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OBJECTIVE Recent guidelines recommend targeting a systolic blood pressure (SBP) < 140 mm Hg in the early management of patients with spontaneous intracerebral hemorrhage (ICH). The optimal SBP targets for ICH patients after hematoma evacuation (HE) remain unclear. Here, the authors aimed to define the optimal SBP range based on multimodal neuromonitoring data. METHODS Forty poor-grade ICH patients who had undergone HE and then monitoring of intracerebral pressure, brain tissue oxygen tension (PbtO2), and cerebral metabolism (via cerebral microdialysis [CMD]) were prospectively included. Episodes of brain tissue hypoxia (BTH) (1-hour averaged PbtO2 < 20 mm Hg) and metabolic distress (CMD–lactate/pyruvate ratio [LPR] ≥ 40) were identified and linked to corresponding parameters of hemodynamic monitoring (SBP and cerebral perfusion pressure [CPP]). Multivariable regression analysis was performed using generalized estimating equations to identify associations between SBP levels, PbtO2, and brain metabolism. RESULTS The mean patient age was 60 (range 51–66) years and the median [IQR] initial ICH volume was 47 [29–60] ml. In multivariable models adjusted for Glasgow Coma Scale score, probe location, ICH volume, and age, lower SBP was independently associated with a higher risk of BTH (≤ 120 mm Hg: adjusted OR 2.9, p = 0.007; 120–130 mm Hg: adj OR 2.4, p = 0.002; 130–140 mm Hg: adj OR 1.6, p = 0.017) compared to a reference range of 140–150 mm Hg at the level of the foramen interventriculare Monroi, which corresponded to a CPP of 70–80 mm Hg and SBP levels between 150 and 160 mm Hg at the heart level. After exclusion of episodes with mitochondrial dysfunction, SBP targets < 140 mm Hg were associated with higher odds of cerebral metabolic distress (≤ 130 mm Hg: OR 2.5, p = 0.041; 130–140 mm Hg: OR 2.3, p = 0.033). Patients with a modified Rankin Scale score ≥ 5 at neurological ICU discharge more often exhibited BTH than patients with better outcomes (51% vs 10%, p = 0.003). CONCLUSIONS These data suggest that lower SPB and CPP levels are associated with a higher risk for BTH. Further studies are needed to evaluate whether a higher SPB target may prevent BTH and improve outcomes.

Purpose Hyperactive delirium is common after subarachnoid hemorrhage (SAH). We aimed to identify risk factors for delirium and to evaluate its impact on outcome. Methods We collected daily Richmond Agitation Sedation Scale (RASS) and Intensive Care Delirium Screening Checklist (ICDSC) scores in 276 SAH patients. Hyperactive delirium was defined as ICDSC ≥4 when RASS was >0. We investigated risk factors for delirium and its association with 3-month functional outcome using generalized linear models. Results Patients were 56 (IQR 47–67) years old and had a HuntH 95%-CI = 1.89–10.56; p = 0.001), the detection of an aneurysm (adjOR = 4.38; 95%-CI = 1.48–12.97; p = 0.008), a lower HH 95%-CI = 0.48–0.83; p = 0.001) and a pre-treated psychiatric disorder (adjOR = 3.17; 95%-CI = 1.14–8.83; p = 0.027) were associated with the development of delirium. Overall, delirium was not associated with worse outcome (p = 0.119). Interestingly, patients with delirium more often had a modified Rankin Scale Score (mRS) of 1–3 (77%) compared to an mRS of 0 (14%) or 4–6 (9%). Conclusion Our data indicate that hyperactive delirium is common after SAH patients and requires a certain degree of brain connectivity based ono the highest prevalence found in SAH patients with intermediate outcomes.

Purpose Cardiac complications are common after spontaneous intracerebral hemorrhage (ICH). In this study we intended to investigate factors associated with higher alterations in heart rate and their impact on outcome. Methods Eighty-eight ICH patients were included. A simplified approach to calculate heart rate variability (HRSD) in analogy to systolic blood pressure variability (SBPSD) with daily standard deviations of HR in the acute (first 24 h) and subacute phase (day1-day7) was used. Using multivariable regression, factors associated with higher HRSD and the association between higher HRSD and poor 3-month outcome (modified Rankin Scale > 3) were analyzed. All models were adjusted for age, atrial fibrillation, mechanical ventilation, vasopressor administration, and mean HR. Results Patients were 71 (IQR = 60–79) years old and presented with an admission ICH-Score of 2 (IQR = 1–3). In multivariable analysis, intraventricular hemorrhage (adjOR = 8.66, 95%-CI = 1.89–39.60, p = 0.005), a QRS complex >120 ms (adjOR = 19.02; 95%-CI = 2.08–175.05, p = 0.009) and female sex (adjOR = 4.24; 95%-CI = 1.08–16.64, p = 0.038) were associated with higher HRSD in the acute phase. A higher HRSD (adjOR = 1.29, 95%-CI = 1.01–1.66, p = 0.045) in the acute but not in the subacute phase (p = 0.764) was associated with poor 3-month outcome. Conclusion The study suggests that a higher variation in heart rate in the early phase after ICH may discriminate patients with poor outcome.

