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Severe traumatic brain injury (sTBI) is a condition of increasing epidemiologic concern worldwide. Outcomes are worse as observed in low- and middle-income countries (LMICs) versus high-income countries. Global targets are in place to address the surgical burden of disease. At the same time, most of the published literature and evidence on the clinical approach to sTBI comes from wealthy areas with an abundance of resources. The available paradigms, including the Brain Trauma Foundation guidelines, the Seattle International Severe Traumatic Brain Injury Consensus Conference, Consensus Revised Imaging and Clinical Examination, and multimodality approaches, may fit differently depending on local resources, expertise, and sociocultural factors. A first step toward addressing heterogeneity in practice is to consider comparative effectiveness approaches that can capture actual practice patterns and record short-term and long-term outcomes of interest. Decompressive craniectomy (DC) decreases intracranial pressure burden and can be lifesaving. Nevertheless, completed randomized controlled trials took place within high-income settings, leaving important questions unanswered and making extrapolations to LMICs questionable. The concept of preemptive DC specifically to address limited neuromonitoring resources may warrant further study to establish a benefit/risk profile for the procedure and its role within local protocols of care.

Introduction Intracranial Pressure (ICP) can be continuously and reliably measured using invasive monitoring through an external ventricular catheter or an intraparenchymal probe. We explore Electroencephelograhy (EEG) to identify a reliable real time, non-invasive ICP correlate. Methods Utilizing a previously described porcine model of intracranial hypertension, we examine the cross correlation between ICP time series and the slope of the EEG power spectral density as described by Φ. We calculate Φ= tan−1(slope of PSD) and normalized it by π where slope is that of the power-law fit (log frequency versus log power) to the power spectral density of the EEG signal. Additionally, we explore the relationship between the Φ time series and cerebral perfusion pressure (CPP). A total of 11 intracranial hypertension episodes across three different animals are studied. Results Mean correlation between Φ-angle and ICP was -0.85 (0.15); mean correlation with CPP was 0.92 (0.02). Significant correlation occurred at zero lag. In the absence of intracranial hypertension, the absolute value of the Φ-angle was greater than 0.9 (mean 0.936 radians). However, during extreme intracranial hypertension causing cerebral circulatory arrest, the Φ-angle is on average below 0.9 radians (mean 0.855 radians). Conclusion EEG Φ-angle is a promising real-time noninvasive measure of ICP/cerebral perfusion using surface electroencephalography. While intra-species variation is presumably minimal, validation in human subjects is needed.

Background Insufficient attention has been devoted to shared decision-making (SDM) in the setting of acute brain injury (ABI). Communication occupies a central role that has been highlighted in recent research on SDM with brain injured patients, with respect to “the impact of specific clinician words and expressions”. In this investigation, we seek to understand lay public understandings of the term “coma.” Methods Qualitative analysis of lay interpretations of the term “cComa” using modified open coding of a free-text response question at the end of a survey exploring public attitudes in the context of hypothetical ABI. Respondents (n = 511) were drawn from a convenience sample using Amazon Mechanical Turk. This analysis focuses on respondents' free-text responses to the question: “When doctors say a patient is in a coma, what does that mean?” Results We analyzed 206 unique responses in order to derive emergent lay conceptualizations of coma. The following 4 themes emerged in how respondents understood coma: (1) State descriptive. (2) Marker of injury severity. (3) As in distinction (or lack thereof) from brain death or sleep. (4) Covert consciousness. For each concept, we discuss its salient elements and offer representative quotes. Conclusions This study provides preliminary qualitative evidence of lay public understandings of the neurologic term “coma”. These findings can have implications for surrogate/family–clinician communications. While a physician may intend “coma” to convey a technical description, a family member or surrogate may interpret it as a very different activity (e.g., prognostication, emotional signaling), setting the stage for miscommunication.

Unplanned readmission to the neurological intensive care unit (ICU) is an underinvestigated topic in patients admitted after spontaneous intracerebral hemorrhage (ICH). The purpose of this study is to investigate the frequency, clinical risk factors, and outcome of bounce back to the neurological ICU in a cohort of patients admitted after ICH.This is a retrospective observational study inspecting bounce back to the neurological ICU in patients admitted with spontaneous ICH over an 8-year period. For each patient, demographics, medical history, clinical presentation, length of ICU stay, unplanned readmission to neurological ICU, cause of readmission, and mortality were reviewed. Bounce back to the neurological ICU was defined as an unplanned readmission to the neurological ICU from a general floor service during the same hospitalization. A multivariable analysis was used to define independent variables associated with bounce back to the neurological ICU as well as association between bounce back to the neurological ICU and mortality. The significance level was set at p 0.05.A total of 221 patients were included. Among those, 20 (9%) had a bounce back to the neurological ICU. Respiratory complications (n = 11) was the most common reason for bounce back to the neurological ICU, followed by neurological (n = 5) and cardiological (n = 4) complications. In a multivariable logistic regression, location of hemorrhage in the basal ganglia (odds ratio [OR]: 3.0, 95% confidence interval [CI]: 1.0-8.9, p = 0.03) and dysphagia at the time of transfer (OR: 3.9, 95% CI: 1.0-15.4, p = 0.04) were significantly associated with bounce back to the neurological ICU. After we controlled for ICH score, readmission to the ICU was also independently associated with higher mortality (OR: 14.1, 95% CI: 2.8-71.7, p 0.01).Bounce back to the neurological ICU is not an infrequent complication in patients with spontaneous ICH and is associated with higher hospital length of stay and mortality. We identified relevant and potentially modifiable risk factors associated with bounce back to the neurological ICU. Future prospective studies are necessary to develop patient-centered strategies that may improve transition from the neurological ICU to the general floor.

Introduction: The COVID-19 pandemic has exacerbated health disparities associated with socioeconomic status across the United States. However, little is known about how income mediates recovery and functional outcomes after stroke associated with COVID-19. Methods: This was a multi-institutional, retrospective study of consecutively hospitalized patients presenting in March through November 2020 to one of five comprehensive stroke centers in the Chicago area. Patients who tested positive for SARS-CoV-2 by RT-PCR assay of nasopharyngeal or oropharyngeal swabs and had radiographically confirmed stroke were included. Patient income was dichotomized at the median Chicago household income ($72800 annually). Logistic regression was used to examine the relationship between income and good functional outcome, defined as modified Rankin Scale (mRS) 0-3 at discharge, after ischemic stroke. Race and ethnicity were not included in the adjusted models given these variables were highly collinear with income. Results: Across five hospitals, 159 patients were included. Black patients comprised 48.1% of the sample, White patients 38.6%, and Hispanic patients 27.7%. Patients were most frequently publicly insured (60.7%), with severe COVID-19 symptoms requiring ICU care (49.7%) and symptomatic stroke at presentation (77.7%). Median patient income was $46,938 [SD: $32,460-63,219]. Ischemic stroke occurred in 115 (72.3%) patients (median NIHSS 7, IQR: 0.5-18.5); hemorrhagic stroke in 37 (23.7%); and cerebral venous sinus thrombosis (CVST) in 4 (3.4%). When controlling for age, sex, severe COVID-19 disease, and NIHSS, functional outcome from ischemic stroke was mediated by patient income. Patients with household income above the reported median for the Chicago area were more likely to have a good functional outcome at discharge (OR 7.53, 95% CI 1.61 - 45.73; P=0.016). Conclusions: Patients with lower household income were more likely to have poor functional outcomes, despite controlling for stroke and COVID-19 severity. Income may play a role in mediating recovery from COVID-19-associated stroke. Further studies are needed to evaluate the influence of other social determinants of health on COVID-19 associated stroke outcome and recovery.

