Reversible cerebral vasoconstriction syndrome (RCVS) refers to segmental, multifocal constriction of intracranial arteries along with acute headache and resolves within weeks. It occurs more commonly in women, and 1 well-known manifestation of RCVS is postpartum angiopathy. Furthermore, the female sex is included in scoring systems designed to assist with diagnosing RCVS. Nonetheless, the literature is mixed regarding the true role of female and pregnancy-related factors in the pathophysiology of RCVS, and it is similarly unclear whether management of this disorder differs by sex. Given the association of RCVS with female sex and the importance of highlighting, recognizing, and managing stroke etiologies in women, herein, the author reviews what is currently known and unknown about the topic of RCVS in women.

BackgroundMultimodal neuromonitoring (MMM) aims to improve outcome after acute brain injury, and thus admission in specialized Neurocritical Care Units with potential access to MMM is necessary. Various invasive and noninvasive modalities have been developed, however there is no strong evidence to support monitor combinations nor is there a known standardized approach. The goal of this study is to identify the most used invasive and non-invasive neuromonitoring modalities in daily practice as well as ubiquitousness of MMM standardization.MethodsIn order to investigate current availability and protocolized implementation of MMM among neurocritical care units in US and non-US intensive care units, we designed a cross-sectional survey consisting of a self-administered online questionnaire of 20 closed-ended questions disseminated by the Neurocritical Care Society.ResultsTwenty-one critical care practitioners responded to our survey with a 76% completion rate. The most commonly utilized non-invasive neuromonitoring modalities were continuous electroencephalography followed by transcranial doppler. The most common invasive modalities were external ventricular drain followed by parenchymal intracranial pressure (ICP) monitoring. MMM is most utilized in patients with subarachnoid hemorrhage and there were no differences regarding established institutional protocol, 24-h cEEG availability and invasive monitor placement between teaching and non-teaching hospitals. MMM is considered standard of care in 28% of responders' hospitals, whereas in 26.7% it is deemed experimental and only done as part of clinical trials. Only 26.7% hospitals use a computerized data integration system.ConclusionOur survey revealed overall limited use of MMM with no established institutional protocols among institutions. Ongoing research and further standardization of MMM will clarify its benefit to patients suffering from severe brain injury.

Central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) are quality metrics for many ICUs, and financial ramifications can be applied to hospitals and providers who perform poorly on these measures. Despite some perceived benefits to tracking these metrics, there are a range of issues associated with this practice: lack of a solid evidence base that documenting them has led to decreased infection rates, moral distress associated with identifying these infections, problems with their definitions, and others. We discuss each of these concerns while also including international perspectives then recommend practical steps to attempt to remediate use of the CLABSI and CAUTI metrics. Specifically, we suggest forming a task force consisting of key stakeholders (e.g., providers, Centers for Medicare & Medicaid Services (CMS), patients/families) to review CLABSI and CAUTI-related issues and then to create a summary statement containing recommendations to improve the use of these metrics.

EDITORIAL article Front. Neurol., 03 May 2023Sec. Endovascular and Interventional Neurology Volume 14 - 2023 | https://doi.org/10.3389/fneur.2023.1186473

Background Coronavirus disease (COVID-19) has led to changes in how healthcare is delivered. Here, through the administration of surveys, we evaluated telehealth use and views in US intensive care units (ICUs) during the pandemic. Methods From June 2020 to July 2021, voluntary, electronic surveys were provided to ICU leaders of Johns Hopkins Medical Institution (JHMI) hospitals, members of the Neurocritical Care Society (NCS) who practice in the US, and Society of Critical Care Medicine (SCCM) members practicing adult medicine. Results Response rates to our survey were as follows: 18 of 22 (81.8%) JHMI-based ICU leaders, 22 of 2218 (1.0%) NCS members practicing in the US, and 136 of 13,047 (1.0%) SCCM members. COVID-19 patients were among those cared for in the ICUs of 77.7, 86.4, and 93.4% of respondents, respectively, in April 2020 (defined as the peak of the pandemic). Telehealth technologies were used by 88.9, 77.3, and 75.6% of respondents, respectively, following the start of COVID-19 while only 22.2, 31.8, and 43.7% utilized them prior. The most common telehealth technologies were virtual meeting software and telephone (with no video component). Provider, nurse, and patient communications with the patient's family constituted the most frequent types of interactions utilizing telehealth. Most common reasons for telehealth use included providing an update on a patient's condition and conducting a goals of care discussion. 93.8-100.0% of respondents found telehealth technologies valuable in managing patients. Technical issues were noted by 66.7, 50.0, and 63.4% of respondents, respectively. Conclusions Telehealth use increased greatly among respondents following the start of COVID-19. In US ICUs, telehealth technologies found diverse uses during the pandemic. Future studies are needed to confirm our findings.