Background Endotracheal suctioning (ES) provokes a cumulative hemodynamic response by activation of sympathetic and parasympathetic circuits in the central nervous system. In this proof-of-concept study, we aimed to analyze hemodynamic changes during ES in ventilated subarachnoid hemorrhage (SAH) patients and investigated whether the associated hemodynamic changes relate to the time to arousal and functional outcome. Methods For the current observational study, 191 SAH patients admitted to the neurological intensive care unit of a tertiary hospital requiring mechanical ventilation were included. One thousand eighty ES episodes during the first 72 h of admission were analyzed. Baseline median heart rate (HR) and mean arterial pressure (MAP) were compared to peak HR and MAP during ES based on 5-min averaged data (ΔHR and ΔMAP). Multivariable analysis to assess associations between ΔHR and ΔMAP and time to arousal (time to Richmond Agitation Sedation Scale ≥ 0, RASS) and poor functional outcome (modified Rankin Scale Score > 2, mRS) was performed using generalized estimating equations. Results Patients were 59 (IQR, 50–70) years old and presented with a median admission H&H grade of 4 (IQR, 3–5). In-hospital mortality was 22% (25% at 3 months) and median time to arousal was 13 (IQR, 4–21) days. HR increased by 2.3 ± 7.1 beats per minute (bpm) from 75.1 ± 14.8 bpm at baseline. MAP increased by 3.2 ± 7.8 mmHg from baseline 80.9 ± 9.8 mmHg. In multivariable analysis, ΔHR (p p = 0.087) nor with functional outcome (p = 0.263). Conclusion Augmentation in heart rate may quantify the hemodynamic response during endotracheal suctioning in brain-injured patients. The value as a biomarker to early discriminate the time to arousal and functional outcome in acutely brain-injured patients needs prospective confirmation.

Elevated body temperature (Tcore) is associated with poor outcome after subarachnoid hemorrhage (SAH). Brain temperature (Tbrain) is usually higher than Tcore. However, the implication of this difference (Tdelta) remains unclear. We aimed to study factors associated with higher Tdelta and its association with outcome. We included 46 SAH patients undergoing multimodal neuromonitoring, for a total of 7879 h of averaged data of Tcore, Tbrain, cerebral blood flow, cerebral perfusion pressure, intracranial pressure and cerebral metabolism (CMD). Three-months good functional outcome was defined as modified Rankin Scale ≤2. Tbrain was tightly correlated with Tcore (r = 0.948, p delta +0.18°C, IQR −0.01 – 0.37°C). A higher Tdelta was associated with better metabolic state, indicated by lower CMD-glutamate ( p = 0.003) and CMD-lactate ( p delta was significantly lower (0°C, IQR −0.2 – 0.1; p delta was associated with improved outcome (OR = 7.7, p = 0.002). Our study suggests that Tbrain is associated with brain metabolic activity and exceeds Tcore when mitochondrial function is preserved. Further studies are needed to understand how Tdelta may serve as a surrogate marker for brain function and predict clinical course and outcome after SAH.

Background Despite the tremendous impact of swallowing disorders on outcome following ischemic stroke, little is known about the incidence of dysphagia after subarachnoid hemorrhage (SAH) and its contribution to hospital complications, length of intensive care unit stay, and functional outcome. Methods This is a retrospective analysis of an ongoing prospective cohort study. Swallowing ability was assessed in consecutive non-traumatic SAH patients admitted to our neurological intensive care unit using the Bogenhausen Dysphagia Score (BODS). A BODS > 2 points indicated dysphagia. Functional outcome was assessed 3 months after the SAH using the modified Rankin Scale with a score > 2 defined as poor functional outcome. Results Two-hundred and fifty consecutive SAH patients comprising all clinical severity grades with a median age of 57 years (interquartile range 47–67) were eligible for analysis. Dysphagia was diagnosed in 86 patients (34.4%). Factors independently associated with the development of dysphagia were poor clinical grade on admission (Hunt & Hess grades 4–5), SAH-associated parenchymal hematoma, hydrocephalus, detection of an aneurysm, and prolonged mechanical ventilation (> 48 h). Dysphagia was independently associated with a higher rate of pneumonia (OR = 4.32, 95% CI = 2.35–7.93), blood stream infection (OR = 4.3, 95% CI = 2.0–9.4), longer ICU stay [14 (8–21) days versus 29.5 (23–45) days, p Conclusions Dysphagia is a frequent complication of non-traumatic SAH and associated with poor functional outcome, infectious complications, and prolonged stay in the intensive care unit. Early identification of high-risk patients is needed to timely stratify individual patients for dysphagia treatment.

