Secondary brain injury is a common cause of poor outcome after trauma, subarachnoid hemorrhage, and intracerebral hemorrhage, and optimizing treatment requires real-time insight into cerebral metabolism. Cerebral microdialysis (CMD) uniquely provides key related information, yet consensus on its use has not been updated since publication of the consensus statement from the 2014 International Microdialysis Forum. We aimed to assess expert consensus on the use of CMD in critical care and provide contemporary guidance to standardize practice and advance clinical implementation. We conducted a 3-round modified Delphi study with international experts in CMD and neurocritical care. Consensus was defined as ≥ 75

Background : Many randomized controlled trials (RCT) have assessed new treatments in subarachnoid hemorrhage (SAH), yet most show no treatment efficacy. One explanation is the statistical analysis of the primary endpoint was not as efficient as possible. We reanalyzed SAH RCTs with various statistical tests to determine whether the statistical method affects RCT primary outcome. Methods : Individual patient data for the primary outcome (Glasgow outcome scale [GOS]) of two SAH RCTs were analyzed using 15 statistical methods. For tests requiring outcome dichotomization, multiple cut-points in the 5-level GOS were assessed. Next, a synthetic dataset generated using random sampling with replacement from ten SAH RCTs was assessed using the same statistical tests. A Friedman test (two-way non-parametric analysis of variance) determined which tests produced the highest average absolute Z -values. The number of times each test reported significance of p <0.05 across the different datasets was calculated. Results : Bootstrapping with replacement produced the best-ranking results, followed by three χ 2 -tests: one differentiating excellent (GOS=5) from good (GOS=4), poor (GOS=2-3), or dead (GOS=1) outcomes; one differentiating favorable (GOS=4-5) from poor or dead outcomes; and one differentiating favorable (GOS=4-5) from unfavorable outcomes. Each of these reported statistical significance for both RCTs, as did the following ranked tests, respectively: Wilcoxon median test, Student’s t-test, ordinal logistic regression, median test, and a chi-square dichotomizing excellent (GOS≥4) and inferior outcomes. Statistical significance for one or neither RCT was reported by two Cochrane-Armitage tests and two logistic regressions with alternate versions of bucketing, the Kolmogorov-Smirnov test and chi-square test differentiating surviving from dead patients. The synthetic dataset returned similar results, with the same nine most and six least efficient tests. Conclusions : Bootstrapping produced the most efficient results but is time-and resource-intensive. Chi-square tests grouping outcomes into dichotomous or multiple buckets are also efficient, and their ease of use and popularity make them appropriate candidates for statistical analysis in future SAH RCTs.

