many patients who experience severe TBI have persistent disorders of consciousness. Amantadine and modafinil are used for some neurological disorders; however, a comparison of the 2 medications in TBI has not been reported. This study compared the effectiveness of amantadine, modafinil, and standard of care (SOC) on disorders of consciousness after TBI.

Methods: All adult TBI patients admitted between January 1, 2017, and September 31, 2020 who received amantadine, modafinil, or SOC treatments were screened. Data collection included: demographics, change in Glasgow Coma Scale (GCS), location of hemorrhage, medication duration, intensive care unit and hospital length of stay, adverse drug reactions, and concomitant sedative medications. Patients in the amantadine and modafinil groups were matched 1:2 with patients who received SOC therapies. The primary outcome was change in GCS ≥ 3 from baseline to discharge.

Results: A total of 142 patients met inclusion criteria. Medications were initiated a median of 8 days from admission. Patients in the SOC group experienced a greater improvement in GCS and shorter hospital length of stay compared with amantadine. A change in GCS ≥ 3 from medication initiation to hospital discharge occurred in 46.5% of amantadine patients and 53.8% of modafinil patients.

Conclusions: In this study, TBI patients did not benefit from amantadine or modafinil compared with SOC therapies, and no differences were found between medication groups. Further studies are warranted to determine whether the addition of amantadine or modafinil in the weeks after TBI provides benefit.
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http://dx.doi.org/10.1097/WNF.0000000000000487DOI Listing
January 2022

Factors Affecting Outcomes in Geriatric Traumatic Subdural Hematoma in a Neurosurgical Intensive Care Unit.

World Neurosurg 2021 Nov 9. Epub 2021 Nov 9.

Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA. Electronic address:

Background And Objective: Geriatric patients (age ≥65 years) who sustain a traumatic brain injury have an increased risk of poor outcomes and higher mortality compared with younger cohorts. We aimed to evaluate the risk factors for discharge outcomes in a geriatric traumatic subdural hematoma population, stratified by age and pretraumatic medical comorbidities. This was a single-center retrospective cohort study of geriatric patients (N = 207).

Methods: Patient charts were evaluated for factors including patient characteristics, comorbidities, injury-related and seizure-related factors, neurosurgical intervention, and patient disposition on discharge.

Results: Bivariate and multivariate analyses showed that age was nonpredictive of patient outcomes. Underlying vasculopathic comorbidities were the primary determinant of posttraumatic seizure, surgical, and discharge outcomes. Multifactor analysis showed that patients who went on to develop status epilepticus (n = 11) had a higher frequency of vasculopathic comorbidities with strong predictive power in poor patient outcomes.

Conclusions: Our findings suggest a need to establish unique prognostic risk factors based on patient outcomes that guide medical and surgical treatment in geriatric patients.
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http://dx.doi.org/10.1016/j.wneu.2021.11.004DOI Listing
November 2021

Refractory Elevated Intracranial Pressure (ICP) in the Setting of a Traumatic Cerebral Sinus Venous Thrombosis (CSVT).

Cureus 2021 Sep 7;13(9):e17801. Epub 2021 Sep 7.

Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, USA.

The management of patients with elevated intracranial pressure (ICP) requires a systematic approach. After the failure of tier zero, tier one, and tier two therapies, all potential secondary causes of elevated ICP must be reviewed. Up to 28% of patients with blunt traumatic brain injury (TBI) develop cerebral sinus venous thrombosis (CSVT), among these, patients up to 55% have occlusive thrombi. A literature review revealed a dearth of specific treatment guidelines in this scenario. Here, we present one such case of refractory elevated ICP due to occlusive CSVT secondary to skull fractures. Initial CT venogram (CTV) on admission showed an occlusive CSVT; however, subsequent CTV on the post-trauma day (PTD) 4 and 6 showed non-occlusive thrombi only. The risks of worsening acute TBI-related hemorrhage with systemic anticoagulation versus the benefit of treating an occlusive CSVT are discussed here. In cases of occlusive CSVT with refractory elevated ICP and stable intracranial hemorrhage, the benefit of anticoagulation may outweigh the overall risks of hemorrhage expansion as prolonged uncontrolled ICP elevation is inevitably fatal. In this case, anticoagulation started on PTD 6, led to the resolution of ICP elevation and an excellent outcome for the patient, who was discharged to an acute rehab center, subsequently discharged home with no residual motor deficits, and was able to resume employment. Further prospective trials are necessary to develop guidelines for the management of occlusive CSVT in patients with severe TBI and to determine which patient populations are likely to benefit from early initiation of therapeutic anticoagulation.
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http://dx.doi.org/10.7759/cureus.17801DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8497043PMC
September 2021

