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Multiple studies demonstrate that fever/elevated temperature is associated with poor outcomes in patients with vascular brain injury; however, there are no conclusive studies that demonstrate that fever prevention/controlled normothermia is associated with better outcomes. The primary objective of the INTREPID (Impact of Fever Prevention in Brain-Injured Patients) trial is to test the hypothesis that fever prevention is superior to standard temperature management in patients with acute vascular brain injury. INTREPID is a prospective randomized open blinded endpoint study of fever prevention versus usual care in patients with ischemic or hemorrhagic stroke. The fever prevention intervention utilizes the Arctic Sun System and will be compared to standard care patients in whom fever may spontaneously develop. Ischemic stroke, intracerebral hemorrhage or subarachnoid hemorrhage patients will be included within disease-specific time-windows. Both awake and sedated patients will be included, and treatment is initiated immediately upon enrollment. Eligible patients are expected to require intensive care for at least 72 h post-injury, will not be deemed unlikely to survive without severe disability, and will be treated for up to 14 days, or until deemed ready for discharge from the ICU, whichever comes first. Fifty sites in the USA and worldwide will participate, with a target enrollment of 1176 patients (1000 evaluable). The target temperature is 37.0 °C. The primary efficacy outcome is the total fever burden by °C-h, defined as the area under the temperature curve above 37.9 °C. The primary secondary outcome, on which the sample size is based, is the modified Rankin Scale Score at 3 months. All efficacy analyses including the primary and key secondary endpoints will be primarily based on an intention-to-treat population. Analysis of the as-treated and per protocol populations will also be performed on the primary and key secondary endpoints as sensitivity analyses. The INTREPID trial will provide the first results of the impact of a pivotal fever prevention intervention in patients with acute stroke ( www.clinicaltrials.gov ; NCT02996266; registered prospectively 05DEC2016).

OBJECTIVEThere is variability and uncertainty about the optimal approach to the management and discontinuation of an external ventricular drain (EVD) after subarachnoid hemorrhage (SAH). Evidence from single-center randomized trials suggests that intermittent CSF drainage and rapid EVD weans are safe and associated with shorter ICU length of stay (LOS) and fewer EVD complications. However, a recent survey revealed that most neurocritical care units across the United States employ continuous CSF drainage with a gradual wean strategy. Therefore, the authors sought to determine the optimal EVD management approach at their institution.METHODSThe authors reviewed records of 200 patients admitted to their institution from 2010 to 2016 with aneurysmal SAH requiring an EVD. In 2014, the neurocritical care unit of the authors’ institution revised the internal EVD management guidelines from a continuous CSF drainage with gradual wean approach (continuous/gradual) to an intermittent CSF drainage with rapid EVD wean approach (intermittent/rapid). The authors performed a retrospective multivariable analysis to compare outcomes before and after the guideline change.RESULTSThe authors observed a significant reduction in ventriculoperitoneal (VP) shunt rates after changing to an intermittent CSF drainage with rapid EVD wean approach (13% intermittent/rapid vs 35% continuous/gradual, OR 0.21, p = 0.001). There was no increase in delayed VP shunt placement at 3 months (9.3% vs 8.6%, univariate p = 0.41). The intermittent/rapid EVD approach was also associated with a shorter mean EVD duration (10.2 vs 15.6 days, p < 0.001), shorter ICU LOS (14.2 vs 16.9 days, p = 0.001), shorter hospital LOS (18.2 vs 23.7 days, p < 0.0001), and lower incidence of a nonfunctioning EVD (15% vs 30%, OR 0.29, p = 0.006). The authors found no significant differences in the rates of symptomatic vasospasm (24.6% vs 20.2%, p = 0.52) or ventriculostomy-associated infections (1.3% vs 8.8%, OR 0.30, p = 0.315) between the 2 groups.CONCLUSIONSAn intermittent CSF drainage with rapid EVD wean approach is associated with fewer VP shunt placements, fewer complications, and shorter LOS compared to a continuous CSF drainage with gradual EVD wean approach. There is a critical need for prospective multicenter studies to determine if the authors’ experience is generalizable to other centers.

