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Purpose: The Multicentre Acute ischemic stroke imaGIng and Clinical data (MAGIC) repository is a collaboration established in 2024 by seven stroke centres in Europe. MAGIC consolidates clinical and radiological data from acute ischemic stroke (AIS) patients who underwent endovascular therapy, intravenous thrombolysis, a combination of both, or conservative management. Participants: All centres ensure accuracy and completeness of the data. Only patients who did not refuse use of their routine data collected during or after their hospital stay are included in the repository. Approvals or waivers are obtained from the responsible ethics committees before data exchange. A formal data transfer agreement (DTA) is signed by all contributing centres. The centres then share their data, and files are stored centrally on a safe server at the University Hospital Zurich. There, patient identifiers are removed and images are algorithmically de-faced. De-identified structured clinical data are connected to the imaging data by a new identifier. Data are made available to participating centres which have entered into a DTA for stroke research projects. Repository setup: Initially, MAGIC is set to comprise initial and first follow-up imaging of 2,500 AIS patients. Clinical data consist of a comprehensive set of patient characteristics and routine prehospital metrics, treatment and laboratory variables. Outlook: Our repository will support research by leveraging the entire range of routinely collected imaging and clinical data. This dataset reflects the current state of practice in stroke patient evaluation and management and will enable researchers to retrospectively study clinically relevant questions outside the scope of randomized controlled clinical trials. New centres are invited to join MAGIC if they meet the requirements outlined here. We aim to reach approximately 10,000 cases by 2026. [ABSTRACT FROM AUTHOR]

Purpose: Examining the impact of scoring aids on the accuracy of assessing the Glasgow Coma Score (GCS) in a standardized trauma scenario (primary outcome). Evaluating physicians’ understanding of the GCS assessment and clinical application (secondary outcome). Materials and methods: This randomized trial was performed at the simulator center of a Swiss tertiary academic medical hospital. Participants included intensivists, emergency physicians, internists, and neurologists. The setting involved a trauma patient portraying a GCS of 8 (eyes 1, verbal 2, motor 5). Participants were randomized to receiving or not receiving a scoring aid. Video/audio recordings of the assessments and questionnaires were analyzed by two investigators. Results: Among 109 participants, 55 received a scoring aid. Overall, 52% scored correctly (score interquartile range 7–8); 43% scored too low and 90% scored within a range of ± 1. A scoring aid increased accuracy (62% vs. 43%, p = 0.045) and participants’ confidence, whilst decreasing assessment duration. Clinical experience further improved reliability. 89% found assessing a GCS of 8 most challenging, particularly with motor response evaluation (64%). 26% indicated tracheal intubation to be mandatory with a score of GCS ≤ 8. Conclusions: GCS assessment is improved by professional experience and a scoring aid, the use of which needs to be promoted in daily clinical practice. Frequent inaccuracy and misunderstanding regarding clinical applications may alter patient management and misguide treatment and prognosis. Trial registration: ISRCTN registry (IDISRCTN12257237) Retrospectively registered (last amendment 08/22/2023). [ABSTRACT FROM AUTHOR]