The Rothman Index Does Not Predict a Successful Extubation in the Neurosurgical Critical Care Unit.

Cureus 2021 Jul 12;13(7):e16339. Epub 2021 Jul 12.

Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, USA.

Background Identification of risk factors associated with successful extubation in neurosurgical critical care units (NSICUs) has been elusive due to the complex nature of neurocritical care injuries and patient factors. Traditional risk factors for extubation were shown to have poor predictive value in neurocritical care patients as compared to mixed ICU patients. The aim of this study was to determine if any risk factors, including the Rothman Index, could reliably predict successful extubation in a large sample size of neurocritical care patients. Methods We retrospectively analyzed 610 consecutively intubated patients in an NSICU while collecting variables of interest in airway management. Furthermore, Rothman Indices were collected immediately after intubations and extubations. A paired t-test of the immediate changes in Rothman Indices after airway manipulation was compared in patients who needed reintubation. In a smaller cohort of 88 patients, in whom complete data points existed for airway management, we performed a principal component analysis (PCA) to determine which risk factors were associated with extubation success when indexed with the magnitude of the Rothman Index. Results In 610 consecutively intubated patients, the mean pre-intubation Rothman Index average was 41.0 compared to the mean post-extubation Rothman Index was 35.4 (p<0.0001). Compared to those who were re-intubated, the Rothman Index did not correlate well with the prediction of extubation (p=0.355). Furthermore, an analysis of the PCA plot showed that a higher respiratory rate, longer length of stay, shorter length of intubation, and smaller cuff leak percentage were identified as risk factors associated with reintubation. Age and change in rapid shallow breathing index (RSBI) did not correlate with reintubation. Conclusion The Rothman Index does not predict extubation success in patients in an NSICU. Risk factors associated with reintubation were respiratory rate, length of stay, length of intubation, and cuff leak percentage. Reintubation rates in our single-center NSICU are on par with general critical care populations.
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http://dx.doi.org/10.7759/cureus.16339DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8357080PMC
July 2021

Resolution of cryptogenic new onset refractory status epilepticus with tocilizumab.

Epilepsy Behav Rep 2021 4;15:100431. Epub 2021 Feb 4.

Departments of Neurology, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States.

New onset refractory status epilepticus (NORSE) was defined by the International League Against Epilepsy as occurring in patients presenting without a prior diagnosis of epilepsy or other neurological disease, with seizures that persist beyond 24 h. There is still a need to develop new treatment strategies for NORSE, particularly for those patients who are least responsive to conventional medical therapies. We present a case of a young female patient without any medical history presenting with status epilepticus, which was refractory not only to anti-seizure medications and anesthetics, but also to conventional immunomodulatory therapies. After nine weeks of electroclinical seizure activity, the patient responded to two doses of tocilizumab.
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http://dx.doi.org/10.1016/j.ebr.2021.100431DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7972955PMC
February 2021

Lost to Follow-Up: Complications of an Invasive Giant Prolactinoma.

Cureus 2020 Aug 15;12(8):e9763. Epub 2020 Aug 15.

Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, USA.