Abstract Purpose External ventricular drains (EVD) are commonly used in aneurysmal subarachnoid hemorrhage (aSAH) patients and can be life-saving by diverting cerebrospinal fluid. However, the overall relationship between EVD use and outcome is poorly understood. Methods In an exploratory analysis of an aSAH patient cohort, we examined EVD use in relation to modified Rankin Scale (mRS) at hospital discharge and at 6 months (unfavorable outcome = mRS > 2) using univariable and multivariable analyses. Results EVDs were placed in 31 of 56 (55.4%) patients and more often in women than men (66.7% vs 35.0%, p = 0.022) despite similar rates of hydrocephalus. Women had greater ICU [18 (13.5–25) vs 11.5 (6.5–18.5) days, p = 0.014] and hospital lengths of stay (LOS) [20.5 (16.5–34) vs 13.5 (10.5–27) days, p = 0.015] than men and greater mRS at discharge [4 (3–5) vs 3 (2–3.5), p = 0.011] although mRS at 6 months was similar. Patients with EVDs had longer ICU and hospital LOS and greater mRS at discharge [5 (3–6) vs 2 (2–3), p < 0.001] and at 6 months [4 (2–6) vs 1 (0–2), p = 0.001] than those without an EVD. In multivariable models, EVD use was associated with unfavorable 6-month outcome accounting for age, sex, and admission modified Fisher scale, but not in models adjusting for Hunt and Hess scale and World Federation of Neurological Surgeons scale. Conclusion In an aSAH cohort, the use of EVDs was associated with female sex and longer LOS, and may be linked to functional outcomes at discharge and at 6 months, although these associations warrant further investigation.

Objectives: Telephone-based consults using remote imaging review and standardization of evaluation but without visualizing the patient are an alternative to video-telestroke consults but are less well-studied. We aim to demonstrate the safety and efficacy of telephone-based acute consults in which IV tPA was administered over nearly a decade within one health system. Materials and Methods: Clinical characteristics and outcomes were compared between a community hospital (spoke; uses telephone-based consults) and the academic comprehensive stroke center (hub; uses oversight of on-site neurology trainees) from 2008-2017. In both institutions acute therapy decisions are made by the same stroke neurologists. Results: 2518 acute ischemic stroke consults were evaluated at hub and 2049 at spoke. Of these, 191 patients received IV tPA at hub and 184 at spoke. Patients at hub were younger (median (IQR): 61 (51-74) vs 69 (56-81) years, p = 0.0021) but admission National Institutes of Health Stroke Scale (NIHSS) was similar. There were no differences between door-to-needle times (69 (56-101) vs 69 (51-92) minutes, p = 0.13), last known well-to-tPA times (157 (113-202) vs 144 (110-175) minutes, p = 0.053), and rates of overall intracranial hemorrhage (ICH) after tPA (n = 23 (13.5%) vs 31 (17.0%), p = 0.35). In multivariable analyses, hospital was not an independent predictor of ICH after tPA. Conclusions: In a large dataset over nearly a decade, assessment for IV tPA administration using telephone assessment along with imaging review and emergency department standardization resulted in similar safety and outcomes as in the presence of on-site stroke/neurology expertise. Future studies are needed to confirm these findings

Solnicky, Veronika1; Ritzl, Eva2; Carhuapoma, Juan2; Johnson, Emily2; Sigmon, Alexander3; Suarez, Jose2; Stevens, Robert4; Nelson, Sarah5 Author Information

Delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage continues to be associated with high levels of morbidity and mortality. This complication had long been thought to occur secondary to severe cerebral vasospasm, but expert opinion now favors a multifactorial etiology, opening the possibility of new therapies. To date, no definitive treatment option for DCI has been recommended as standard of care, highlighting a need for further research into potential therapies. Milrinone has been identified as a promising therapeutic agent for DCI, possessing a mechanism of action for the reversal of cerebral vasospasm as well as potentially anti-inflammatory effects to treat the underlying etiology of DCI. Intra-arterial and intravenous administration of milrinone has been evaluated for the treatment of DCI in single-center case series and cohorts and appears safe and associated with improved clinical outcomes. Recent results have also brought attention to the potential outcome benefits of early, more aggressive dosing and titration of milrinone. Limitations exist within the available data, however, and questions remain about the generalizability of results across a broader spectrum of patients suffering from DCI. The development of a standardized protocol for milrinone use in DCI, specifically addressing areas requiring further clarification, is needed. Data generated from a standardized protocol may provide the impetus for a multicenter, randomized control trial. We review the current literature on milrinone for the treatment of DCI and propose a preliminary standardized protocol for further evaluation of both safety and efficacy of milrinone.

Coronavirus disease 2019 (COVID-19), the infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has brought about dramatic changes worldwide. Here we explore the interwoven medical and legal challenges posed by the COVID-19 pandemic, including legal restrictions impacting public health measures. Understanding these conflicts against the backdrop of human psychological tendencies can help inform ways of achieving greater compliance with and development of public health initiatives. As we are acutely aware, SARS-CoV-2 has led to a worldwide pandemic and millions of deaths. Because it is a novel virus, the incubation period is up to 2 weeks, its spread is increased with close social gatherings, and people may be infectious without exhibiting symptoms (i.e., carriers), SARS-CoV-2 unfortunately spread rapidly. Furthermore, COVID-19 is an unusual epidemic because it is neither common source (ie, people are not exposed at a common place and time) nor propagative (ie, it is not necessarily characterized by multiple generation times) and has a possible zoonotic source, leading to a complex transmission pattern and making establishment of effective control measures challenging. Subsequently, multi-fold interventions have been required to curb SARS-CoV-2's transmission (eg, social distancing, wearing masks, frequent hand washing, quarantining and self-isolating, and contact tracing).1Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/. Accessed June 16, 2021.Google Scholar More divisive methods have included government orders requiring businesses, schools, and places of worship to limit patrons or shut down, travel limitations, and vetting people's departure points at airports and train stations. Although vaccination is likely the most sustainable prevention method, mandating this particular intervention is incredibly controversial. Of course, the success of many interventions is heavily dependent upon each individual's voluntary compliance—an ethical choice of personal responsibility. Prime examples where compliance was not met included spring break parties, holiday travel, and defiance to mask wearing. Further, these public health measures— which may seem medically justifiable—have raised legal questions and illuminated tensions between law and public health, particularly where individuals' constitutional rights and personal liberties are at stake. Table 1 provides some examples, and detailed cases follow.Table 1Public Health Measures Implemented During the COVID-19 Pandemic and Examples of Legal ActionsPublic Health MeasureExample of Legal ActionHand washing and cleaning surfacesLos Angeles County Public Health Protocols for Office Worksites included accommodations for frequent hand washing and washing of frequently touched areas.7County of Los Angeles Department of Public Health: Order of the Health Officer. Protocols for Office Worksites: Appendix D. 2021. Available at: http://publichealth.lacounty.gov/media/coronavirus/docs/protocols/Reopening_OfficeBasedWorksites.pdf. Accessed April 26, 2021.Google ScholarWearing masksFollowing a Florida