Malignant hemispheric stroke occurs in 10% of ischemic strokes and has one of the highest mortality and morbidity rates. This stroke, also known as malignant middle cerebral artery stroke, may cause ischemia to an entire hemisphere causing edema, herniation, and death. A collaborative interdisciplinary team approach is needed to manage these complex stroke patients. The nurse plays a vital role in bedside management and support of the patient and family through this complex course of care. This article discusses malignant middle cerebral artery stroke pathophysiology, techniques to predict patients at risk for herniation, collaborative care strategies, and nursing care.

Targeted temperature management (TTM) is often used in neurocritical care to minimize secondary neurologic injury and improve outcomes. TTM encompasses therapeutic hypothermia, controlled normothermia, and treatment of fever. TTM is best supported by evidence from neonatal hypoxic-ischemic encephalopathy and out-of-hospital cardiac arrest, although it has also been explored in ischemic stroke, traumatic brain injury, and intracranial hemorrhage patients. Critical care clinicians using TTM must select appropriate cooling techniques, provide a reasonable rate of cooling, manage shivering, and ensure adequate patient monitoring among other challenges. The Neurocritical Care Society recruited experts in neurocritical care, nursing, and pharmacotherapy to form a writing Committee in 2015. The group generated a set of 16 clinical questions relevant to TTM using the PICO format. With the assistance of a research librarian, the Committee undertook a comprehensive literature search with no back date through November 2016 with additional references up to March 2017. The Committee utilized GRADE methodology to adjudicate the quality of evidence as high, moderate, low, or very low based on their confidence that the estimate of effect approximated the true effect. They generated recommendations regarding the implementation of TTM based on this systematic review only after considering the quality of evidence, relative risks and benefits, patient values and preferences, and resource allocation. This guideline is intended for neurocritical care clinicians who have chosen to use TTM in patient care; it is not meant to provide guidance regarding the clinical indications for TTM itself. While there are areas of TTM practice where clear evidence guides strong recommendations, many of the recommendations are conditional, and must be contextualized to individual patient and system needs.

Informal caregivers (e.g., family and friends) are at risk for developing depression, which can be detrimental to both caregiver and patient functioning. Initial evidence suggests that resiliency may reduce the risk of depression. However, gender differences in associations between multiple psychosocial resiliency factors and depression have not been examined among neuroscience intensive care unit (neuro-ICU) caregivers. We explored interactions between caregiver gender and baseline resiliency factors on depression symptom severity at baseline through 3 and 6 months post-discharge. Caregivers (N = 96) of neuro-ICU patients able to provide informed consent to participate in research were enrolled as part of a prospective, longitudinal study in the neuro-ICU of a major academic medical center. Caregiver sociodemographics and resiliency factors (coping, mindfulness, self-efficacy, intimate care, and preparedness for caregiving) were assessed during the patient’s hospitalization (i.e., baseline). Levels of depressive symptoms were measured using the Hospital Anxiety and Depression Scale at baseline, 3 months, and 6 months post-discharge. Baseline depressive symptoms predicted depressive symptoms at both 3- and 6-month follow-ups, with no difference at any time point in rates of depression by gender. At baseline, greater levels of coping, mindfulness, and preparedness for caregiving were individually associated with lower levels of concurrent depression regardless of gender (ps