Invasive giant prolactinomas are a rare type of prolactin-secreting tumors. Most lactotroph adenomas, including giant prolactinomas, consist of the sparsely granulated subtype and respond well to medical therapy with dopamine agonists. Proptosis due to intra-orbital tumor extension and ischemic infarction are two rare complications associated with these tumors. We report a case of a 51-year-old woman with a 30-year history of a macroprolactinoma who was lost to follow-up and returned with severe proptosis, a 10-cm invasive sellar mass on imaging, and markedly elevated serum prolactin levels, consistent with invasive giant prolactinoma. She was initially managed with dopamine agonists followed by palliative debulking of the tumor, which microscopically demonstrated a highly proliferative neoplasm predominantly consisting of sparsely granulated lactotroph adenoma with a minor component of the rare and aggressive acidophil stem cell adenoma subtype. Postoperatively, she developed a large left middle cerebral artery infarct and ultimately died. This case is notable in that it demonstrates the aggressive nature of invasive giant prolactinomas when not treated and highlights two rare findings in patients with this tumor: orbital invasion and ischemic infarct.
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http://dx.doi.org/10.7759/cureus.9763DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489779PMC
August 2020

Adult-onset Rasmussen's Syndrome with associated cortical dysplasia.

Epilepsy Behav Case Rep 2019 28;11:54-57. Epub 2018 Nov 28.

Department of Neurosurgery, UT Health San Antonio, San Antonio, TX, United States of America.

We describe a 23-year-old woman with previous right temporal lobe surgeries for underlying cortical dysplasia, presenting with right hemispheric seizures and epilepsia partialis continua (EPC). After anti-seizure medication adjustments, she developed focal status epilepticus with progressive EEG and neuroimaging changes. Cerebrospinal fluid and serum autoimmune panels were negative except for an elevated serum acetylcholine-receptor antibody titer, but she underwent immunosuppressive therapy. Stereotactic-EEG evaluation demonstrated multifocal independent ictal patterns in the right hemisphere. Rasmussen's Syndrome was confirmed by brain biopsy, and a hemispherectomy was performed. This patient demonstrates the rare association of adult-onset EPC with cortical dysplasia, precipitously evolving into Rasmussen's Syndrome.
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http://dx.doi.org/10.1016/j.ebcr.2018.11.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6349012PMC
November 2018

Systematic Review of Intrathecal Nicardipine for the Treatment of Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage.

Neurocrit Care 2019 10;31(2):399-405

Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA.

Intrathecal nicardipine has been shown to have some efficacy for the treatment of symptomatic cerebral vasospasm in aneurysmal subarachnoid hemorrhage (aSAH). We performed a PRISMA-based systematic review of intrathecal nicardipine for the treatment of cerebral vasospasm in aneurysmal subarachnoid hemorrhage. A total of 825 articles were reviewed. After duplicates were removed and the search criteria was applied, 9 articles remained that were eligible for inclusion and analysis. 377 patients received a total of 6,596 injections of intrathecal nicardipine for aSAH-related cerebral vasospasm. The cumulative ventriculostomy-associated infection risk was 6%. Intrathecal nicardipine injections for aSAH-related cerebral vasospasm appears efficacious and safe. Administration of 4 mg of nicardipine every 12 hours was the most commonly reported dosing regimen. Intrathecal nicardipine decreases mean flow velocities on transcranial Doppler and reduces angiographic and clinical vasospasm. The infection risk appears to be in-line with studies in which rates of EVD-related infections have been reported.
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http://dx.doi.org/10.1007/s12028-018-0659-9DOI Listing
October 2019

External validation of the epidemiology-based mortality score in status epilepticus in an American intensive care population.

Epilepsy Res 2018 12 3;148:32-36. Epub 2018 Oct 3.

Department of Neurosurgery, UT Health San Antonio Lozano School of Medicine, United States.

Introduction: Although overall mortality of status epilepticus is high, baseline patient characteristics and co-morbidities may be helpful to predict outcomes and shape treatment decisions. Two previously published scoring systems exist to predict outcomes: the Status Epilepticus Severity Score (STESS) and the Epidemiology-based Mortality Score in Status Epilepticus (EMSE). However, a comparison of the two scores has not previously been completed in an American intensive care unit. We hypothesize that both scores will adequately predict the primary outcome of in-hospital death, but that the EMSE may more accurately predict functional outcomes, and significantly impact treatment decisions for both clinicians and families.