Background Establishing whether a patient who survived a cardiac arrest has suffered hypoxic-ischemic brain injury (HIBI) shortly after return of spontaneous circulation (ROSC) can be of paramount importance for informing families and identifying patients who may benefit the most from neuroprotective therapies. We hypothesize that using deep transfer learning on normal-appearing findings on head computed tomography (HCT) scans performed after ROSC would allow us to identify early evidence of HIBI. Methods We analyzed 54 adult comatose survivors of cardiac arrest for whom both an initial HCT scan, done early after ROSC, and a follow-up HCT scan were available. The initial HCT scan of each included patient was read as normal by a board-certified neuroradiologist. Deep transfer learning was used to evaluate the initial HCT scan and predict progression of HIBI on the follow-up HCT scan. A naive set of 16 additional patients were used for external validation of the model. Results The median age (interquartile range) of our cohort was 61 (16) years, and 25 (46%) patients were female. Although findings of all initial HCT scans appeared normal, follow-up HCT scans showed signs of HIBI in 29 (54%) patients (computed tomography progression). Evaluating the first HCT scan with deep transfer learning accurately predicted progression to HIBI. The deep learning score was the most significant predictor of progression (area under the receiver operating characteristic curve = 0.96 [95% confidence interval 0.91–1.00]), with a deep learning score of 0.494 having a sensitivity of 1.00, specificity of 0.88, accuracy of 0.94, and positive predictive value of 0.91. An additional assessment of an independent test set confirmed high performance (area under the receiver operating characteristic curve = 0.90 [95% confidence interval 0.74–1.00]). Conclusions Deep transfer learning used to evaluate normal-appearing findings on HCT scans obtained early after ROSC in comatose survivors of cardiac arrest accurately identifies patients who progress to show radiographic evidence of HIBI on follow-up HCT scans.

ImportanceCivilian penetrating brain injury (PBI) is associated with high mortality. However, scant literature is available to guide neurocritical care monitoring and management of PBI.ObjectiveTo examine the association of intracranial pressure (ICP) monitoring with mortality, intensive care unit (ICU) length of stay (LOS), and dispositional outcomes in patients with severe PBI.Design, Setting, and ParticipantsThis comparative effectiveness research study analyzed data from the Trauma Quality Improvement Program of the National Trauma Data Bank in the US from January 1, 2017, to December 31, 2019. Patients with PBI were identified, and those aged 16 and 60 years who met these inclusion criteria were included: ICU LOS of more than 2 days, Glasgow Coma Scale (GCS) score lower than 9 on arrival and at 24 hours, and Abbreviated Injury Scale score of 3 to 5 for the head region and lower than 3 for other body regions. Patients with bilaterally fixed pupils or incomplete data were excluded. A 1:1 propensity score (PS) matching was used to create a subgroup of patients. Patients were divided into 2 groups: with vs without ICP monitoring. Data analysis was conducted between September and December 2022.ExposuresIntracranial pressure monitoring vs no monitoring.Main Outcomes and MeasuresOutcomes were mortality, rate of withdrawal, ICU LOS, and dispositional outcome. Measures were age, initial systolic blood pressure, initial oxygen saturation level on a pulse oximeter, first-recorded GCS score, GCS score at 24 hours, Abbreviated Injury Scale score, midline shift, and pupillary reactivity.ResultsA total of 596 patients (505 males [84.7%]; mean [SD] age, 32.2 [12.3] years) were included, among whom 220 (36.9%) died and 288 (48.3%) had ICP monitoring. The PS matching yielded 466 patients (233 in each group with vs without ICP monitoring). Overall mortality was 35.8%; 72 patients with ICP monitoring (30.9%) died compared with 95 patients (40.8%) without ICP monitoring . Patients with ICP monitoring were more likely to survive (odds ratio [OR], 1.54; 95% CI, 1.05-2.25; P = .03; number needed to treat, 10). No difference in favorable discharge disposition was observed. The PS-weighted analysis included all 596 patients and found that patients with ICP monitoring were more likely to survive than those without (OR, 1.40; 95% CI, 1.10-1.78; P = .005). The E-value for the OR calculated from the PS-matched data set was 1.79. In addition, ICP monitoring vs no monitoring was associated with an increase in median (IQR) ICU LOS (15.0 [8.0-21.0] days vs 7.0 [4.0-12.0] days; P Conclusions and RelevanceIn this comparative effectiveness research study, PBI management guided by ICP monitoring was associated with decreased mortality and increased ICU LOS, challenging the notion of universally poor outcomes after civilian PBI. Randomized clinical trials that evaluate the efficacy of ICP monitoring in PBI are warranted.

Background Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation (MISTIE) procedure was recently tested in a large phase III randomized trial showing a significant probability of functional benefit in those cases that reached the goal hematoma evacuation of ≤15 mL residual (or ≥70% removal). Benefit of thrombolysis was also identified in cases with large intraventricular hemorrhage, and achieving at least 85% volume reduction in the Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR) III trial. Objective To protocolize steps in the MISTIE and CLEAR procedures in order to maximize hematoma evacuation and minimize complications. Methods We articulate data-driven lessons and expert opinions surrounding the factors of patient selection, catheter placement, and dosing, which impacted safety and surgical performance in the MISTIE and CLEAR trials. Results Modifiable factors to maximize evacuation efficiency include optimizing catheter placement and pursuing aggressive dosing to achieve treatment goals, while strictly adhering to the safety steps as articulated in the respective trials. Prognostic factors that are viewed as nonmodifiable include greater initial intracerebral hemorrhage volume with irregular shape, smaller intraventricular bleeds, and the uncommon but consequential development of new bleeding during the dosing period despite strict protocol adherence. Conclusions Surgeon education in this tutorial is aimed at maximizing the benefit of the MISTIE and CLEAR procedures by reviewing case selection, safety steps, treatment objectives, and technical nuances. Key lessons include stability imaging, etiology screening, and technical adherence to the protocol in order to achieve defined thresholds of evacuation.

Patients with imaging findings concerning for subarachnoid hemorrhage, however, with no evidence of hemorrhage following autopsy or cerebrospinal fluid testing are diagnosed with having pseudo-subarachnoid hemorrhage. A 73-year-old female presented to the emergency department with altered mental status one day after undergoing a lumbar epidural steroid injection at an outside hospital; a noncontrast computed tomography scan of the head revealed evidence of diffuse hyperdensity within the subarachnoid space concerning for subarachnoid hemorrhage. The patient underwent magnetic resonance imaging which demonstrated diffuse opacification of the cerebrospinal fluid spaces with gadolinium and the diagnoses of pseudo-subarachnoid hemorrhage and gadolinium encephalopathy were made. The combination of the neurologic symptoms related to gadolinium encephalopathy and the radiographic findings of pseudo-subarachnoid hemorrhage can create a clinical presentation nearly identical to ruptured aneurysmal subarachnoid hemorrhage. Patient history, magnetic resonance imaging findings, and temporal changes in computed tomography provide vital tools in establishing a diagnosis of pseudo-subarachnoid hemorrhage, especially after an iatrogenic intrathecal contrast administration.