HomeStrokeVol. 52, No. 8Safety of the Mobile Stroke Unit: A Descriptive Review and Results of Radiation Monitoring Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toSupplementary MaterialsFree AccessLetterPDF/EPUBSafety of the Mobile Stroke Unit: A Descriptive Review and Results of Radiation Monitoring Stephen Susa, BS Redi Rahmani, MD David Conover, MS, LMP Samuel Carr, MSc Nathaniel Ellens, MD Diana Proper, MS Peter Le Roux, MD Joshua Catapano, MD Visish Srinivasan, MD Tarun BhallaMD, PhD Stephen SusaStephen Susa https://orcid.org/0000-0002-7817-9077 Department of Neurosurgery, University of Rochester Medical Center, NY (S.S., R.R., N.E., D.P., P.L.R., T.B.). , Redi RahmaniRedi Rahmani Correspondence to: Redi Rahmani, MD, Department of Neurosurgery, Strong Memorial Hospital, 601 Elmwood Ave, Rochester, NY 14620. Email E-mail Address: [email protected] https://orcid.org/0000-0003-3161-2125 Department of Neurosurgery, University of Rochester Medical Center, NY (S.S., R.R., N.E., D.P., P.L.R., T.B.). , David ConoverDavid Conover https://orcid.org/0000-0002-7948-4612 Radiation Safety Unit, University of Rochester, NY (D.C., S.C.). , Samuel CarrSamuel Carr Radiation Safety Unit, University of Rochester, NY (D.C., S.C.). , Nathaniel EllensNathaniel Ellens https://orcid.org/0000-0001-6901-1160 Department of Neurosurgery, University of Rochester Medical Center, NY (S.S., R.R., N.E., D.P., P.L.R., T.B.). , Diana ProperDiana Proper https://orcid.org/0000-0003-2483-4192 Department of Neurosurgery, University of Rochester Medical Center, NY (S.S., R.R., N.E., D.P., P.L.R., T.B.). , Peter Le RouxPeter Le Roux Department of Neurosurgery, University of Rochester Medical Center, NY (S.S., R.R., N.E., D.P., P.L.R., T.B.). Division of Neurosurgery, Bassett HealthCare, Cooperstown, NY (P.L.R.). , Joshua CatapanoJoshua Catapano Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (J.C., V.S.). , Visish SrinivasanVisish Srinivasan https://orcid.org/0000-0001-7673-6805 Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (J.C., V.S.). , and Tarun BhallaTarun Bhalla Department of Neurosurgery, University of Rochester Medical Center, NY (S.S., R.R., N.E., D.P., P.L.R., T.B.). Originally published4 Jun 2021https://doi.org/10.1161/STROKEAHA.120.033545Stroke. 2021;52:e497–e498Despite interventions like intravenous tPA (tissue-type plasminogen activator) and endovascular thrombectomy, acute ischemic stroke remains a major health burden. Many patients experience morbidity and mortality that earlier therapy could prevent.Mobile stroke units (MSUs) developed in response to the need for expedited acute ischemic stroke care. MSUs incorporate a portable head computed tomography (CT) scanner into a conventional ambulance platform, which can rule out acute intracranial hemorrhage and allow initiation of intravenous tPA therapy while the patient is in transit to a care facility. Since MSUs carry a CT scanner, they carry a risk of exposing the public, the patient, and the care team to radiation. To reduce this risk, MSUs are specially shielded to prevent radiation exposure. There has been limited study of the radiation exposure associated with MSUs, and concerns remain about their safety.1 We measured the radiation generated by the MSU CT scanner to characterize their potential risk.To test ambient radiation, a CT scan was performed in the MSU using standard scanning parameters with a phantom in the bore. Using a dosimeter, scatter radiation exposure was measured at various locations. Measurements were then converted to whole-body effective radiation dose.Inside the MSU, effective dose per scan was 0.0052 mSv at the control panel and 0.0043 mSv at the operator console. Outside the MSU, the dose was 0.0003 mSv on the right and 0.0001 mSv at the rear of the unit. Inside the truck cab, the dose was 0.00004 mSv. Since October 2018, we have scanned 203 patients. During this period, our CT technologist's dosimeter registered 0.240 mSv. The radiation dose (CT Dose Index [CTDIvol]) delivered to the patient's head in our MSU was 47.15 mGy or ≈2 mSv. Further details on our methods and results can be found in the Table, and in the Materials in the Data Supplement.Table. Whole-Body Effective Dose Equivalent2mSvDescriptorReference values 10 000Fatal dose for 100% of recipients 50Annual occupational dose limit (United States)3 10Dose from typical CT scan 6.2Average dose per year in the United States 2Dose from typical head CT4 1Annual dose limit for the public3,5 0.1Dose from chest radiographMSU recorded values 2Average dose for head CT scan in MSU 0.24Total dose to MSU CT technologist (October 2018 to February 2020) 0.0052Control panel (1 m) 0.0043Operator console (3 m) 0.0003Right of unit (3 m) 0.0001Rear of unit (6 m) 0.00004Truck cab (1 m)CT indicates computed tomography; and MSU, mobile stroke unit.Our findings suggest that the radiation dose to the public associated with MSU operation is <0.006 mSv per scan. This level is significantly less than conventional international radiation exposure limits to the general public, 20 µSv/h or 1.0 mSv/y.5 Our values are also within the US Nuclear Regulatory Commission occupational limit of 50 mSv/y.3 While there is no safe radiation dose, all levels measured are much lower than doses proven to cause health problems.2 Our data indicate that MSUs do not produce an amount of radiation that could be harmful. The public should feel confident that MSUs do not pose an undue risk of radiation exposure. We hope that our findings will encourage the expansion of MSU programs.Sources of FundingNone.Disclosures None. The data that support the findings of this study are available from the corresponding author upon reasonable request.Footnotes*S. Susa and R. Rahmani contributed equally.The Data Supplement is available with this article at https://www.ahajournals.org/doi/suppl/10.1161/STROKEAHA.120.033545.For Sources of Funding and Disclosures, see page e497.Correspondence to: Redi Rahmani, MD, Department of Neurosurgery, Strong Memorial Hospital, 601 Elmwood Ave, Rochester, NY 14620. Email [email protected]rochester.eduReferences1. Gutiérrez JM, Emery RJ, Parker SA, Jackson K, Grotta JC. Radiation monitoring results from the first year of operation of a unique ambulance-based computed tomography unit for the improved diagnosis and treatment of stroke patients.Health Phys. 2016; 110(5suppl 2):S73–S80. doi: 10.1097/HP.0000000000000502Google Scholar2. Centers for Disease Control. Radiation Thermometer.Accessed January 30, 2021. https://www.cdc.gov/nceh/radiation/emergencies/radiationthermometer.htmGoogle Scholar3. United States Nuclear Regulatory Commission. Occupational Dose Limits.Accessed January 30, 2021. https://www.nrc.gov/reading-rm/doc-collections/cfr/part020/part020-1201.html. 1991.Google Scholar4. Hendrick RE, Dodd GD, Fullerton GD, Hendee WR, Borgstede JP, Larke F. The University of Colorado radiology adult dose-risk smartcard.J Am Coll Radiol. 2012; 9:290–292. doi: 10.1016/j.jacr.2011.12.034Google Scholar5. ICRP. Recommendations of the International Commission on Radiological Protection. ICRP Publication 60.Ann ICRP. 1991; 21:45–46.Google Scholar Previous Back to top Next FiguresReferencesRelatedDetails August 2021Vol 52, Issue 8Article InformationMetrics Download: 94 © 2021 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.120.033545PMID: 34082572 Originally publishedJune 4, 2021 Keywordsstrokehemorrhageischemic strokemorbidityradiationPDF download SubjectsComputerized Tomography (CT)Ischemic StrokeImagingCerebrovascular Disease/Stroke