Methods: We performed a retrospective analysis of all cases of status epilepticus admitted to the Neuro-Critical Care Unit (NCCU) at the Ohio State University Wexner Medical Center from 6/1/2014 - 8/31/2015. We collected data on age, comorbidities, EEG findings, and seizure history. The primary outcome measured was in-hospital death; secondary outcomes included length of stay in the NCCU, placement of a tracheostomy and/or a percutaneous endoscopic gastrostomy upon discharge, and discharge location were used as surrogate markers for outcome severity. A sensitivity and specificity analysis was carried out, in addition to a student's t-test for a comparison of the two scores. ANOVA was completed to compare secondary outcomes RESULTS: Forty-six patients were admitted to the NCCU for management of status epilepticus during June 2014 and January 2016, thirteen of which experienced in-hospital death. The median age of the sample was 60, with approximately half of the sample (52.63%) having 3 or more comorbidities. The sensitivity of both EMSE and STESS were very high (100% and 90% respectively); however, the specificities were very low (28.6% and 42.9% respectively). A student's t-test between those who experienced in-hospital death and those who did not was only significant for EMSE at the p < 0.1 level (p = 0.055). Additionally, mean EMSE scores but not STESS scores, were significantly higher (p < 0.001) for those patients who were discharged to skilled nursing facilities or with hospice than compared to those who were discharged to home or to acute inpatient rehabilitation.

Conclusions: The EMSE and STESS may be useful to predict outcomes of status epilepticus in populations with few comorbid conditions, but are less helpful when patients have multiple medical problems. Secondly, while neither score may be specific enough to differentiate for the primary outcome of death, their utility may be helpful to predict secondary outcomes that strongly affect clinical decisions. Based on these results, we believe a prospective trial of EMSE and STESS should be carried out to obtain more information on their utility, especially in American patients who may have more relevant comorbidities than in other countries.
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http://dx.doi.org/10.1016/j.eplepsyres.2018.10.001DOI Listing
December 2018

Laboratory characteristics of ischemic stroke patients with atrial fibrillation on or off therapeutic warfarin.

Clin Cardiol 2017 Dec 18;40(12):1347-1351. Epub 2017 Dec 18.

Department of Neurology, University of Texas Lozano Long School of Medicine, San Antonio.

Background: In patients with atrial fibrillation (AF), despite adequate anticoagulation, ischemic stroke (IS) is an uncommon yet concerning occurrence.

Hypothesis: Specific laboratory parameters may affect the efficacy of warfarin despite therapeutic international normalized ratio (INR) in patient with AF who present with IS.

Methods: We used the database from a multicenter clinical trial to identify AF patients who presented with IS. We trichotomized the cohort into patients with therapeutic INR on warfarin, subtherapeutic INR on warfarin, and on no anticoagulants. We then compared baseline laboratory characteristics and other baseline features among the groups.

Results: Patients with therapeutic INR presented with higher serum creatinine (P = 0.01) and blood urea nitrogen (P = 0.02) and lower glomerular filtration rates (P = 0.001) compared with other groups. Other laboratory parameters were not different among the 3 groups. Patients with therapeutic INR also presented with milder stroke symptoms (P = 0.01). Medical history of the 3 groups was not different, except for history of valvular heart disease, which was more prevalent in patients with therapeutic INR (P = 0.004). In-hospital mortality rates and 90-day disability were not different among the 3 groups.

Conclusions: AF patients who presented with IS on therapeutic warfarin had higher average serum creatinine and blood urea nitrogen, and lower glomerular filtration rates, compared with others. Impaired renal function may be a factor contributing to occurrence of IS in AF patients despite adequate anticoagulation. Larger, targeted studies are needed to confirm these findings.
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http://dx.doi.org/10.1002/clc.22838DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6490348PMC
December 2017

Complications of invasive intracranial pressure monitoring devices in neurocritical care.