county passing a resolution requiring face coverings inside public businesses, a pastor filed a lawsuit, which he later dismissed after the county voted to exclude places of worship from the order.4UniCort. Joel D. Tillis vs. Manatee County. Available at:https://unicourt.com/case/fl-man-joel-d-tillis-vs-manatee-county-376264. Accessed June 16, 2021.Google ScholarSocial distancingCalifornia Governor Gavin Newsom signed an executive order placing attendance limitations and other restrictions on indoor worship services. Despite lawsuits, his action was in part supported by the US Supreme Court.2Supreme Court of the United States. Available at: https://www.supremecourt.gov. Accessed June 16, 2021.Google ScholarQuarantining and isolatingPer CDC guidelines, people in close contact with someone who has COVID-19 (except those vaccinated or who had COVID-19 within the past 3 months) are required to quarantine for 14 days.1Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/. Accessed June 16, 2021.Google ScholarContact tracingNo specific law about its implementation; however, confidentiality has been considered.6The New York State Senate. Senate Bill S8450C. 2020. Available at:https://www.nysenate.gov/legislation/bills/2019/s8450/amendment/c. Accessed April 26, 2021.Google ScholarVaccinationThe federal government cannot mandate that people become vaccinated, even for COVID-19.1Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/. Accessed June 16, 2021.Google ScholarLimiting or closing businessesPennsylvania Governor Tom Wolf mandated that non-life-sustaining businesses temporarily close; however, these shutdowns "violated businesses' rights to due process and equal protection under the Fourteenth Amendment."5Duston NA. Coronavirus and the constitutional rights of businesses: Butler v. Wolf. Norris McLaughlin, P.A. 2020. Available at:https://norrismclaughlin.com/blb/2020/09/24/coronavirus-constitutional-rights-businesses-butler-wolf/. Accessed April 26, 2021.Google ScholarVetting departure pointsFor international travel, testing ≤3 days before flying into the United States or documentation of recovery from COVID-19 is required.1Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/. Accessed June 16, 2021.Google ScholarLimiting travel between statesKentucky Governor Andy Beshear issued an executive order prohibiting out-of-state travel except for limited circumstances; this order was later overturned.3Theodore Joseph Roberts et al. v. Hon. Robert Neace et al., Memorandum Opinion and Order, No. 2:20-cv-00054-WOB-CJS, Eastern District of Kentucky (May 4, 2020).Google ScholarLimiting medical interventionsTexas Governor Greg Abbott attempted to halt all elective surgeries for ∼1 month; this was effectively later dismissed2Supreme Court of the United States. Available at: https://www.supremecourt.gov. Accessed June 16, 2021.Google ScholarCDC = Centers for Disease Control and Prevention; COVID-19 = coronavirus disease 2019. Open table in a new tab CDC = Centers for Disease Control and Prevention; COVID-19 = coronavirus disease 2019. For about 1 month in March 2020, Texas Governor Greg Abbott attempted to halt elective surgeries in an attempt to increase hospital capacity for COVID-19 patients.2Supreme Court of the United States. Available at: https://www.supremecourt.gov. Accessed June 16, 2021.Google Scholar Planned Parenthood for Choice subsequently filed a lawsuit in Texas federal court seeking to limit the Governor's ability to stop abortions that, if delayed, would result in significant health risks for the mother.2Supreme Court of the United States. Available at: https://www.supremecourt.gov. Accessed June 16, 2021.Google Scholar The case moved to a quick appeal to the United States Court of Appeals for the Fifth Circuit. Although a new executive order issued by Abbott suggested the abortion ban had expired, petitioners appealed to the US Supreme Court, likely to ensure clarity in the law.2Supreme Court of the United States. Available at: https://www.supremecourt.gov. Accessed June 16, 2021.Google Scholar The Supreme Court granted Planned Parenthood's request to vacate the Fifth Circuit decisions that had allowed Abbott's executive order banning abortions to go into effect and remanded the case to the Fifth Circuit with instructions to dismiss as moot.2Supreme Court of the United States. Available at: https://www.supremecourt.gov. Accessed June 16, 2021.Google Scholar The health impact on expecting mothers and likely out-of-state travel (possibly further contributing to additional COVID-19 spread) caused by the abortion ban were plausible adverse consequences of emergency legal action purportedly intended to curb a public health emergency. In addition, some states discouraged