OBJECTIVE Rescue therapies have been recommended for patients with angiographic vasospasm (aVSP) and delayed cerebral ischemia (DCI) following subarachnoid hemorrhage (SAH). However, there is little evidence from randomized clinical trials that these therapies are safe and effective. The primary aim of this study was to apply game theory-based methods in explainable machine learning (ML) and propensity score matching to determine if rescue therapy was associated with better 3-month outcomes following post-SAH aVSP and DCI. The authors also sought to use these explainable ML methods to identify patient populations that were more likely to receive rescue therapy and factors associated with better outcomes after rescue therapy. METHODS Data for patients with aVSP or DCI after SAH were obtained from 8 clinical trials and 1 observational study in the Subarachnoid Hemorrhage International Trialists repository. Gradient boosting ML models were constructed for each patient to predict the probability of receiving rescue therapy and the 3-month Glasgow Outcome Scale (GOS) score. Favorable outcome was defined as a 3-month GOS score of 4 or 5. Shapley Additive Explanation (SHAP) values were calculated for each patient-derived model to quantify feature importance and interaction effects. Variables with high SHAP importance in predicting rescue therapy administration were used in a propensity score-matched analysis of rescue therapy and 3-month GOS scores. RESULTS The authors identified 1532 patients with aVSP or DCI. Predictive, explainable ML models revealed that aneurysm characteristics and neurological complications, but not admission neurological scores, carried the highest relative importance rankings in predicting whether rescue therapy was administered. Younger age and absence of cerebral ischemia/infarction were invariably linked to better rescue outcomes, whereas the other important predictors of outcome varied by rescue type (interventional or noninterventional). In a propensity score-matched analysis guided by SHAP-based variable selection, rescue therapy was associated with higher odds of 3-month GOS scores of 4-5 (OR 1.63, 95% CI 1.22-2.17). CONCLUSIONS Rescue therapy may increase the odds of good outcome in patients with aVSP or DCI after SAH. Given the strong association between cerebral ischemia/infarction and poor outcome, trials focusing on preventative or therapeutic interventions in these patients may be most able to demonstrate improvements in clinical outcomes. Insights developed from these models may be helpful for improving patient selection and trial design.