Neurosurg Focus 2017 Nov;43(5):E6

Department of Neurosurgery, University of Texas Health San Antonio, Texas; and.

Intracranial pressure monitoring devices have become the standard of care for the management of patients with pathologies associated with intracranial hypertension. Given the importance of invasive intracranial monitoring devices in the modern neurointensive care setting, gaining a thorough understanding of the potential complications related to device placement-and misplacement-is crucial. The increased prevalence of intracranial pressure monitoring as a management tool for neurosurgical patients has led to the publication of a plethora of papers regarding their indications and complications. The authors aim to provide a concise review of key contemporary articles in the literature concerning important complications with the hope of elucidating practices that improve outcomes for neurocritically ill patients.
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http://dx.doi.org/10.3171/2017.8.FOCUS17450DOI Listing
November 2017

The Effect of Morbid Obesity on Subarachnoid Hemorrhage Prognosis in the United States.

World Neurosurg 2017 Sep 20;105:732-736. Epub 2017 Jun 20.

Department of Neurology, School of Medicine, University of Texas Health at San Antonio, Texas, USA; Department of Neurosurgery, School of Medicine, University of Texas Health at San Antonio, Texas, USA. Electronic address:

Objective: The association between obesity and nontraumatic subarachnoid hemorrhage (SAH) patient outcome is unclear. The aim of this study was to determine the impact of morbid obesity (body mass index ≥40 kg/m) on nontraumatic SAH outcomes.

Methods: Using the Nationwide Inpatient Sample, we identified hospitalized, nontraumatic SAH patients who received their diagnoses from 2008 to 2013 and tested the effect of obesity on their mortality and clinical outcomes. Odds ratios were estimated with a mixed effects linear logistic model with adjustment for hospital clustering. All statistical testing was 2-sided, with a significance level of 5%.

Results: Out of 224,561 discharged patients with a diagnosis of nontraumatic SAH, 4714 (2.10%) were defined as morbidly obese. Patients with morbid obesity were younger (54.3 ± 0.44 vs. 59.5 ± 0.08 years; P < 0.001) and had longer length of stay (LOS) (13 ± 0.46 vs. 11.5 ± 0.06 days; P = 0.002). Morbid obesity was associated with significantly higher hospital costs (P < 0.001) and charges (P < 0.001). The risk of acute respiratory failure was higher in morbidly obese patients (odds ratio [OR] 1.49, 95% confidence interval [CI]: 1.3-1.71, P < 0.001). In a multivariate analysis of hospital mortality, obesity had a negative impact on mortality (OR 0.83, 95% CI: 0.74-0.92, P < 0.001). Overall, in-hospital mortality was associated with age, morbid obesity, LOS, clipping and coiling, and acute respiratory failure but not the symptomatic vasospasm.

Conclusions: Morbid obesity is associated with increased LOS, hospital costs and charges and with acute respiratory failure. However, it is also associated with a decrease in hospital mortality.
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http://dx.doi.org/10.1016/j.wneu.2017.06.068DOI Listing
September 2017

Clinical Course and Outcomes of Small Supratentorial Intracerebral Hematomas.

J Stroke Cerebrovasc Dis 2017 Jun 3;26(6):1216-1221. Epub 2017 Feb 3.

Neurological Service, San Camillo de' Lellis General Hospital, Rieti, Italy; The Neurological Section, SMDN, Centre for Cardiovascular Medicine and Cerebrovascular Disease Prevention, Sulmona, L'Aquila, Italy.

Background And Purpose: Intracerebral hemorrhage (ICH) volume, particularly if ≥30 mL, is a major determinant of poor outcome. We used a multinational ICH data registry to study the characteristics, course, and outcomes of supratentorial hematomas with volumes <30 mL.