Family of patients hospitalized in an intensive care unit (ICU) often immediately assume the role of caregiver to an individual with significant health care needs. The transition into this caregiver role may be sudden and unexpected; their experiences are not well understood. The purpose of this qualitative study was to explore experiences of family caregivers in the neurocritical care unit in order to identify areas for enhancing patient- and family-centered care. This single-center ethnographic study explored the use of systems theory to investigate the perceptions, experiences, and attitudes of family/caregivers regarding their relationships and interactions between the patient, other family, members of the healthcare provider team, and health system after an acute neurological event in Argentina. Field notes from 9 weeks of direct observation together with transcripts from nine semi-structured interviews (transcribed verbatim and translated from Spanish to English) were analyzed using a grounded theory approach. Nine themes emerged based on iterative thematic analysis, including: adjusting to a changed life, managing emotions, changing role, relying on faith, redefining recovery, participating in patient care, depending on clinical experts, el tratohumano, and finding unity in purpose. In the neurocritical care environment, an important intermediary role exists for family/caregivers and the patient, other family, and healthcare providers. The results demonstrate the potential for family, providers, and the health system to influence family/caregivers’ experience with neurocritical care. Involving families as part of the care team could have implications for patient- and family-centered care.

Intracranial hemorrhage (ICH) may occur in patients admitted to the hospital for unrelated medical conditions, resulting in prolonged hospitalization and worse prognosis. We aim to assess the clinical presentation and outcomes of in-hospital ICH compared to patients with ICH presenting from the community. We conducted a retrospective analysis of all acute stroke alerts diagnosed with ICH in an urban academic hospital over a 4-year period. Demographics, clinical presentation, use of antithrombotic therapy, and presence of coagulopathy were recorded. ICH score and a sequential organ failure assessment score were calculated during the initial assessment. Initial head computed tomography was reviewed to determine ICH subtype, location, and volume of the hematoma. In-hospital mortality and discharge disposition were used as surrogate of clinical outcome. From the 1965 stroke alert cases analyzed over the studied years, 145 (7.4%) were diagnosed with ICH. Overall, the mean age was 62.9 ± 13.9 and 53.7% were women. Thirty-two patients (22%) developed ICH in the inpatient setting and 113 (78%) presented from the community. Systolic blood pressure at presentation was lower in the in-hospital group (p

Civilian firearm-inflicted penetrating brain injury (PBI) carries high morbidity and mortality. Concurrently, the evidence base guiding management decisions remains limited. Faced with large volume of PBI patients, we have made observations in relation to coagulopathy and cerebrovascular injuries. We here review this literature in addition to the question about early prognostication as it may inform neurosurgical decision-making. The triad of coagulopathy, low motor score, and radiographic compression of basal cisterns comprises a phenotype of injury with exceedingly high mortality. PBI leads to high rates of cerebral arterial and venous injuries, and projectile trajectory is emerging as an independent predictor of outcome. The combination of coagulopathy with cerebrovascular injury creates a specific endophenotype. The nature and role of coagulopathy remain to be deciphered, and consideration to the use of tranexamic acid should be given. Prospective controlled trials are needed to create clinical evidence free of patient selection bias.

Introduction: Cardiac dysfunction directly caused by spontaneous intracerebral hemorrhage (ICH) is a poorly understood phenomenon, and its impact on outcome is still uncertain. Aim of this study is to investigate the relationship between electrocardiographic (EKG) abnormalities and mortality in ICH. Methods: This is a retrospective study analyzing EKG patterns on admission in patients admitted with ICH at a tertiary care center over eight-year period. For each patient, demographics, medical history, clinical presentation, EKG on admission and repeated during hospitalization, and head CT at presentation were reviewed. Mortality was noted. Results: A total of 301 ICHs were included in the study. The most prevalent EKG abnormalities were QTc prolongation in 56% of patients (n=168) followed by inversion of T waves (TWI) in 37% of patients (n=110). QTc prolongation was associated with ganglionic location (p=0.03) and intraventricular hemorrhage (IVH) (p=0.01), TWI was associated with ganglionic location (p=0.02), PR prolongation with IVH (p=0.01), while QRS prolongation was associated with lobar location (p Conclusion: Presence of TWI on admission is an independent and unmodifiable factor associated with mortality in ICH. TWI may be implemented as an additional early prognostic tool in clinical practice.

Background: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection is associated with stroke. The role of sex on stroke outcome has not been investigated. We describe the characteristics of a diverse cohort of acute stroke patients with COVID-19 disease, and investigate the role of sex on outcome. Methods: This is a retrospective study of patients with acute stroke and SARS-CoV-2 infection admitted between March 15 to May 15, 2020 to one of the six participating comprehensive stroke centers from Chicago metropolitan area. Baseline characteristics, stroke subtype, workup, treatment and outcome are presented as total number and percentage. Outcome at discharge was determined by the modified Rankin Scale Score (mRS). Variables and outcomes were compared for males and females using univariate and multivariate analysis. Results: The study included 83 patients. Median age was 64 years and the majority were Blacks (47%) followed by Hispanics (28%) and whites (16%). Approximately 89% had at least one preexisting vascular risk factor (VRF). The most common complications were respiratory failure (59%) and septic shock (34%). Higher proportions of male experienced severe SARS-CoV-2 symptoms requiring ICU hospitalization (73% vs. 49%; p=0.04). When divided by stroke subtype, there were 77% ischemic, 19% intracerebral hemorrhage and 3% subarachnoid hemorrhage. The most common ischemic stroke etiologies were cryptogenic (39%) and cardioembolic (27%). Compared to female, males had higher mortality (38% vs. 13%; p=0.02) and were less likely to be discharged home (12% vs. 33%; p=0.04). After adjustment for age, race/ethnicity, and number of VRFs, mRS was higher in males than in females (OR=1.47, 95% CI=1.03-2.09) Conclusion: In this cohort of SARS-CoV-2 stroke patients, most had clinical evidence of coronavirus infection on admission and preexisting VRFs. Severe in-hospital complications and worse outcomes after ischemic strokes were higher in males, than females.

Cardiac dysfunction directly caused by spontaneous intracerebral hemorrhage (ICH) is a poorly understood phenomenon, and its impact on outcome is still uncertain. The aim of this study is to investigate the relationship between electrocardiographic (EKG) abnormalities and mortality in ICH.This is a retrospective study analyzing EKG patterns on admission in patients admitted with ICH at a tertiary care center over an eight-year period. For each patient, demographics, medical history, clinical presentation, EKG on admission and during hospitalization, and head CT at presentation were reviewed. Mortality was noted.A total of 301 ICH patients were included in the study. The most prevalent EKG abnormalities were QTc prolongation in 56% of patients (n = 168) followed by inversion of T waves (TWI) in 37% of patients (n = 110). QTc prolongation was associated with ganglionic location (p = 0.03) and intraventricular hemorrhage (IVH) (p = 0.01), TWIs were associated with ganglionic location (p = 0.02), and PR prolongation was associated with IVH (p = 0.01), while QRS prolongation was associated with lobar location (p 0.01). Volume of ICH, hemispheric laterality, and involvement of insular cortex were not correlated with specific EKG patterns. In a logistic regression model, after correcting for ICH severity and prior cardiac history, presence of TWI was independently associated with mortality (OR: 3.04, CI:1.6-5.8, p 0.01). Adding TWI to ICH score improved its prognostic accuracy (AUC 0.81, p = 0.04). Disappearance of TWI during hospitalization did not translate into improvement of survival (p = 0.5).Presence of TWI on admission is an independent and unmodifiable factor associated with mortality in ICH. Further research is needed to elucidate the pathophysiologic mechanisms underlying electrocardiographic changes after primary intracerebral hemorrhage.