Purpose: Examining the impact of scoring aids on the accuracy of assessing the Glasgow Coma Score (GCS) in a standardized trauma scenario (primary outcome). Evaluating physicians’ understanding of the GCS assessment and clinical application (secondary outcome). Materials and methods: This randomized trial was performed at the simulator center of a Swiss tertiary academic medical hospital. Participants included intensivists, emergency physicians, internists, and neurologists. The setting involved a trauma patient portraying a GCS of 8 (eyes 1, verbal 2, motor 5). Participants were randomized to receiving or not receiving a scoring aid. Video/audio recordings of the assessments and questionnaires were analyzed by two investigators. Results: Among 109 participants, 55 received a scoring aid. Overall, 52% scored correctly (score interquartile range 7–8); 43% scored too low and 90% scored within a range of ± 1. A scoring aid increased accuracy (62% vs. 43%, p = 0.045) and participants’ confidence, whilst decreasing assessment duration. Clinical experience further improved reliability. 89% found assessing a GCS of 8 most challenging, particularly with motor response evaluation (64%). 26% indicated tracheal intubation to be mandatory with a score of GCS ≤ 8. Conclusions: GCS assessment is improved by professional experience and a scoring aid, the use of which needs to be promoted in daily clinical practice. Frequent inaccuracy and misunderstanding regarding clinical applications may alter patient management and misguide treatment and prognosis. Trial registration: ISRCTN registry (IDISRCTN12257237) Retrospectively registered (last amendment 08/22/2023). [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to assess the efficacy and tolerability of intranasal midazolam (in-MDZ) administration for antiseizure treatment in adults. Methods: Embase and Medline literature databases were searched. We included randomized trials and cohort studies (excluding case series) of adult patients (≥ 18 years of age) examining in-MDZ administration for epilepsy, epileptic seizures, or status epilepticus published in English between 1985 and 2022. Studies were screened for eligibility based on predefined criteria. The primary outcome was the efficacy of in-MDZ administration, and the secondary outcome was its tolerability. Extracted data included study design, patient characteristics, intervention details, and outcomes. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Results: A total of 12 studies with 929 individuals treated with in-MDZ were included. Most studies were retrospective, with their number increasing over time. Administered in-MDZ doses ranged from 2.5 to 20 mg per single dose. The mean proportion of successful seizure termination after first in-MDZ administration was 72.7% (standard deviation [SD] 18%), and the proportion of seizure recurrence or persistent seizures ranged from 61 to 75%. Most frequent adverse reactions to in-MDZ were dizziness (mean 23.5% [SD 38.6%]), confusion (one study; 17.4%), local irritation (mean 16.6% [SD 9.6%]), and sedation (mean 12.7% [SD 9.7%]). Conclusions: Administration of in-MDZ seems promising for the treatment of prolonged epileptic seizures and seizure clusters in adults. Limited evidence suggests that intranasal administration is safe. Further research is warranted because of the heterogeneity of cohorts, the variation in dosages, and the lack of uniformity in defining successful seizure termination. [ABSTRACT FROM AUTHOR]

Objectives: This review examined studies regarding the implementation and translation of patients' advance directives (AD) in intensive care units (ICUs), focusing on practical difficulties and obstacles. Methods: The digital PubMed and Medline databases were screened using predefined keywords to identify relevant prospective and retrospective studies published until 2022. Results: Seventeen studies from the United States, Europe, and South Africa (including 149,413 patients and 1210 healthcare professionals) were identified. The highest prevalence of ADs was described in a prospective study in North America (49%), followed by Central Europe (13%), Asia (4%), Australia and New Zealand (4%), Latin America (3%), and Northern and Southern Europe (2.6%). While four retrospective studies reported limited effects of ADs, four retrospective studies, one survey and one systematic review indicated significant effects on provision of intensive care, higher rates of do-not-resuscitate orders, and care withholding in patients with ADs. Four of these studies showed shorter ICU stays, and lower treatment costs in patients with ADs. One prospective and two retrospective studies reported issues with loss, delayed or no transmission of ADs. One survey revealed that 91% of healthcare workers did not regularly check for ADs. Two retrospective studies and two survey revealed that the implementation of directives is further challenged by issues with their applicability, phrasing, and compliance by the critical care team and family members. Conclusions: Although ADs may improve intensive- and end-of-life care, insufficient knowledge, lack of awareness, poor communication between healthcare providers and patients or surrogates, lack of standardization of directives, as well as ethical and legal concerns challenge their implementation. [ABSTRACT FROM AUTHOR]

Background: The DEFUSE-3 and DAWN trials showed that mechanical thrombectomy (MT) improves the outcome of selected patients with anterior circulation large vessel occlusions (LVO) up to 24 h after stroke onset. However, it is unknown whether only those patients fulfilling the trial inclusion criteria benefit, or whether benefit is seen in a broader range of patients presenting between 6 and 24 h. Aims: We determined whether fulfilling the DEFUSE-3 and DAWN selection criteria affects outcomes in MT patients in clinical practice. Methods: We reviewed adult patients with LVO treated with MT between 6 and 24 h after stroke onset at five Swiss stroke centers between 2014 and 2021. We compared two groups: (1) patients who satisfied neither DEFUSE-3 nor DAWN criteria (NDND) and (2) those who satisfied DEFUSE-3 or DAWN criteria (DOD). We used logistic regression to examine the impact of trial eligibility on two safety outcomes (symptomatic intracranial hemorrhage [sICH] and all-cause mortality at 3 months) and two efficacy outcomes (modified Rankin Score [mRS] shift toward lower categories and mRS of 0–2 at 3 months). Results: Of 174 patients who received MT, 102 (59%) belonged to the NDND group. Rates of sICH were similar between the NDND group and the DOD group (3% vs. 4%, p = 1.00). Multivariable regression revealed no differences in 3-month all-cause mortality (aOR 2.07, 95% CI 0.64–6.84, p = 0.23) or functional outcomes (mRS shift: acOR 0.81, 95% CI 0.37–1.79, p = 0.60; mRS 0–2: aOR 0.91, 95% CI 0.31–2.57, p = 0.85). Conclusion: Among adult patients with LVO treated with MT between 6 and 24 h, safety and efficacy outcomes were similar between DEFUSE-3/DAWN eligible and ineligible patients. Our data provide a compelling rationale for randomized trials with broader inclusion criteria for MT. [ABSTRACT FROM AUTHOR]