Methods: Basic characteristics, clinical and radiological course, and 30-day outcomes of these patients were recorded. Outcomes were categorized as early neurological deterioration (END), hematoma expansion, Glasgow Outcome Scale (GOS), and in-hospital death. Poor outcome was defined as composite of in-hospital death and severe disability (GOS ≤ 3). Comparison was conducted based on hemorrhage location. Logistic regression using dichotomized outcome scales was applied to determine predictors of poor outcome.

Results: Among 375 cases of supratentorial ICH with volumes <30 mL, expansion and END rates were 19.2% and 7.5%, respectively. Hemorrhage growth was independently associated with END (odds ratio: 28.7, 95% confidence interval [CI]: 8.51-96.5; P < .0001). Expansion rates did not differ according to ICH location. Overall, 13.9% (exact binomial 95% CI: 10.5-17.8) died in the hospital and 29.1% (CI: 24.5-34.0) had severe disability at 30 days; there was a cumulative poor outcome rate of 42.9% (CI: 37.9-48.1). Age, admission Glasgow Coma Scale, intraventricular extension, and END were independently associated with poor outcome. There was no difference in poor outcome rates between lobar and deep locations (40.2% versus 43.8%, P = .56).

Conclusion: Patients with supratentorial ICH <30 mL have high rates of poor outcome at 30 days, regardless of location. Nearly 1 in 5 hematomas <30 mL expands, leading to END or death.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2017.01.010DOI Listing
June 2017

Superficial temporal artery haemorrhage caused by neurophysiological monitoring: a unique MRI finding.

BMJ Case Rep 2017 Jan 10;2017. Epub 2017 Jan 10.

Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.

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http://dx.doi.org/10.1136/bcr-2016-218557DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5256507PMC
January 2017

Hypomagnesemia in Intracerebral Hemorrhage.

World Neurosurg 2015 Dec 1;84(6):1929-32. Epub 2015 Sep 1.

Neurological Intensive Care Unit, Neuroscience Regional Development and Clinical Integration, OhioHealth, Columbus, Ohio, USA.

Background: Magnesium (Mg) is an essential element for the body's normal physiological functioning. It has a major role in modulating vascular smooth muscle tone and peripheral arterial resistance. A low serum Mg level on admission (HMg0) has been associated with more severe presentation in patients with subarachnoid hemorrhage. However, data on HMg0 specifically in relation to intracerebral hemorrhage (ICH) are scarce. We sought to determine the incidence and clinical significance of HMg0 in patients with ICH.

Methods: We reviewed the records of consecutive patients with ICH over a 2-year period. Data collected included initial Mg levels (Mg0), clinical and radiologic characteristics on presentation, and discharge outcomes. Regression analysis was performed to look for any association of low Mg0 with admission blood pressure (BP) and Glasgow Coma Scale (GCS) scores. We also examined the correlation of HMg0 with clinical/radiologic features, admission severity (based on the ICH score), and poor outcome on discharge.

Results: In all, 33.6% presented with HMg0. Mg0 levels were negatively associated with systolic BP presentation (P < 0.0001) and positively associated with the initial GCS scores (P = 0.01). Multivariate logistic regression showed an association between HMg0 and severity at presentation (P = 0.03), but not with poor outcome on discharge (P = 0.26).

Conclusions: HMg0 occurs in one third of patients with ICH and is associated with more severe presentation and intraventricular hemorrhage. Mg levels on admission correlate inversely with systolic BP and directly with GCS scores at presentation. HMg0 does not influence outcomes at discharge.
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http://dx.doi.org/10.1016/j.wneu.2015.08.036DOI Listing
December 2015

The Safety and Feasibility of Admitting Patients With Intracerebral Hemorrhage to the Step-Down Unit.

J Intensive Care Med 2016 Jul 29;31(6):409-11. Epub 2015 Mar 29.