External ventricular drains (EVDs) are commonly placed to monitor intracranial pressure and manage acute hydrocephalus in patients with a variety of intracranial pathologies. The indications for EVD insertion and their efficacy in the management of these various conditions have been previously addressed in guidelines published by the Brain Trauma Foundation, American Heart Association and combined committees of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. While it is well recognized that placement of an EVD may be a lifesaving intervention, the benefits can be offset by procedural and catheter-related complications, such as hemorrhage along the catheter tract, catheter malposition, and CSF infection. Despite their widespread use, there are a lack of high-quality data regarding the best methods for placement and management of EVDs to minimize these risks. Existing recommendations are frequently based on observational data from a single center and may be biased to the authors' view. To address the need for a comprehensive set of evidence-based guidelines for EVD management, the Neurocritical Care Society organized a committee of experts in the fields of neurosurgery, neurology, neuroinfectious disease, critical care, pharmacotherapy, and nursing. The Committee generated clinical questions relevant to EVD placement and management. They developed recommendations based on a thorough literature review using the Grading of Recommendations Assessment, Development, and Evaluation system, with emphasis placed not only on the quality of the evidence, but also on the balance of benefits versus risks, patient values and preferences, and resource considerations.

Background:Pressure ulcers resulting from continuous EEG (cEEG) monitoring in hospitalized patients have gained attention as a preventable medical complication. We measured their incidence and risk factors.Methods:We performed an observational investigation of cEEG-electrode-related pressure ulcers (EERPU) among acutely ill patients over a 22-month period. Variables analyzed included age, sex, monitoring duration, hospital location, application methods, vasopressor usage, nutritional status, skin allergies, fever, and presence/severity of EERPU. We examined risk for pressure ulcers vs monitoring duration using Kaplan-Meyer survival analysis, and performed multivariate risk assessment using Cox proportional hazard model.Results:Among 1,519 patients, EERPU occurred in 118 (7.8%). Most (n = 109, 92.3%) consisted of hyperemia only without skin breakdown. A major predictor was monitoring duration, with 3-, 5-, and 10-day risks of 16%, 32%, and 60%, respectively. Risk factors included older age (mean age 60.65 vs 50.3, p < 0.01), care in an intensive care unit (9.37% vs 5.32%, p < 0.01), lack of a head wrap (8.31% vs 27.3%, p = 0.02), use of vasopressors (16.7% vs 9.64%, p < 0.01), enteral feeding (11.7% vs 5.45%, p = 0.04), and fever (18.4% vs 9.3%, p < 0.01). Elderly patients (71–80 years) were at higher risk (hazard ratio 6.84 [1.95–24], p < 0.01), even after accounting for monitoring time and other pertinent variables in multivariate analysis.Conclusions:EERPU are uncommon and generally mild. Elderly patients and those with more severe illness have higher risk of developing EERPU, and the risk increases as a function of monitoring duration.

Many prior nursing studies regarding family members specifically of neuroscience intensive care unit (neuro-ICU) patients have focused on identifying their primary needs. A concept related to identifying these needs and assessing whether they have been met is determining whether families explicitly report satisfaction with the care that both they and their loved ones have received. The objective of this study was to explore family satisfaction with care in an academic neuro-ICU and compare results with concurrent data from the same hospital's medical ICU (MICU). Over 38 days, we administered the Family Satisfaction-ICU instrument to neuro-ICU and MICU patients' families at the time of ICU discharge. Those whose loved ones passed away during ICU admission were excluded. When asked about the respect and compassion that they received from staff, 76.3% (95% CI [66.5, 86.1]) of neuro-ICU families were completely satisfied, as opposed to 92.7% in the MICU (95% CI [84.4, 101.0], p = .04). Respondents were less likely to be completely satisfied with the courtesy of staff if they reported participation in zero formal family meeting. Less than 60% of neuro-ICU families were completely satisfied by (1) frequency of physician communication, (2) inclusion and (3) support during decision making, and (4) control over the care of their loved ones. Parents of patients were more likely than other relatives to feel very included and supported in the decision-making process. Future studies may focus on evaluating strategies for neuro-ICU nurses and physicians to provide better decision-making support and to implement more frequent family meetings even for those patients who may not seem medically or socially complicated to the team. Determining satisfaction with care for those families whose loved ones passed away during their neuro-ICU admission is another potential avenue for future investigation.