Background: Cerebral microbleeds (CMBs) may have a differential impact on clinical outcome in stroke patients with atrial fibrillation (AF) treated with different types of oral anticoagulation (OAC). Methods: Observational single-center study on AF-stroke-patients treated with OAC. Magnetic-resonance-imaging was performed to assess CMBs. Outcome measures consisted of recurrent ischemic stroke (IS), intracranial hemorrhage (ICH), death, and their combined analysis. Functional disability was assessed by mRS. Using adjusted logistic regression and Cox proportional-hazards models, we assessed the association of the presence of CMBs and OAC type (vitamin K antagonists [VKAs] vs. direct oral anticoagulants [DOACs]) with clinical outcome. Results: Of 310 AF-stroke patients treated with OAC [DOACs: n = 234 (75%); VKAs: n = 76 (25%)], CMBs were present in 86 (28%) patients; of these, 66 (77%) received DOACs. In both groups, CMBs were associated with an increased risk for the composite outcome: VKAs: HR 3.654 [1.614; 8.277]; p = 0.002; DOACs: HR 2.230 [1.233; 4.034]; p = 0.008. Patients with CMBs had ~50% higher absolute rates of the composite outcome compared to the overall cohort, with a comparable ratio between treatment groups [VKAs 13/20(65%) vs. DOACs 19/66(29%); p < 0.01]. The VKA-group had a 2-fold higher IS [VKAs:4 (20%) Frontiers inNeurology vs. DOACs:6 (9%); p = 0.35] and a 10-fold higher ICH rate [VKAs: 3 (15%) vs. DOACs: 1 (1.5%); p = 0.038]. No significant interaction was observed between type of OAC and presence of CMBs. DOAC-patients showed a significantly better functional outcome (OR 0.40 [0.17; 0.94]; p = 0.04). Conclusions: In AF-stroke patients treated with OAC, the presence of CMBs was associated with an unfavorable composite outcome for both VKAs and DOACs, with a higher risk for recurrent IS than for ICH. Strokes were numerically higher under VKAs and increased in the presence of CMBs. [ABSTRACT FROM AUTHOR]

Background: We investigate the frequency and diagnostic yield of cerebrospinal fluid (CSF) analysis in adult patients with status epilepticus (SE) and its impact on the outcome. Methods: From 2011 to 2018, adult patients treated at the University Hospital Basel were included. Primary outcomes were defined as the frequency of lumbar puncture and results from chemical, cellular, and microbiologic CSF analyses. Secondary outcomes were differences between patients receiving and not receiving lumbar puncture in the context of SE. Results: In 18% of 408 patients, a lumbar puncture was performed. Of those, infectious pathogens were identified in 21% with 15% detected ± 24 h around SE diagnosis. 74% of CSF analyses revealed abnormal chemical or cellular components without infectious pathogens. Screening for autoimmune diseases was only performed in 22%. In 8%, no or late (i.e., > 24 after SE diagnosis) lumbar puncture was performed despite persistent unknown SE etiology in all, transformation into refractory SE in 78%, and no recovery to premorbid neurologic function in 66%. Withholding lumbar puncture was associated with no return to premorbid neurologic function during hospital stay independent of potential confounders. Not receiving a lumbar puncture was associated with presumed known etiology and signs of systemic infectious complications. Conclusions: Withholding lumbar puncture in SE patients is associated with increased odds for no return to premorbid neurologic function, and CSF analyses in SE detect infectious pathogens frequently. These results and pathologic chemical and cellular CSF findings in the absence of infections call for rigorous screening to confirm or exclude infectious or autoimmune encephalitis in this context which should not be withheld. [ABSTRACT FROM AUTHOR]