Department of Neurology, Division of Cerebrovascular Diseases & Neurosciences Critical Care, The Ohio State University College of Medicine, Columbus, OH, USA

Background: Intracerebral hemorrhage (ICH) is a devastating and costly condition. Although the American Heart Association/American Stroke Association recommends admitting patients with ICH to a neurocritical care unit (NCCU), this strategy may accrue unnecessary cost for patients with relatively milder presentation. We conducted a prospective observational study to determine the safety and feasibility of admitting patients with mild ICH directly to a step-down unit (SDU) instead of an NCCU.

Methods: Consecutive patients with "mild presentation," defined as a combination of ICH score ≤2, National Institutes of Health Stroke Scale (NIHSS) ≤ 15, and Graeb score ≤2 (if intraventricular hemorrhage was present), were admitted to the SDU. Data were collected on age, gender as well as the initial NIHSS, Glasgow Coma Scale (GCS), ICH, and Graeb scores. Primary end point was any complication or death during hospital stay.

Results: Twenty patients were admitted to the SDU. No patient was transferred to the NCCU from the SDU. One patient, who eventually died, had respiratory insufficiency due to hospital-acquired pneumonia.

Conclusion: Admission of ICH patients with mild symptoms to the SDU is safe and feasible. Larger prospective studies are needed to define the specific criteria for admission.
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http://dx.doi.org/10.1177/0885066615578113DOI Listing
July 2016

Admission Leukocytosis in Intracerebral Hemorrhage: Associated Factors and Prognostic Implications.

Neurocrit Care 2015 Dec;23(3):370-3

Neuroscience Regional Development and Clinical Integration, Ohio Health, Columbus, OH, USA.

Background And Purpose: Leukocytosis is a reaction that is usually, but not always, associated with an infectious process. There is very little data on the significance of admission leukocytosis (AL) in patients with intracerebral hemorrhage (ICH). The purpose of this study was to investigate the associated clinical and radiologic findings and prognostic significance of AL in patients with ICH.

Methods: We retrospectively reviewed the records of consecutive ICH patients admitted over a 2-year period. Key data we collected included ICH size, location, intraventricular hemorrhage (IVH), age, admission Glasgow Coma Scale (GCS0) score, peak leukocyte count and temperature in the first 24 h of hospitalization, and outcomes on discharge. Severity of IVH was calculated using the Graeb Scale. Logistic regression was performed to determine association of variables.

Results: In 128 consecutive ICH patients, AL was present in 41.4 %. AL was significantly associated with presence (OR 2.28, 95 % CI 1.11-4.68; p = 0.024), but not severity of IVH and with admission GCS0. Leukocyte count showed a strong association with IVH (p = 0.01) and with decreasing GCS0 (p = 0.007). There was no correlation between AL and poor outcome at discharge. There was also no evidence of infection in any patient with AL.

Conclusion: AL in ICH patients is often non-infectious, strongly associated with the presence of IVH, but not specifically an ominous indicator for outcome. Leukocyte count has an inverse relationship with GCS0. Prospective studies are needed to confirm these findings.
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http://dx.doi.org/10.1007/s12028-015-0128-7DOI Listing
December 2015

Recent innovations in the management of low-grade gliomas.

Curr Treat Options Neurol 2012 Aug;14(4):369-80

Department of Neurology/Neurosurgery, Wexner Medical Center at The Ohio State University Medical Center, 456 West 10th Avenue, Suite 1200, Columbus, OH, 43210, USA,

Opinion Statement: Advancement in the understanding of biologic mechanisms of low-grade glioma pathophysiology has allowed the modern era of patient-specific genetic profiling, molecular biology, and neuroimaging to design new methods of surgery, radiation, and chemotherapy in hopes of preventing malignant transformation and improving outcomes. Recent innovations in the understanding of MGMT promoter methylation, IDH1 and IDH2 mutations, temozolomide chemotherapy, vascular monoclonal antibody treatment, use of radiation therapy, choice of antiepileptic drugs, surgical resection, and neuroimaging of low-grade gliomas are reviewed.
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http://dx.doi.org/10.1007/s11940-012-0185-6DOI Listing
August 2012
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