Background: Patients with computed tomography (CT) findings consistent with subarachnoid hemorrhage without evidence of hemorrhage following autopsy or cerebrospinal fluid testing are termed to have pseudosubarachnoid hemorrhage (pSAH). Methods: A systematic review of literature was conducted based on the preferred reporting items for systematic reviews and meta-analysis statement. Studies were evaluated for associated cause of pSAH, imaging modality used in assessment, method of confirmatory testing, and clinical outcome. Results: Fifty studies were included in qualitative analysis including 197 cases of pSAH. Systematic review revealed 23 studies including 110 patients with pSAH attributed to hypoxic-ischemic brain injury following cardiac arrest. Three studies were included in meta-analysis that quantitatively analyzed differences in CT densities in patients with pSAH and true subarachnoid hemorrhage (true SAH). A random effects model meta-analysis showed a statistically significant decrease in densities in the Sylvian fissure in patients with pSAH compared to true SAH and a statistically significant decrease in densities in adjacent parenchyma in patients with pSAH compared to true SAH. Systematic review further revealed 32 patients with pSAH associated with spontaneous intracranial hypotension, 11 patients with pSAH related to infectious etiologies, 15 patients with pSAH associated with subdural hemorrhage, 20 cases of pSAH related to hyperhemoglobinemia, 2 cases related to valproate toxicity, and individual cases related to hyponatremia, diabetic ketoacidosis, sudden infant death syndrome, cerebellar infarction, and dialysis disequilibrium syndrome. Conclusion: This study is the first systematic review of causes, diagnostic modalities, and outcomes in patients who present with pSAH. A diagnosis of pSAH may be considered following assessment of CT densities following cardiac arrest.

Background Data on neuroendocrine dysfunction (NED) in the acute setting of penetrating brain injury (PBI) are scarce, and the clinical approach to diagnosis and treatment remains extrapolated from the literature on blunt head trauma. Methods Three databases were searched (PubMed, Scopus, and Cochrane). Risk of bias was computed using the Newcastle-Ottawa Scale, or the methodological quality of case series and case reports, as indicated. This systematic review was registered in PROSPERO (42020172163). Results Six relevant studies involving 58 patients with PBI were included. Two studies were prospective cohort analyses, whereas 4 were case reports. The onset of NED was acute in all studies, by the first postinjury day. Risk factors for NED included worse injury severity and the presence of cerebral edema on imaging. Dysfunction of the anterior hypophysis involved the hypothalamic-pituitary-thyroid axis, treated with hormonal replacement, and hypocortisolism, treated with hydrocortisone. The prevalence of central diabetes insipidus was up to 41%. Most patients showed persistent NED months after injury. In separate reports, diabetes insipidus and hypocortisolism showed an association with higher mortality. The available literature for this review is poor, and the studies included had overall low quality with high risk of bias. Conclusions NED seems to be prevalent in the acute phase of PBI, equally involving both anterior and posterior hypophysis. Despite a potential association between NED and mortality, data on the optimal management of NED are limited. This situation defines the need for prospective studies to better characterize the clinical features and optimal therapeutic interventions for NED in PBI.

Highlights • COVID-19 disease is associated with stroke • All strokes subtypes are seen in association with COVID-19, with ischemic stroke being most prevalent • The most common etiology for ischemic stroke in SARS-CoV2 infection is cryptogenic • Sex plays an important role in stroke outcomes in patients with COVID-19 disease • Males have higher rates of ICU admission, in-hospital complications and more likely to have worse outcome at hospital discharge compare with females, Background and Purpose Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection is associated with stroke. The role of sex on stroke outcome has not been investigated. To objective of this paper is to describe the characteristics of a diverse cohort of acute stroke patients with COVID-19 disease and determine the role of sex on outcome. Methods This is a retrospective study of patients with acute stroke and SARS-CoV-2 infection admitted between March 15 to May 15, 2020 to one of the six participating comprehensive stroke centers. Baseline characteristics, stroke subtype, workup, treatment and outcome are presented as total number and percentage or median and interquartile range. Outcome at discharge was determined by the modified Rankin Scale Score (mRS). Variables and outcomes were compared for males and females using univariate and multivariate analysis. Results The study included 83 patients, 47% of which were Black, 28% Hispanics/Latinos, and 16% whites. Median age was 64 years. Approximately 89% had at least one preexisting vascular risk factor (VRF). The most common complications were respiratory failure (59%) and septic shock (34%). Compared with females, a higher proportion of males experienced severe SARS-CoV-2 symptoms requiring ICU hospitalization (73% vs. 49%; p = 0.04). When divided by stroke subtype, there were 77% ischemic, 19% intracerebral hemorrhage and 3% subarachnoid hemorrhage. The most common ischemic stroke etiologies were cryptogenic (39%) and cardioembolic (27%). Compared with females, males had higher mortality (38% vs. 13%; p = 0.02) and were less likely to be discharged home (12% vs. 33%; p = 0.04). After adjustment for age, race/ethnicity, and number of VRFs, mRS was higher in males than in females (OR = 1.47, 95% CI = 1.03–2.09). Conclusion In this cohort of SARS-CoV-2 stroke patients, most had clinical evidence of coronavirus infection on admission and preexisting VRFs. Severe in-hospital complications and worse outcomes after ischemic strokes were higher in males, than females.

OBJECTIVE: This study investigates the presence of cerebrovascular injuries in a large sample of civilian penetrating brain injury (PBI) patients, determining the prevalence, radiographic characteristics, and impact on short-term outcome. METHODS: We retrospectively reviewed patients with PBI admitted to our institution over a two-year period. Computed tomography head scans, computer tomography angiograms and venograms of the intracranial vessels were evaluated to determine the wound trajectory, intracranial injury characteristics, and presence of arterial (AI) and venous sinus (VSI) injuries. Demographics, clinical presentation, and treatment were also reviewed. Discharge disposition was used as surrogate of short-term outcome. RESULTS: Seventy-two patients were included in the study. The mechanism of injury was gunshot wounds in 71 patients and stab wound in one. Forty-one of the 72 patients (60%) had at least one vascular injury. Twenty-six out of 72 patients suffered an AI (36%), mostly pseudoaneurysms and occlusions, involving the anterior and middle cerebral arteries. Of the 72 patients included, 45 had dedicated computed tomography venograms, and of those 22 had VSI (49%), mainly manifesting as superior sagittal sinus occlusion. In a multivariable regression model Intraventricular hemorrhage at presentation was associated with AI (OR=9.9, p=0.004). The same was not true for VSI. CONCLUSION: Acute traumatic cerebrovascular injury is a prevalent complication in civilian PBI, frequently involving both the arterial and venous sinus systems. Although some radiographic features might be associated with presence of vascular injury, assessment of the intracranial vasculature in the acute phase of all PBI is essential for early diagnosis. Treatment of vascular injury remains variable depending on local practice.

