Utilization Review Determination: Continued Inpatient Stay for Vertebral Artery Dissection with Post-Procedural Complications
CERTIFY continued inpatient stay through the requested dates. This patient requires ongoing hospital-level monitoring and management for significant post-neurointerventional complications that cannot be safely managed in an outpatient setting.
Primary Justification for Continued Stay
The patient has developed gross hematuria with clot formation requiring continuous bladder irrigation (CBI) following two separate neurointerventional procedures (left transverse sinus stenting and straight sinus stenting), which necessitates inpatient urological management and monitoring. 1
Post-Procedural Complications Requiring Inpatient Management
Significant hematuria with clot formation developed after the neurointerventional procedures, with estimated overnight blood loss of substantial volume requiring foley catheter placement and continuous bladder irrigation 1
Femoral access site complication with patient-reported bulging at the left groin access site noted during ambulation, raising concern for pseudoaneurysm or hematoma formation requiring vascular surgery evaluation 1
Ongoing CBI requirement with clots still present in the foley bag, though improving, indicates unresolved bleeding that requires hospital-level monitoring and intervention 1
Guideline-Based Support for Post-Procedural Monitoring
The AHA/ASA guidelines explicitly state that the immediate post-procedure period requires "continued in-hospital support and monitoring with control of blood pressure, prevention of bleeding and access-site complications, and neurological reassessment." 1
Specific Post-Procedural Requirements Met
Blood pressure monitoring and management is essential post-stenting to prevent hyperperfusion syndrome and maintain systolic BP <180 mmHg to minimize intracranial hemorrhage risk 1
Access-site complication monitoring is a recognized guideline requirement, and this patient has developed a concerning femoral access site bulge requiring evaluation 1
Bleeding complication management requires hospital-level care, particularly when involving antiplatelet therapy (ASA and Plavix) that cannot be discontinued given the recent stent placement 1
Vertebral Artery Dissection Management Context
For symptomatic vertebral artery dissection, antithrombotic treatment for 3-6 months is recommended, and this patient is on dual antiplatelet therapy (ASA and Plavix) following stent placement, which increases bleeding risk and complicates outpatient management of hematuria. 2, 3
Disease-Specific Considerations
Vertebral artery dissection with suspected dissection of the proximal right vertebral artery was the initial presentation, requiring neurointerventional management 2, 3
Recurrent symptoms (headache, visual disturbances, facial numbness) prompted the transverse and straight sinus stenting procedures, indicating refractory disease requiring invasive intervention 2, 3, 4
Dual antiplatelet therapy is mandatory for at least 6 months post-stenting and cannot be interrupted, making bleeding complications particularly challenging to manage 3, 5
Barriers to Safe Discharge
The patient explicitly expressed concern about discharge with a foley catheter given lack of established outpatient care, and premature discharge with ongoing hematuria, CBI requirement, and potential vascular access complication would pose significant safety risks. 1
Specific Discharge Barriers
Active bleeding requiring CBI cannot be safely managed in an outpatient setting, particularly in a patient on mandatory dual antiplatelet therapy 1
Lack of established outpatient care as noted by the patient creates a care coordination barrier that must be resolved prior to discharge 1
Potential femoral pseudoaneurysm or hematoma requires vascular surgery evaluation and possible intervention before discharge 1
Dysuria and ongoing urological issues require urology consultation and management plan completion before safe discharge 1
Clinical Stability Requirements Not Yet Met
Guidelines specify that post-procedural patients require observation until hemodynamic stability is achieved and complications are resolved or have a clear outpatient management plan. 1
Outstanding Clinical Issues
Hematuria resolution must be documented with clear urine and successful voiding trial off CBI before foley removal can be considered 1
Vascular access site evaluation must be completed with ultrasound if pseudoaneurysm is suspected, and intervention performed if indicated 1
Outpatient care coordination including urology follow-up, neurology follow-up, and primary care establishment must be arranged 1
Patient education on dual antiplatelet therapy, bleeding precautions, and neurological warning signs must be completed 3
MCG Criteria Alignment
The case meets MCG criteria for extended stay beyond goal length given the post-procedural complications (hematuria requiring CBI, access site complication) that require hospital-level monitoring and intervention. While the MCG reference to "crescendo TIA with carotid plaque" is not perfectly matched to this vertebral dissection case, the principle of extended stay for procedural complications and ongoing intervention needs is applicable.
Common Pitfalls to Avoid
Do not discharge patients on dual antiplatelet therapy with active bleeding until the bleeding source is controlled and a safe outpatient plan exists 1, 3
Do not overlook femoral access site complications as these can lead to catastrophic hemorrhage or limb ischemia if pseudoaneurysm ruptures or thromboses 1
Do not discharge without established outpatient care for complex neurointerventional patients requiring close follow-up and medication management 1
DETERMINATION: CERTIFY continued inpatient stay. The patient requires ongoing management of post-procedural hematuria with CBI, evaluation and management of potential femoral access site complication, and care coordination prior to safe discharge.