Continuous EEG screening using spectrograms or compressed spectral arrays (CSAs) by neurophysiologists has shorter review times with minimal loss of sensitivity for seizure detection when compared with visual analysis of raw EEG. Limited data are available on the performance characteristics of CSA-based seizure detection by neurocritical care nurses.This is a prospective cross-sectional study that was conducted in two academic neurocritical care units and involved 33 neurointensive care unit nurses and four neurophysiologists.All nurses underwent a brief training session before testing. Forty two-hour CSA segments of continuous EEG were reviewed and rated for the presence of seizures. Two experienced clinical neurophysiologists masked to the CSA data performed conventional visual analysis of the raw EEG and served as the gold standard. The overall accuracy was 55.7% among nurses and 67.5% among neurophysiologists. Nurse seizure detection sensitivity was 73.8%, and the false-positive rate was 1-per-3.2 hours. Sensitivity and false-alarm rate for the neurophysiologists was 66.3% and 1-per-6.4 hours, respectively. Interrater agreement for seizure screening was fair for nurses (Gwet AC1 statistic: 43.4%) and neurophysiologists (AC1: 46.3%).Training nurses to perform seizure screening utilizing continuous EEG CSA displays is feasible and associated with moderate sensitivity. Nurses and neurophysiologists had comparable sensitivities, but nurses had a higher false-positive rate. Further work is needed to improve sensitivity and reduce false-alarm rates.

Delayed cerebral ischemia (DCI) is the most common and disabling complication among patients admitted to the hospital for subarachnoid hemorrhage (SAH). Clinical and radiographic methods often fail to detect DCI early enough to avert irreversible injury. We assessed the clinical feasibility of implementing a continuous EEG (cEEG) ischemia monitoring service for early DCI detection as part of an institutional guideline. An institutional neuromonitoring guideline was designed by an interdisciplinary team of neurocritical care, clinical neurophysiology, and neurosurgery physicians and nursing staff and cEEG technologists. The interdisciplinary team focused on (1) selection criteria of high-risk patients, (2) minimization of safety concerns related to prolonged monitoring, (3) technical selection of quantitative and qualitative neurophysiologic parameters based on expert consensus and review of the literature, (4) a structured interpretation and reporting methodology, prompting direct patient evaluation and iterative neurocritical care, and (5) a two-layered quality assurance process including structured clinician interviews assessing events of neurologic worsening and an adjudicated consensus review of neuroimaging and medical records. The resulting guideline's clinical feasibility was then prospectively evaluated. The institutional SAH monitoring guideline used transcranial Doppler ultrasound and cEEG monitoring for vasospasm and ischemia monitoring in patients with either Fisher group 3 or Hunt-Hess grade IV or V SAH. Safety criteria focused on prevention of skin breakdown and agitation. Technical components included monitoring of transcranial Doppler ultrasound velocities and cEEG features, including quantitative alpha:delta ratio and percent alpha variability, qualitative evidence of new focal slowing, late-onset epileptiform activity, or overall worsening of background. Structured cEEG reports were introduced including verbal communication for findings concerning neurologic decline. The guideline was successfully implemented over 27 months, during which neurocritical care physicians referred 71 SAH patients for combined transcranial Doppler ultrasound and cEEG monitoring. The quality assurance process determined a DCI rate of 48% among the monitored population, more than 90% of which occurred during the duration of cEEG monitoring (mean 6.9 days) beginning 2.7 days after symptom onset. An institutional guideline implementing cEEG for SAH ischemia monitoring and reporting is feasible to implement and efficiently identify patients at high baseline risk of DCI during the period of monitoring.

The use of rapid infusion of large-volume cold saline (CS) as an adjunctive therapy for treating refractory fever in nine patients is reported. A decline in temperature (39.2 +/- 0.3 vs 37.1 +/- 1.2 degrees C, p = 0.006) at 2 hours and fever burden (97.3 +/- 343.8 vs 734.3 +/- 422.3 degrees C*min, p = 0.02) at 12 hours was noted after CS bolus. Rapid infusion of large-volume CS may be used as an adjunct for inducing normothermia in refractory febrile patients.