The present study considers patients with spontaneous intracerebral hemorrhage (ICH) admitted to the neurocritical care unit (NCCU) through the Emergency Department (ED). It aims to identify patient-specific clinical variables that can be assessed on presentation and that are associated with prolonged NCCU length of stay (LOS). A cross-sectional, single-center, retrospective analysis of ICH patients directly admitted from the ED to the NCCU over an 8-year period was performed. Patients’ demographics, clinical exam characteristics, serum laboratory values, intubation status, and neurosurgical procedures at presentation were recorded. Head computed tomography scans obtained on presentation were reviewed. LOS was calculated based on the number of midnights spent in the NCCU. Prolonged LOS was determined using a change point analysis, adopting the method of Taylor which utilizes CUMSUM charts and bootstrap analysis. A decision tree model was trained and validated to identify reliable variables associated with prolonged LOS. Two hundred and five patients with ICH were analyzed. Prolonged LOS was calculated to be a stay that exceeds 8 days; 68 patients (33%) had a prolonged LOS in NCCU. Median LOS did not differ between survivors and patients who died in hospital. Clinical variables explored through the decision tree model were intubation status, neurosurgical intervention (EVD, decompression or evacuation within 24 h from presentation), and components of the ICH score: age, GCS, hematoma volume, the presence of intraventricular hemorrhage (IVH), and infratentorial location. The model accuracy was 0.8 and AUC was 0.83 (95% CI 0.78–0.89). We propose an ICH-LOS model based on neurosurgical intervention, intubation status and GCS at presentation to predict prolonged LOS in the NCCU in patients with ICH. This simple clinical tool, if prospectively validated, could help with medical planning, contribute to patient care-directed conversations, assist in optimizing hospital resource utilization, and, more importantly, motivating patient-specific interventions aimed at optimizing outcomes and decreasing LOS.

Purpose Stroke mimics takes upto 30% of patients presenting with stroke-like symptoms. We aim to evaluate the stroke mimic rate and to identify factors that may differentiate stroke mimics from real strokes in a population with a high prevalence of vascular risk factors. Materials and Methods From January 1st to December 31st 2013, patients who had Stroke Alert activations were retrospectively reviewed. Stroke mimics were defined as patients who had Stroke Alert activation, but the discharge ICD-9 codes did not include the diagnosis of ischemic stroke, hemorrhagic stroke, or transient ischemic attack. Demographics, clinical history, laboratory data, neurologic examinations, Acute Stroke Scales were analyzed in univariate and multiple logistic regression analyses. Results In 368 Stroke Alert activations, 184 (50%) were stroke mimics. Common causes of strokes mimics were seizure disorders (11.4%), and other malaise and fatigue (4.9%). 93% of patients for whom a Stroke Alert was activated had at least one vascular risk factor. Univariate analysis found that seizure history, seizure at onset, negative findings on neurological exam, and lower scores on three different stroke scales/screen were associated with stroke mimic. Multiple logistic regression analysis showed that normal visual fields, lack of unilateral arm weakness, seizure at onset, lack of lateralizing symptoms, no exact onset, and lower glucose levels were independent predictors of stroke mimics. Conclusion Assessment of vascular risk factors is not useful for differentiating between stroke and mimic in our population. Attention to seizure history and a thorough neurological examination can assist in identifying stroke mimics.

To assess the association between specific electrolyte levels (sodium, potassium, calcium, magnesium, and phosphorus) on presentation and hematoma expansion (HE) and outcome in intracerebral hemorrhage (ICH).This review was conducted in accordance with the PRISMA statement recommendations. Three databases were searched (Pubmed, Scopus, and Cochrane). Risk of bias was computed using the Newcastle-Ottawa Scale tool.18 full-text articles were included in this systematic review including 10,385 ICH patients. Hypocalcemia was associated with worse short-term outcome in four studies, and two other studies were neutral. All studies investigating HE in hypocalcemia (n = 5) reported an association between low calcium level and HE. Hyponatremia (Na 135 mEq/L) was shown to correlate with worse short-term outcome in two studies, and worse long-term outcome in one. There was one report showing no association between sodium level and HE. Hypomagnesemia was shown to be associated with worse short-term outcome in one study, while other reports were neutral. Studies evaluating hypophosphatemia or hypokalemia in ICH were limited, with no demonstrable significant effect on outcome.This review suggests a significant association between hypocalcemia, hyponatremia and, of lesser degree, hypomagnesemia on admission and HE or worse outcome in ICH.

Family of patients hospitalized in an intensive care unit (ICU) often immediately assume the role of caregiver to an individual with significant health care needs. The transition into this caregiver role may be sudden and unexpected; their experiences are not well understood. The purpose of this qualitative study was to explore experiences of family caregivers in the neurocritical care unit in order to identify areas for enhancing patient- and family-centered care.This single-center ethnographic study explored the use of systems theory to investigate the perceptions, experiences, and attitudes of family/caregivers regarding their relationships and interactions between the patient, other family, members of the healthcare provider team, and health system after an acute neurological event in Argentina. Field notes from 9 weeks of direct observation together with transcripts from nine semi-structured interviews (transcribed verbatim and translated from Spanish to English) were analyzed using a grounded theory approach.Nine themes emerged based on iterative thematic analysis, including: adjusting to a changed life, managing emotions, changing role, relying on faith, redefining recovery, participating in patient care, depending on clinical experts, el tratohumano, and finding unity in purpose. In the neurocritical care environment, an important intermediary role exists for family/caregivers and the patient, other family, and healthcare providers.The results demonstrate the potential for family, providers, and the health system to influence family/caregivers' experience with neurocritical care. Involving families as part of the care team could have implications for patient- and family-centered care.

Objective: In-hospital mortality rates in patients successfully resuscitated following out-of-hospital cardiac arrest (OHCA) remains high. Little has been published regarding the timing and putative causes of in-hospital death during the post-cardiac arrest resuscitation phase of care. In this study, we aimed to develop a novel two-stage categorization system and investigate the timing and factors associated with post-CA in-hospital death. Design: Single-centered retrospective observational human study. Setting: Adult Emergency Department and ICU in a university affiliated hospital. Patients: Two hundred and forty-one adult, non-traumatic OHCA patients. Interventions: None. Measurements and Main Results: Through an expert consensus process, a two-stage classification system of hospital deaths was developed. Data abstraction was performed by two researchers and inter-reliability was 0.858. We categorized deaths as being due to withdrawal of life sustaining treatment (WOLST) 159 (66.0%), recurrent in-hospital cardiac arrest 51 (21.1%), and declared dead by neurological criteria 31 (12.9%). Half of WOLST decisions occurred primarily in the setting of isolated neurological injury. Early in-hospital death (≤ 3 days) was associated with recurrent in-hospital cardiac arrest and WOLST with refractory shock or multi-organ injury. Late in-hospital death (> 3 days) was associated with WOLST due to neurological injury. Age, initial lactate level, duration of CPR exceeding 30 minutes, and vasopressor dependence post ROSC was found to be the dependent predictors for Early death during hospital stay. Conclusions: Our novel two-stage categorization scheme for post-CA deaths demonstrated high inter-rater reliability. The majority of in-hospital post-CA deaths were due to neurological injury associated with WOLST. Early deaths were largely attributed to recurrent in-hospital cardiac arrest, and WOLST due to refractory shock or multi-organ injury while Late deaths occurred in the context of neurological injury demonstrating two phases of injury in the post-CA syndrome.