Bassett Healthcare, Cooperstown NY, USA Correspondence to Peter Le Roux, Bassett Healthcare, Cooperstown NY, USA. E-mail: [email protected]

Purpose of review Since the development of intravenous tissue plasminogen activator (tPA) for acute ischemic stroke (AIS), functional outcome has improved when treatment occurs within 4.5 h of stroke onset and treatment benefits are greater with earlier treatment. Endovascular revascularization also is better the sooner it is delivered. Recent findings The Get with the Guidelines Stroke registry found that less than one-third of treatment-eligible AIS patients receive intravenous tPA within 60 min of hospital arrival. Initiatives have tried to improve public education and awareness of stroke symptoms to decrease time to presentation. The mobile stroke unit (MSU) facilitates earlier computed tomography scans, delivery of tPA, proper triage and on-scene goal-directed care. MSUs reduce time from stroke alarm to treatment by 25–40 min and increase the rate of intravenous tPA use without an increase in hemorrhage risk. In addition, three-month favorable outcome is increased. Summary MSUs likely will evolve further and be used for other acute neurologic disorders, help triage patients for endovascular therapy, and be incorporated into systems of care in remote areas. Further studies are awaited to fully understand the overall medical and health-economic benefit of MSUs.

Objectives: To estimate the impact of goal-directed therapy on outcome after traumatic brain injury, our team applied goal-directed therapy to standardize care in patients with moderate to severe traumatic brain injury, who were enrolled in a large multicenter clinical trial. Design: Planned secondary analysis of data from Progesterone for the Treatment of Traumatic Brain Injury III, a large, prospective, multicenter clinical trial. Setting: Forty-two trauma centers within the Neurologic Emergencies Treatment Trials network. Patients: Eight-hundred eighty-two patients were enrolled within 4 hours of injury after nonpenetrating traumatic brain injury characterized by Glasgow Coma Scale score of 4–12. Measurements and Main Results: Physiologic goals were defined a priori in order to standardize care across 42 sites participating in Progesterone for the Treatment of Traumatic Brain Injury III. Physiologic data collection occurred hourly; laboratory data were collected according to local ICU protocols and at a minimum of once per day. Physiologic transgressions were predefined as substantial deviations from the normal range of goal-directed therapy. Each hour where goal-directed therapy was not achieved was classified as a “transgression.” Data were adjudicated electronically and via expert review. Six-month outcomes included mortality and the stratified dichotomy of the Glasgow Outcome Scale-Extended. For each variable, the association between outcome and either: 1) the occurrence of a transgression or 2) the proportion of time spent in transgression was estimated via logistic regression model. Results: For the 882 patients enrolled in Progesterone for the Treatment of Traumatic Brain Injury III, mortality was 12.5%. Prolonged time spent in transgression was associated with increased mortality in the full cohort for hemoglobin less than 8 gm/dL (p = 0.0006), international normalized ratio greater than 1.4 (p < 0.0001), glucose greater than 180 mg/dL (p = 0.0003), and systolic blood pressure less than 90 mm Hg (p < 0.0001). In the patient subgroup with intracranial pressure monitoring, prolonged time spent in transgression was associated with increased mortality for intracranial pressure greater than or equal to 20 mm Hg (p < 0.0001), glucose greater than 180 mg/dL (p = 0.0293), hemoglobin less than 8 gm/dL (p = 0.0220), or systolic blood pressure less than 90 mm Hg (p = 0.0114). Covariates inversely related to mortality included: a single occurrence of mean arterial pressure less than 65 mm Hg (p = 0.0051) or systolic blood pressure greater than 180 mm Hg (p = 0.0002). Conclusions: The Progesterone for the Treatment of Traumatic Brain Injury III clinical trial rigorously monitored compliance with goal-directed therapy after traumatic brain injury. Multiple significant associations between physiologic transgressions, morbidity, and mortality were observed. These data suggest that effective goal-directed therapy in traumatic brain injury may provide an opportunity to improve patient outcomes.

Objective - To develop and validate a set of practical prediction tools that reliably estimate the outcome of subarachnoid haemorrhage from ruptured intracranial aneurysms (SAH). Design - Cohort study with logistic regression analysis to combine predictors and treatment modality. Setting - Subarachnoid Haemorrhage International Trialists' (SAHIT) data repository, including randomised clinical trials, prospective observational studies, and hospital registries. Participants - Researchers collaborated to pool datasets of prospective observational studies, hospital registries, and randomised clinical trials of SAH from multiple geographical regions to develop and validate clinical prediction models. Main outcome measure - Predicted risk of mortality or functional outcome at three months according to score on the Glasgow outcome scale. Results - Clinical prediction models were developed with individual patient data from 10 936 patients and validated with data from 3355 patients after development of the model. In the validation cohort, a core model including patient age, premorbid hypertension, and neurological grade on admission to predict risk of functional outcome had good discrimination, with an area under the receiver operator characteristics curve (AUC) of 0.80 (95% confidence interval 0.78 to 0.82). When the core model was extended to a "neuroimaging model," with inclusion of clot volume, aneurysm size, and location, the AUC improved to 0.81 (0.79 to 0.84). A full model that extended the neuroimaging model by including treatment modality had AUC of 0.81 (0.79 to 0.83). Discrimination was lower for a similar set of models to predict risk of mortality (AUC for full model 0.76, 0.69 to 0.82). All models showed satisfactory calibration in the validation cohort. Conclusion - The prediction models reliably estimate the outcome of patients who were managed in various settings for ruptured intracranial aneurysms that caused subarachnoid haemorrhage. The predictor items are readily derived at hospital admission. The web based SAHIT prognostic calculator (http://sahitscore.com) and the related app could be adjunctive tools to support management of patients.