Fever may aggravate secondary brain injury after traumatic brain injury (TBI). The aim of this study was to identify episodes of temperature increases through visual plot analysis and algorithm supported detection, and to describe associated patterns of changes in on brain tissue oxygen tension (PbtO2). Data derive from the high-resolution cohort of the multicenter prospective Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study. Temperature increases (≥0.5°C) were visually identified in 33 patients within the first 11 days of monitoring. Generalized estimating equations were used to detect significant changes of systemic and neuromonitoring parameters from baseline to the highest temperature. Patients were median 50 (interquartile range [IQR], 35-62) years old, and presented with a Glasgow Coma Scale (GCS) of 8 (IQR, 4-10). In 202 episodes of temperature increases, mean temperature rose by 1.0°C ± 0.5°C within 4 hours. Overall, PbtO2 slightly increased (ΔPbtO2 = 0.9 ± 6.1 mmHg, p = 0.022) during temperature increases. PbtO2 increased in 35% (p < 0.001), was stable in 49% (p = 0.852), and decreased in 16% (p < 0.001) of episodes. During episodes of temperature increases and simultaneous drops in PbtO2, cerebral perfusion pressure (CPP) decreased (ΔCPP -6.3 ± 11.5 mmHg; p < 0.001). Brain tissue hypoxia (PbtO2

Background and purpose To assess neurological manifestations and health‐related quality of life (QoL) 3 months after COVID‐19. Methods In this prospective, multicenter, observational cohort study we systematically evaluated neurological signs and diseases by detailed neurological examination and a predefined test battery assessing smelling disorders (16‐item Sniffin Sticks test), cognitive deficits (Montreal Cognitive Assessment), QoL (36‐item Short Form), and mental health (Hospital Anxiety and Depression Scale, Posttraumatic Stress Disorder Checklist–5) 3 months after disease onset. Results Of 135 consecutive COVID‐19 patients, 31 (23%) required intensive care unit (ICU) care (severe), 72 (53%) were admitted to the regular ward (moderate), and 32 (24%) underwent outpatient care (mild) during acute disease. At the 3‐month follow‐up, 20 patients (15%) presented with one or more neurological syndromes that were not evident before COVID‐19. These included polyneuro/myopathy (n = 17, 13%) with one patient presenting with Guillain‐Barré syndrome, mild encephalopathy (n = 2, 2%), parkinsonism (n = 1, 1%), orthostatic hypotension (n = 1, 1%), and ischemic stroke (n = 1, 1%). Objective testing revealed hyposmia/anosmia in 57/127 (45%) patients at the 3‐month follow‐up. Self‐reported hyposmia/anosmia was lower (17%) at 3 months, however, improved when compared to the acute disease phase (44%; p, Three months after COVID‐19, 20/135 patients (15%) presented with one or more neurological syndromes that were not evident before disease onset. Objective testing revealed hyposmia/anosmia in 45% of patients at the 3‐month follow‐up in comparison to 17% who reported hyposmia/anosmia. Cognitive deficits were apparent in 23%, quality of life was impaired in 31%, depression was found in 11%, anxiety in 25% and posttraumatic stress disorders in 11%.