Objective We hypothesize that procedure deployment rates and technical performance with minimally invasive surgery and thrombolysis for intracerebral hemorrhage (ICH) evacuation (MISTIE) can be enhanced in post-trial clinical practice, per Phase III trial results and lessons learned. Materials and Methods We identified ICH patients and those who underwent MISTIE procedure between 2017–2021 at a single site, after completed enrollments in the Phase III trial. Deployment rates, complications and technical outcomes were compared to those observed in the trial. Initial and final hematoma volume were compared between site measurements using ABC/2, MISTIE trial reading center utilizing manual segmentation, and a novel Artificial Intelligence (AI) based volume assessment. Results Nineteen of 286 patients were eligible for MISTIE. All 19 received the procedure (6.6% enrollment to screening rate 6.6% compared to 1.6% at our center in the trial; p=0.0018). Sixteen patients (84%) achieved evaculation target 70% removal, compared to 59.7% in the trial surgical cohort (p=0.034). No poor catheter placement occurred and no surgical protocol deviations. Limitations of ICH volume assessments using the ABC/2 method were shown, while AI based methodology of ICH volume assessments had excellent correlation with manual segmentation by experienced reading centers. Conclusions Greater procedure deployment and higher technical success rates can be achieved in post-trial clinical practice than in the MISTIE III trial. AI based measurements can be deployed to enhance clinician estimated ICH volume. Clinical outcome implications of this enhanced technical performance cannot be surmised, and will need assessment in future trials.

PRELIMINARY REMARKSGuideline LimitationsPractice guidelines are not intended as absolute requirements. The use of the practice guidelines does not, in anyway, project or guarantee any specific benefit in outcome or survival. The judgment of the healthcare professional based on individual circumstanc

Background: Approximately 30% of patients resuscitated following Out of Hospital Cardiac Arrest (OHCA) survive to hospital admission, but only 10% of these patients survive to hospital discharge. Reasons for in hospital death of these patients is not well known or categorized. Understanding the principle reason for death among successfully resuscitated OHCA patients could guide the development of therapeutic and management strategies Methods: Using a retrospective OHCA cohort database at a single urban academic hospital, death of admitted adult OHCA patients from January 1, 2016 until June 30, 2019 was classified as primarily due to withdrawal of life-sustaining treatments (WOLST), in-hospital cardiac arrest, or formal declaration of death by neurologic criteria (brain death). Family/caregiver decisions to WOLST were categorized as occurring primarily in the setting of isolated severe neurological injury, multi-organ failure, in hospital cardiac arrest, severe hemodynamic shock, pre-existing comorbidities/terminal health condition, or prior unknown DNR status. Traumatic arrests were excluded. Results: During the study period there were 578 cardiac arrests brought to the emergency department; 291 (50%) patients survived to hospital admission. Of admitted patients, 95 patients (33%) survived to hospital discharge and 194 patients (67%) died. In non-surviving patients, death was attributable to WOLST (77%), brain death 25 (13%), in-hospital cardiac arrest (9%), and failure to achieve return of spontaneous circulation on ECMO 1 (1%). Decisions to WOLST by family members were complex and multi-factorial but were determined in the context of poor neurologic prognosis 93 (62%), multi-organ failure 27 (18%), in hospital cardiac arrest 11 (7%), severe shock 11 (7%), unknown prior DNR status 7 (5%), and pre-existing terminal illness 2 (1%). Conclusion: In this single center study, the majority of OHCA patients who survived to hospital admission from the emergency department subsequently died in the hospital due to the severity of their neurological injury in the context of WOLST. Death in the setting of multiorgan failure, re-arrest, or severe hemodynamic shock was less common.

Purpose There has been a dramatic increase in penetrating gunshot-inflicted civilian penetrating brain injuries (cvPBI). We undertook a systematic review with exclusive focus on the management of cvPBI. Methods We explored: (1) cervical spine immobilization, (2) seizure incidence and prophylaxis, (3) infection incidence and antibiotic prophylaxis, (4) coagulopathy (5) vascular complications, and (6) surgical management. We searched PubMed, EMBASE, and Cochrane (1985–2019). The PRISMA guidelines were followed. The Newcastle-Ottawa Scale was employed for qualitative assessment; risk of bias was evaluated based upon the RTI item bank. The full protocol was registered to PROSPERO (CRD42019118877). Results The literature is scant, and of overall low quality and high risk of bias. Incidence of c-spine injury with no direct trauma is low; incidence of seizures does not appear to be different from non-penetrating mechanisms; there is no robust data for prophylactic antibiotics; coagulopathy is prevalent and has been independently associated with outcome; there is a high incidence of vascular injuries with traumatic intracranial aneurysms the most common sequelae; neurosurgical decision-making appears largely influenced by operator's assessment of salvageability. Surgery has been associated with decreased mortality. Conclusions Limited amount of published work is clinically meaningful; this systematic review identified key knowledge gaps.

Background: In-Hospital Stroke Alert Protocols (IHSAPs) are designed to evaluate acute thrombolysis candidacy in patients who develop acute ischemic stroke (AIS) while hospitalized for other causes. However, co-existing medical illnesses may result in difficulty in symptom recognition, false positive alerts, and a high number of contraindications to reperfusion therapies. Methods: We analyzed data of all Stroke Alert Protocol cases evaluated by the vascular neurology team in an academic university hospital over 4 consecutive years. Patient demographics and location at the moment of activation were recorded. Clinical presentation, final diagnosis, and acute interventions were compared between inpatients and those presenting to the emergency department (ED). Results: Of 1,965 included cases, 489 (24.9%) Stroke Alerts were activated in already hospitalized patients and 1,476 (75.1%) in the emergency department. IHSAPs cases were more likely to present with non-localizing neurological deficits (46.2 % vs. 32.4%, p Conclusion: Patients who developed in-hospital ischemic stroke rarely received intravenous thrombolysis, however, the rate of endovascular treatment was similar to those presenting from the community to the ED. The vascular neurology team commonly implemented emergent time-sensitive therapeutic interventions other than thrombolysis during the evaluation of inpatients with stroke-like symptoms.