BACKGROUND Seizure is a significant complication in patients under acute admission for aneurysmal SAH and could result in poor outcomes. Treatment strategies to optimize management will benefit from methods to better identify at-risk patients. OBJECTIVE To develop and validate a risk score for convulsive seizure during acute admission for SAH. METHODS A risk score was developed in 1500 patients from a single tertiary hospital and externally validated in 852 patients. Candidate predictors were identified by systematic review of the literature and were included in a backward stepwise logistic regression model with in-hospital seizure as a dependent variable. The risk score was assessed for discrimination using the area under the receiver operator characteristics curve (AUC) and for calibration using a goodness-of-fit test. RESULTS The SAFARI score, based on 4 items (age ≥ 60 yr, seizure occurrence before hospitalization, ruptured aneurysm in the anterior circulation, and hydrocephalus requiring cerebrospinal fluid diversion), had AUC = 0.77, 95% confidence interval (CI): 0.73-0.82 in the development cohort. The validation cohort had AUC = 0.65, 95% CI 0.56-0.73. A calibrated increase in the risk of seizure was noted with increasing SAFARI score points. CONCLUSION The SAFARI score is a simple tool that adequately stratified SAH patients according to their risk for seizure using a few readily derived predictor items. It may contribute to a more individualized management of seizure following SAH.

INTRODUCTION: Secondary cerebral insults can adversely affect patients with traumatic brain injury. By contrast, the incidence of secondary cerebral insults after aneurysmal subarachnoid hemorrhage (SAH) and their impact on outcome have been less well studied. METHODS: Four hundred and twenty-one patients with SAH who underwent surgical occlusion of their ruptured aneurysm and who received intensive care unit care for >= 48 hours were retrospectively identified from a prospective observational database. Patients were managed according to standard recommendations for SAH. Three secondary cerebral insults were examined: hypotension (<90 mmHg systolic), hypoxia (PaO2 < 60 mm Hg), and hyperglycemia (>200 mg/dL). RESULTS: A secondary cerebral insult was observed in 309 (73.4%) patients including 135 (32.1%) who had multiple insults. There was an association between worse clinical grade and development of secondary insults (P = 0.0002), particularly multiple insults (P < 0.0001). When stratified by clinical grade, single (adjusted odds ratio [OR], 2.23; 95% confidence interval [CI], 1.10-4.51; P = 0.026) and multiple (adjusted OR, 4.37; 95% CI, 2.14-8.93; P < 0.0001) secondary cerebral insults were associated with worse outcome. In multivariate analysis and controlling for age, admission clinical grade, severity of SAH on computed tomography, intracerebral hematoma, increased intracranial pressure (>20 mm Hg), rebleed, intraoperative rupture, and hydrocephalus, secondary cerebral insults were independently associated with poor outcome (adjusted OR, 2.45; 95% CI, 1.20-5.02; P = 0.014). CONCLUSIONS: Secondary cerebral insults (hypoxia, hypotension, and hyperglycemia) are common after SAH, including among patients with a good clinical grade. These insults after SAH are associated with worse outcome. These data suggest that prevention of secondary cerebral insults may provide an opportunity to improve patient outcome after SAH.