Diabetes mellitus (DM) is a risk factor for cardiovascular disease. However, its effect on procedural and follow-up performance after transcatheter aortic valve replacement (TAVR) remains controversial. We performed an observational study of all consecutive patients treated with a transfemoral TAVR in a single-center cohort (n = 1818). All patients were stratified by diabetes status and gender. All-cause 3-year mortality was the primary endpoint. Male patients with DM were identified to have substantially increased 3-year mortality [125/314 (39.8%)] compared to males without DM [142/478 (29.7%), p

Background: Infectious complications (IC) commonly occur in patients with intracerebral hemorrhage (ICH) and are associated with increased length of hospitalization (LOS) and poor long-term outcome. Little is known about early ICH-related predictors for the development of IC to allow appropriate allocation of resources and timely initiation of preventive measures.Methods: We prospectively enrolled 229 consecutive patients with non-traumatic ICH admitted to the neurocritical care unit (NICU) of a tertiary care hospital. Patients were screened daily for IC. Multivariable regression models using generalized linear models were used to identify associated factors with the occurrence of IC and to study their impact on functional outcome, which was assessed using the modified Rankin Scale Score (mRS) after 3 months. Unfavorable outcome was defined as mRS ≥3.Results: The most common IC were pneumonia (n = 64, 28%) and urinary tract infection (n = 54, 24%), followed by sepsis (n = 9, 4%) and ventriculitis (n = 4, 2%). Patients with a higher admission ICH Score (>2) had higher odds to develop any IC during NICU stay (OR = 1.7, 95% CI 1.2–2.3, p = 0.02). Moreover, early-onset pneumonia (≤48 h after admission) was predictive of sepsis occurring at a later time-point (median at day 11 [IQR = 6–34 days], adjOR = 22.5, 95% CI 4.88–103.6, p < 0.001). Having at least one IC and pneumonia itself were independently associated with unfavorable 3-months outcome (adjOR = 3.0, 95% CI 1.41–6.54, p = 0.005; adjOR = 4.2, 95% CI 1.33–13.19, p = 0.015, respectively). All patients with sepsis died or had poor functional outcome.Conclusions: Infectious complications are common in ICH patients and independently associated with unfavorable outcome. An ICH Score >2 on admission and early pneumonia may help to early identify patients at high risk of IC to allocate resources and start careful surveillance.

Intravenous nonsteroidal anti-inflammatory drugs and nonopioid analgesics are used to achieve normothermia or relieve pain in patients with aneurysmal subarachnoid hemorrhage (aSAH). We investigated the effects of paracetamol (1 g), diclofenac (75 mg) and metamizole (1 g) on systemic and cerebral hemodynamics and temperature during febrile and nonfebrile episodes after aSAH. Prospectively collected data from 77 consecutive poor-grade aSAH patients with invasive neuromonitoring were included. The burden and occurrence of hypotension (mean arterial pressure70 mmHg), brain tissue hypoxia (P

Background Impaired left ventricular (LV) ejection fraction is a common finding in patients with aortic stenosis and serves as a predictor of morbidity and mortality after transcatheter aortic valve replacement. However, conflicting data on the most accurate measure for LV function exist. We wanted to examine the impact of LV ejection fraction, mean pressure gradient, and stroke volume index on the outcome of patients treated by transcatheter aortic valve replacement. Methods and Results Patients treated by transcatheter aortic valve replacement were primarily separated into normal flow ( NF ; stroke volume index >35 mL/m 2 ) and low flow ( LF ; stroke volume index ≤35 mL/m 2 ). Afterwards, patients were divided into 5 groups: “NF–high gradient,” “NF–low gradient” ( NF ‐ LG ), “LF–high gradient,” “paradoxical LF‐LG,” and “classic LF‐LG.” The 3‐year mortality was the primary end point. Of 1600 patients, 789 (49.3%) were diagnosed as having LF , which was characterized by a higher 30‐day ( P =0.041) and 3‐year ( P LF was an independent predictor of all‐cause (hazard ratio, 1.29; 95% confidence interval, 1.03–1.62; P =0.03) and cardiovascular (hazard ratio, 1.37; 95% confidence interval, 1.06–1.77; P =0.016) mortality. Neither mean pressure gradient nor LV ejection fraction was an independent predictor of mortality. Patients with paradoxical LF‐LG (35.0%), classic LF‐LG (35.1%) and LF –high gradient (38.1%) had higher all‐cause mortality at 3 years compared with NF –high gradient (24.8%) and NF ‐ LG (27.9%) ( P =0.001). However, surviving patients showed a similar improvement in symptoms regardless of aortic stenosis entity. Conclusions LF is a common finding within the aortic stenosis population and, in contrast to LV ejection fraction or mean pressure gradient, an independent predictor of all‐cause and cardiovascular mortality. Despite increased long‐term mortality, high procedural success and excellent functional improvement support transcatheter aortic valve replacement in patients with LF severe aortic stenosis.

Studies of infective endocarditis (IE) in transcatheter aortic valve replacement patients are limited by univariate analysis of predictors [(1)][1], incomplete patient data (particularly non-IE cases [[2]][2]), or low number of endpoints [(3)][3]. We aimed to investigate the incidence, treatment