OBJECTIVE: To investigate the radiographic features, temporal evolution, and outcome of patients who develop non-traumatic intracerebral hemorrhage (ICH) while hospitalized for other causes. METHODS: We retrospectively reviewed consecutive Emergency Department ICH (ED-ICH) and in-hospital ICH (IH-ICH) over an 8-year period. Variables including demographics, medical history, lab values, lead time to diagnosis, defined as time from last known well to first CT scan, and clinical characteristics, follow-up CT scan, as well as the frequency of withdrawal of life support were compared in the two groups. Mortality in correlation with ICH score was assessed. RESULTS: Sixty-One IH-ICH and 216 ED-ICH patients were compared. History of cardiac disease, cancer, coagulopathy and higher SOFA score at time of diagnosis were significantly higher in the IH-ICH group (all P< 0.01). Time from symptom onset to diagnosis was shorter in the IH-ICH group (median 95 versus 117 minutes, P=0.011). Thirty six percent of IH-ICH fell into a worse ICH category when recalculated 6 hours from initial scan time, compared to only 10% of the ED-ICH. ICH score was well calibrated in ED-ICH when assessed both at diagnosis and 6 hours later, but underestimated actual mortality in the IH-ICH, particularly at ICH scores 0 to 3. End of life measures were pursued in 69% of IH-ICH group compared to 19% in the ED-ICH group. CONCLUSIONS: IH-ICH, is associated with higher overall mortality rates and often times heralds withdrawal of life sustaining therapies in patients. In addition, IH-ICH in comparison to ED-ICH, significantly changes in severity metrics within the first 6 hours. ICH score is not accurate and not calibrated to reflect reasonable stratification of mortality in IH-ICH. Prospective validation and investigation of variables accounting for higher IH-ICH mortality are needed.

Importance: There are inconsistencies in concept, criteria, practice, and documentation of brain death/death by neurologic criteria (BD/DNC) both internationally and within countries. Objective: To formulate a consensus statement of recommendations on determination of BD/DNC based on review of the literature and expert opinion of a large multidisciplinary, international panel. Process: Relevant international professional societies were recruited to develop recommendations regarding determination of BD/DNC. Literature searches of the Cochrane, Embase, and MEDLINE databases included January 1, 1992, through April 2020 identified pertinent articles for review. Because of the lack of high-quality data from randomized clinical trials or large observational studies, recommendations were formulated based on consensus of contributors and medical societies that represented relevant disciplines, including critical care, neurology, and neurosurgery. Evidence Synthesis: Based on review of the literature and consensus from a large multidisciplinary, international panel, minimum clinical criteria needed to determine BD/DNC in various circumstances were developed. Recommendations: Prior to evaluating a patient for BD/DNC, the patient should have an established neurologic diagnosis that can lead to the complete and irreversible loss of all brain function, and conditions that may confound the clinical examination and diseases that may mimic BD/DNC should be excluded. Determination of BD/DNC can be done with a clinical examination that demonstrates coma, brainstem areflexia, and apnea. This is seen when (1) there is no evidence of arousal or awareness to maximal external stimulation, including noxious visual, auditory, and tactile stimulation; (2) pupils are fixed in a midsize or dilated position and are nonreactive to light; (3) corneal, oculocephalic, and oculovestibular reflexes are absent; (4) there is no facial movement to noxious stimulation; (5) the gag reflex is absent to bilateral posterior pharyngeal stimulation; (6) the cough reflex is absent to deep tracheal suctioning; (7) there is no brain-mediated motor response to noxious stimulation of the limbs; and (8) spontaneous respirations are not observed when apnea test targets reach pH

We conducted an updated systematic review on the safety and efficacy of amantadine in cognitive recovery after traumatic brain injury (TBI), in order to determine if the current literature justifies its use in this clinical condition. A comprehensive search strategy was applied to three databases (PubMed, Scopus, and Cochrane). Only randomized clinical trials (RCTs) that compared the effect of amantadine and placebo in adults within 3 months of TBI were included in the review. Study characteristics, outcomes, and methodological quality were synthesized. This systematic review was conducted and presented in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A quantitative synthesis (meta-analysis) was not feasible due to the large heterogeneity of studies identified. Three parallel RCTs and one cross-over RCT, with a total of 325 patients were included. All of the studies evaluated only severe TBI in adults. Amantadine was found to be well tolerated across the studies. Two RCTs reported improvement in the intermediate-term cognitive recovery (four to six weeks after end of treatment), using DRS (in both studies) and MMSE, GOS, and FIM-Cog (in one study). The effect of amantadine on the short-term (seven days to discharge) and long-term (six months from the injury) cognitive outcome was found not superior to placebo in two RCTs. The rate of severe adverse events was found to be consistently very low across the studies (the incidence of seizures, elevation in liver enzymes and cardiac death was 0.7 %, 1.9 %, and 0.3 %, respectively). In conclusion, amantadine seems to be well tolerated and might hasten the rate of cognitive recovery in the intermediate-term outcome. However, the long-term effect of amantadine in cognitive recovery is not well defined and further large randomized clinical trials in refined subgroups of patients are needed to better define its application.

Development of acute ischemic stroke in hospitalized patients represents a significant proportion of all cerebral ischemia. Several prehospital stroke scales were developed to screen for acute ischemic stroke in the community. Despite the advent of inpatient stroke alert systems, there is a lack of validated screening tools for the inpatient population. This study aims to assess the validity of BE-FAST (Balance, Eyes, Face, Arm, Speech, Time) as a screening tool for acute ischemic stroke among inpatients.We retrospectively analyzed all stroke alert activations at a single academic medical center between 2012 and 2016. We classified the triggering symptom as: focal neurologic deficit, aphasia, dysarthria, ataxia/vertigo/dizziness, alteration of consciousness, acute confusion, or headache. BE-FAST was applied retrospectively, and patients were classified as BE-FAST positive or negative. The final diagnosis was classified as acute ischemic stroke, transient ischemic attack , intracranial hemorrhage or noncerebrovascular diagnosis.Of 1965 stroke alerts, 489 were among inpatients. The mean age was 63 ± 16.1 years; 57% of patients were women (n = 1121). Acute ischemic stroke was diagnosed in 29% of all the activations (n = 567), transient ischemic attack in 12% (n = 232), intracranial hemorrhage in 8 % (n = 160) and noncerebrovascular in 51% (n = 1006). When comparing inpatient with community-onset stroke alerts, the sensitivity of BE-FAST for diagnosing acute ischemic stroke was 85% versus 94% (P = .005), with a specificity of 43% versus 23% (P.001), respectively. However, when evaluating in-patients with an intact level of consciousness separately, BE-FAST sensitivity for diagnosing acute ischemic stroke was 92% compared to 94% in the community (P = .579). Among in-patients with acute ischemic stroke who were (1) candidates for reperfusion therapy and (2) diagnosed with acute large vessel occlusion, the sensitivity of BE-FAST was 83% and 94%, respectively.This is the first study to analyze the performance of BE-FAST among hospitalized patients evaluated through the inpatient stroke alert system. We found BE-FAST to be a very sensitive tool for screening for all in-hospital acute ischemic strokes, including inpatients that were candidates for acute reperfusion therapy.