BACKGROUND: The optimal red blood cell transfusion (RBCT) trigger for patients with aneurysmal subarachnoid hemorrhage (SAH) is unknown. In patients with cerebral vasospasm, anemia may increase susceptibility to ischemic injury; conversely, RBCT may worsen outcome given known deleterious effects. OBJECTIVE: To examine the association between RBCT, delayed cerebral ischemia (DCI), vasospasm, and outcome after SAH. METHODS: A total of 421 consecutive patients with SAH, admitted to a neurocritical care unit at a universityaffiliated hospital and who underwent surgical occlusion of their ruptured aneurysm were retrospectively identified from a prospective observational database. Propensity score methods were used to reduce the bias associated with treatment selection. RESULTS: Two hundred and sixty-one patients (62.0%) received an RBCT. Angiographic vasospasm (odds ratio [OR] 1.6; 95% confidence interval [CI], 1.1-2.3; P = 0.025) but not severe angiographic spasm, DCI, or delayed infarction was associated with RBCT. A total of 283 patients (67.2%) experienced a favorable outcome, defined as good or moderately disabled on the Glasgow Outcome Scale; 47 (11.2%) were severely disabled or vegetative and 91 patients (21.6%) were dead at 6-month follow-up. Among patients who survived >= 2 days, RBCT was associated with unfavorable outcome (OR, 2.6; 95% CI, 1.6-4.1). Transfusion of >= 3 units of blood was associated with an increased incidence of unfavorable outcome. Propensity analysis to control for the probability of exposure to RBCT conditional on observed covariates measured before RBCT indicates that RBCT is associated with unfavorable outcome in the absence of DCI (OR, 2.17; 95% CI, 1.56-3.01; P < 0.0001) but not when DCI is present (OR, 0.82; 95% CI, 0.35-1.92; P = 0.65). CONCLUSIONS: Blood transfusions are associated with unfavorable outcome after SAH particularly when DCI is absent. Propensity analysis suggests that RBCT may be associated with poor outcome rather than being a marker of disease severity. However, when DCI is present, RBCT may help improve outcome.

Neuroprotective strategies that limit secondary tissue loss and/or improve functional outcomes have been identified in multiple animal models of ischemic, hemorrhagic, traumatic and nontraumatic cerebral lesions. However, use of these potential interventions in human randomized controlled studies has generally given disappointing results. In this paper, we summarize the current status in terms of neuroprotective strategies, both in the immediate and later stages of acute brain injury in adults. We also review potential new strategies and highlight areas for future research.

Background and Purpose— Patients are classically at risk of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage. We validated a grading scale—the VASOGRADE—for prediction of DCI. Methods— We used data of 3 phase II randomized clinical trials and a single hospital series to assess the relationship between the VASOGRADE and DCI. The VASOGRADE derived from previously published risk charts and consists of 3 categories: VASOGRADE-Green (modified Fisher scale 1 or 2 and World Federation of Neurosurgical Societies scale [WFNS] 1 or 2); VASOGRADE-Yellow (modified Fisher 3 or 4 and WFNS 1–3); and VASOGRADE-Red (WFNS 4 or 5, irrespective of modified Fisher grade). The relation between the VASOGRADE and DCI was assessed by logistic regression models. The predictive accuracy of the VASOGRADE was assessed by receiver operating characteristics curve and calibration plots. Results— In a cohort of 746 patients, the VASOGRADE significantly predicted DCI ( P <0.001). The VASOGRADE-Yellow had a tendency for increased risk for DCI (odds ratio [OR], 1.31; 95% CI, 0.77–2.23) when compared with VASOGRADE-Green; those with VASOGRADE-Red had a 3-fold higher risk of DCI (OR, 3.19; 95% CI, 2.07–4.50). Studies were not a significant confounding factor between the VASOGRADE and DCI. The VASOGRADE had an adequate discrimination for prediction of DCI (area under the receiver operating characteristics curve=0.63) and good calibration. Conclusions— The VASOGRADE results validated previously published risk charts in a large and diverse sample of subarachnoid hemorrhage patients, which allows DCI risk stratification on presentation after subarachnoid hemorrhage. It could help to select patients at high risk of DCI, as well as standardize treatment protocols and research studies.