An infection of the ventricular system of the brain is referred to as ventriculitis. The signs and symptoms of ventriculitis include the triad of altered mental status, fever, and headache, as seen in the patient with meningitis. Identifying the organism responsible is important in determining the cause and in planning a treatment strategy. Nurses have a pivotal role in the early identification and management of the patient with ventriculitis.

Purpose Prior studies of anxiety and depression among families of intensive care unit patients excluded those admitted for less than 2 days. We hypothesized that families of surviving patients with length of stay less than 2 days would have similar prevalence of anxiety and depression compared with those admitted for longer. Materials and methods One hundred six family members in the neurosciences and medical intensive care units at a university hospital completed the Hospital Anxiety and Depression Scale at discharge. Results The 106 participants represented a response rate of 63.9% among those who received surveys. Fifty-eight surveys (54.7%) were from relatives of patients who were discharged within 2 days of admission, whereas 48 (45.3%) were from those admitted for longer. No difference in anxiety was detected; prevalence was 20.7% (95% confidence interval, 10.4) among shorter stay families and 8.3% (7.8) among longer stay families (P = .10). No difference was also seen with depression; prevalence was 8.6% (7.2) among shorter stay families and 4.2% (5.7) among longer stay families (P = .45). Conclusions Families of surviving patients with brief length of stay may have similar prevalence of anxiety and depression at discharge to those with longer length of stay.

Extubation failure in the neurocritical care unit (NCCU) is difficult to predict, and is an important source of prolonged intensive care, exposure to morbidity, and increased cost. In this observational cohort study in the NCCU of a tertiary care hospital, we examined patients undergoing extubation or tracheostomy with >6 h of intubation. Observational data were collected at the time of the decision to extubate or pursue tracheostomy. The primary end-point was extubation failure within 72 h. A total of 378 tracheostomy versus extubation decisions were made on 339 individuals, resulting in 93 tracheostomies and 285 extubations. The extubation failure rate was 48/285 (16.8%). Individuals who underwent extubation had similar GCS scores [median 10T (IQR 10–11), P = 0.21]. Extubation failures had similar rates of pneumonia and fever, chest X-ray (CXR) findings, and admission diagnoses (P = NS). Factors associated with success in univariate analysis included intact gag reflex, normal eye movements, ability to close eyes to command, and ability to cough to command (all P

More than 700,000 people have a stroke each year in the United States. A diagnosis of stroke formerly elicited a nihilistic approach, but this has substantially changed in the last decade. Currently, time is brain, and it is important for all disciplines to work together to initiate acute stroke protocols in the emergency department and identify patients within the therapeutic time window for thrombolytic and neuroprotective therapies. Evolving protocols, management, and nursing care all have important implications during the acute phase of ischemic stroke. Patient and family education on risk reduction must also be addressed by the entire healthcare team.

Background and Purpose —Immediate access to physicians experienced in acute stroke treatment may improve clinical outcomes in patients with acute stroke. Interactive telemedicine can make stroke specialists available to assist in the evaluation of patients at multiple urban or remote rural facilities. We tested whether interrater agreement for the NIH Stroke Scale (NIHSS), a critical component of acute stroke assessment, would persist if performed over a telemedicine link. Methods —One bedside and 1 remote NIHSS score were independently obtained on each of 20 patients with ischemic stroke. The bedside examination was performed by a stroke neurologist at the patient’s bedside. The remote examination was performed by a second stroke neurologist through an interactive high-speed audio-video link, assisted by a nurse at the patient’s bedside. Kappa coefficients were calculated for concordance between bedside and remote scores. Results —Remote assessments took slightly longer than bedside assessments (mean 9.70 versus 6.55 minutes, P r =0.97, P Conclusions —The NIH Stroke Scale remains a swift and reliable clinical instrument when used over interactive video. Application of this technology can bring stroke expertise to the bedside, regardless of patient location.