Background and Aim: Patients with in-hospital acute ischemic stroke (AIS) have, in general, worse outcomes compared to those presenting from the community, partly attributed to the numerous contraindications to intravenous thrombolysis. We aimed to identify and analyze a group of patients with in-hospital AIS who remain suitable candidates for acute endovascular therapies. Methods: A retrospective 6-year data analysis was conducted in patients evaluated through the in-hospital stroke alert protocol in a single tertiary care university hospital to identify those with in-hospital AIS due to acute intracranial large vessel occlusion (ILVO). Feasibility and safety of mechanical thrombectomy for in-hospital AIS was assessed in a case-control study comparing inpatients to those presenting from the community. Results: From 1460 in-hospital stroke alert activations, 11% had a final diagnosis of AIS (n = 167). One hundred and two patients with in-hospital AIS had emergent intracranial vessel imaging and were included in our cohort. Acute ILVO was identified in 27 patients within this cohort. Patients were younger in the ILVO group and had more severe neurologic deficit on presentation. Compared to a matched (1:2) control group of patients presenting from the community, inpatients who underwent mechanical thrombectomy achieved equivalent technical success, safety, and clinical outcomes. Conclusions: The incidence of acute ILVO in patients with in-hospital AIS who underwent emergent vessel imaging is similar to the reported incidence of ILVO in patients presenting with community-onset AIS. Among patients with in-hospital AIS secondary to ILVO, mechanical thrombectomy is a feasible and safe therapy associated with favorable outcomes.

Emergent evaluation of inpatients with suspected acute ischemic stroke faces difficulty of symptoms recognition, false alarms, and high rate of contraindications to reperfusion therapies. We aim to assess the clinical characteristics and therapeutic interventions implemented in patients evaluated though the in-hospital Stroke Alert Protocol.We analyzed 4 years-worth of Stroke Alert cases at a university hospital. Demographics, clinical presentation, final diagnosis, and acute interventions were compared between inpatients and those presenting to the emergency department.A total of 1965 Stroke Alert cases were included: 959 (48.8%) were acute cerebrovascular events and 1006 (51.2%) were noncerebrovascular. Hospitalized patients accounted for 489 (24.9%) of Stroke Alerts and patients in the emergency department for 1476 (75.1%). Inpatients were more likely to present with nonfocal neurological deficits (46.2% versus 32.4%, P.0001) and be diagnosed with noncerebrovascular disorders (62.4% versus 47.5%, P.0001). Acute interventions other than thrombolysis were delivered in 77.1% of in-hospital cases. Compared to the emergency department, inpatients were more commonly managed with rectification of metabolic abnormalities (21.5% versus 13.7%, P.001), suspension or pharmacological reversal of drugs (11% versus 3.7%, P.001), and initiation of respiratory support (13.5% versus 9.3%, P = .01). Inpatients with acute ischemic stroke received intravenous thrombolysis less frequently (4.9% versus 23.9%, P.001), but the endovascular treatment rate was comparable (9.8% versus 10.3%) to the emergency department.Nonfocal neurological deficits and noncerebrovascular disorders are commonly encountered during in-hospital Stroke Alerts. In the inpatient setting, intravenous thrombolysis is rarely delivered while other time-sensitive therapeutic interventions are frequently implemented.

Background and Issues: Providing nurses with stroke pathology, prevention and management training is essential to diminish the devastating outcomes that this pathology can have on a patient and family. After an overwhelming response to medical education, we identified the possible need for nursing stroke education in Argentina. Purpose: The purpose is to define the status of stroke education among acute care nurses in Argentina and determine the need for stroke educational programs. Methods: For customer discovery, 32 semi-structured interviews were conducted in person, via Skype and via telephone calls with Argentinean nurses, nurse managers, nurse administrators and government officials. Interview questions were guided towards methods of nursing education, evaluations of skills, professional development, means of personal education and opportunities for growth in nursing educational courses regarding stroke pathology, prevention, and management. Responses given by the interviewees were documented and recurring themes were noted. Results: We discovered that there are very few opportunities for nursing continuing education without formal pursuit of a graduate degree. Bedside acute care nurses must seek out conferences or symposiums for topics of educational interest that are directed to physicians. All of our interviewees were in agreement that there is a need and desire toward stroke educational programs, including pathology, prevention and management. One of the recurring themes that was noted was the desire and need for nursing tailored education. Conclusions: Currently no continuing stroke educational programs are provided to nurses in Argentina. Through our interview process we concluded that there is an unattended and substantial need and desire for such training. The findings of these interviews will help in the development of a neurological critical care course for nurses in Spanish. This course will include stroke pathology, prevention and management.

Background The most common pathology associated with an intraluminal carotid thrombus is underlying atherosclerosis. In rare cases, it may be associated with thrombocytosis. Currently there are no clear recommendations for the treatment of ischemic stroke associated with thrombocytosis. Our present case illustrates the use of plateletpheresis for the acute management of thrombocytosis complicated by an internal carotid artery thrombus resulting in a right middle cerebral artery stroke. Case Description A 55-year-old female who presented with symptoms of acute, transient left hemiparesis and a National Institutes of Health Stroke Scale (NIHSS) score of 1. Initial head computed tomography (CT) scan was nonrevealing. Laboratory results revealed a mild hypochromic anemia and a platelet count of 1014 × 103/mL. The patient was not a candidate for thrombolytic therapy due to the time window. Soon after admission, she experienced acute worsening of symptoms, with an NIHSS score of 18. CT angiography of the head and neck showed acute ischemic infarction involving the right middle cerebral artery territory with a nonocclusive intraluminal thrombus within the right carotid bulb. Aspirin 325 mg and intravenous heparin infusion were initiated. After a thorough workup, reactive thrombocytosis secondary to iron deficiency anemia was diagnosed. Plateletpheresis was started, and after 1 cycle the platelet count stabilized at 400 × 103/mL. Complete thrombus resolution was confirmed on follow-up CT angiography on day 10 after admission without the need for surgical revascularization. Conclusions The role for plateletpheresis in treating secondary thrombocytosis is not well established. In cases with extreme thrombocytosis, immediate surgical thrombectomy may be contraindicated owing to a high risk of rethrombosis. Urgent cytoreduction with correction of the putative mechanism for thrombocytosis should be undertaken to provide optimal management.

Objective: To characterize the present state of brain death (BD) determination in actual practice relative to contemporary American Academy of Neurology (AAN) guidelines. Methods: We reviewed the charts of all adult (16 years and older) BD organ donors during 2011 from 68 heterogeneous hospitals in the Midwest United States. Data were collected across 5 categories: guideline performance, preclinical testing, clinical examination, apnea testing, and use of ancillary tests. Practice within categories and overall adherence to AAN guidelines were assessed. Results: Two hundred twenty-six BD organ donors were included. Practice exceeded recommendations in guideline performance but varied widely and deviated from AAN guidelines in all other categories. One hundred two (45.1%) had complete documentation of brainstem areflexia and absent motor response. One hundred sixty-six (73.5%) had completed apnea testing. Of the 60 without completed apnea testing, 56 (93.3%) had ancillary tests consistent with BD. Overall, 101 (44.7%) strictly and 84 (37.2%) loosely adhered to contemporary AAN guidelines. Conclusions: There is wide variability in the documentation of BD determination, likely reflecting similar variability in practice. This is a call for improved documentation, better uniformity of policies, and comprehensive and strategically targeted educational initiatives to ensure consistently contemporary approaches to BD determination in every patient.

Respiratory failure could result from a cardiopulmonary or a primary neurological disease. The latter could happen as a result of involvement of the central nervous system or a neuromuscular disease. Different neuromuscular diseases could result in respiratory failure by causing significant weakness of the respiratory and upper airways muscles. When confronted with a patient who presents with respiratory failure, the first task of the clinician is to secure the airways and stabilize the hemodynamic condition. The next step is the diagnostic approach and potentially a disease specific treatment, which is the focus of this review.