Widely-varying published and presented analyses of the Benchmark Evidence From South American Trials: Treatment of Intracranial Pressure (BEST TRIP) randomized controlled trial of intracranial pressure (ICP) monitoring have suggested denying trial generalizability, questioning the need for ICP monitoring in severe traumatic brain injury (sTBI), re-assessing current clinical approaches to monitored ICP, and initiating a general ICP-monitoring moratorium. In response to this dissonance, 23 clinically-active, international opinion leaders in acute-care sTBI management met to draft a consensus statement to interpret this study. A Delphi method-based approach employed iterative pre-meeting polling to codify the group's general opinions, followed by an in-person meeting wherein individual statements were refined. Statements required an agreement threshold of more than 70% by blinded voting for approval. Seven precisely-worded statements resulted, with agreement levels of 83% to 100%. These statements, which should be read in toto to properly reflect the group's consensus positions, conclude that the BEST TRIP trial: 1) studied protocols, not ICP-monitoring per se; 2) applies only to those protocols and specific study groups and should not be generalized to other treatment approaches or patient groups; 3) strongly calls for further research on ICP interpretation and use; 4) should be applied cautiously to regions with much different treatment milieu; 5) did not investigate the utility of treating monitored ICP in the specific patient group with established intracranial hypertension; 6) should not change the practice of those currently monitoring ICP; and 7) provided a protocol, used in non-monitored study patients, that should be considered when treating without ICP monitoring. Consideration of these statements can clarify study interpretation.

Every 15 seconds someone suffers a traumatic brain injury (TBI) in the United States. TBI causes more deaths in males <35 years old than all other diseases combined, and it is estimated that 2% of the U.S. population lives with TBI-associated disability. Despite extensive research and success in animal studies, successful drug therapies have proved elusive in clinical trials. Instead, TBI care focuses on the early identification and removal of mass lesions and on the detection, prevention, and management of secondary brain insults that adversely affect outcome (e.g., hypotension, hypoxia, seizures, elevated intracranial pressure). TBI is a heterogeneous disease in cause, pathology, severity, and prognosis. Consequently, TBI care depends in large part on careful and repeated assessment of clinical and laboratory findings, imaging studies, and bedside physiological data.A variety of physiological processes can be monitored at the bedside. Traditionally, monitoring and treating intracranial pressure (ICP) that is also used to quantify cerebral perfusion pressure (CPP) has been the cornerstone of severe TBI (sTBI) management, in large part because ICP is considered an indicator of injury severity. In this chapter, the indications, technique, and safety for ICP monitoring will be discussed. In addition, we will examine the relationship between ICP and outcome, treatment thresholds, ICP management, and how ICP management influences outcome. Finally, though ICP and CPP are important, emerging evidence suggests ICP is better viewed as an indicator of an underlying pathophysiological process that needs treatment rather than an independent target. The chapter will finish with a brief discussion on how a multimodal approach may supplement the information obtained from ICP monitoring to better target and individualize care. The focus of this chapter is on adults with TBI and may not apply to pediatric TBI.

Patients receiving anticoagulation therapy who present with any type of intracranial hemorrhage--including subdural hematoma, epidural hematoma, subarachnoid hemorrhage, and intracerebral hemorrhage (ICH)--require urgent correction of their coagulopathy to prevent hemorrhage expansion, limit tissue damage, and facilitate surgical intervention as necessary. The focus of this review is acute ICH, but the principles of management for anticoagulation-associated ICH (AAICH) apply to patients with all types of intracranial hemorrhage, whether acute or chronic. A number of therapies--including fresh frozen plasma (FFP), intravenous vitamin K, activated and inactivated prothrombin complex concentrates (PCCs), and recombinant activated factor VII (rFVIIa)--have been used alone or in combination to treat AAICH to reverse anticoagulation, help achieve hemodynamic stability, limit hematoma expansion, and prepare the patient for possible surgical intervention. However, there is a paucity of high-quality data to direct such therapy. The use of 3-factor PCC (activated and inactivated) and rFVIIa to treat AAICH constitutes off-label use of these therapies in the United States. However, in April 2013, the US Food and Drug Administration (FDA) approved Kcentra (a 4-factor PCC) for the urgent reversal of vitamin K antagonist (VKA) anticoagulation in adults with acute major bleeding. Plasma is the only other product approved for this use in the United States. (1) Inconsistent recommendations, significant barriers (e.g., clinician-, therapy-, or logistics-based barriers), and a lack of approved treatment pathways in some institutions can be potential impediments to timely and evidence-based management of AAICH with available therapies. Patient assessment, therapy selection, whether to use a reversal or factor repletion agent alone or in combination with other agents, determination of site-of-care management, eligibility for neurosurgery, and potential hematoma evacuation are the responsibilities of the neurosurgeon, but ultimate success requires a multidisciplinary approach with consultation from the emergency department (ED) physician, pharmacist, hematologist, intensivist, neurologist, and, in some cases, the trauma surgeon.