interstate travel or required self-quarantine for out-of-state travel, although enforcement mechanisms relied heavily upon self-responsibility and lacked real teeth. Kentucky Governor Andy Beshear prohibited out-of-state travel except in limited circumstances (eg, employment, health care).3Theodore Joseph Roberts et al. v. Hon. Robert Neace et al., Memorandum Opinion and Order, No. 2:20-cv-00054-WOB-CJS, Eastern District of Kentucky (May 4, 2020).Google Scholar Residents challenged this ban because it violated their right to travel for personal reasons. The US District Court for the Eastern District of Kentucky agreed with the residents, finding that "[n]ot only is there a lack of procedural due process with respect to the Travel Ban, but . . . these travel regulations are not narrowly tailored to achieve the government's purpose."3Theodore Joseph Roberts et al. v. Hon. Robert Neace et al., Memorandum Opinion and Order, No. 2:20-cv-00054-WOB-CJS, Eastern District of Kentucky (May 4, 2020).Google Scholar The Court found the ban did not clearly define who would provide facilities for quarantining; would require checkpoints at bridge entrances, resulting in massive traffic jams; and that family members in Kentucky and Cincinnati living <1 mile apart would be unable to visit each other.3Theodore Joseph Roberts et al. v. Hon. Robert Neace et al., Memorandum Opinion and Order, No. 2:20-cv-00054-WOB-CJS, Eastern District of Kentucky (May 4, 2020).Google Scholar Further, this travel ban violated the "constitutional right to travel" embedded in legal precedent and "infringe[d] on the basic right of citizens to engage in interstate travel."3Theodore Joseph Roberts et al. v. Hon. Robert Neace et al., Memorandum Opinion and Order, No. 2:20-cv-00054-WOB-CJS, Eastern District of Kentucky (May 4, 2020).Google Scholar Ordinances mandating mask-wearing also raised constitutional challenges that illuminate the tension between personal freedom and government intervention in public health crises. For example, in July 2020, a Florida county passed an emergency resolution requiring face coverings inside public businesses. A church pastor subsequently filed a lawsuit challenging this mask mandate as unconstitutional, claiming it violated religious freedom and interfered with the ability to pray.4UniCort. Joel D. Tillis vs. Manatee County. Available at:https://unicourt.com/case/fl-man-joel-d-tillis-vs-manatee-county-376264. Accessed June 16, 2021.Google Scholar He later voluntarily dismissed the case after the county voted to exclude places of worship from the order.4UniCort. Joel D. Tillis vs. Manatee County. Available at:https://unicourt.com/case/fl-man-joel-d-tillis-vs-manatee-county-376264. Accessed June 16, 2021.Google Scholar Similar lawsuits have been filed against other counties in Florida. Many businesses also expressed concern that their livelihoods were impacted unfairly by government orders intended to reduce the spread of SARS-CoV-2. Several governors ordered the temporary shutdown of non-life-sustaining businesses early in the pandemic, resulting in strong objections from small businesses. Indeed, in Butler vs Wolf, Judge Stickman IV of the US District Court for the Western District of Pennsylvania ruled that these types of orders shuttering non-life-sustaining businesses "violated businesses' rights to due process and equal protection under the Fourteenth Amendment."5Duston NA. Coronavirus and the constitutional rights of businesses: Butler v. Wolf. Norris McLaughlin, P.A. 2020. Available at:https://norrismclaughlin.com/blb/2020/09/24/coronavirus-constitutional-rights-businesses-butler-wolf/. Accessed April 26, 2021.Google Scholar Contact tracing, intended to locate contacts of people diagnosed with COVID-19, does not appear to be codified in law, although it has been used for decades for other diseases. Although initially met with enthusiasm during the pandemic as an additional tool to help curb the virus, government-mandated contact tracing has raised concerns about personal privacy. In response, New York State passed a law intended to protect the personal information of individuals identified as close contacts of those with a probable or confirmed COVID-19 diagnosis.6The New York State Senate. Senate Bill S8450C. 2020. Available at:https://www.nysenate.gov/legislation/bills/2019/s8450/amendment/c. Accessed April 26, 2021.Google Scholar In sum, public health interventions instituted to help control the spread of SARS-CoV-2 have faced significant legal challenges. Although personal responsibility is critical, it was often deemed essential to institute recommendations and policies more formally. Perhaps a deeper understanding of medicine, public health, psychology, and dangers of the spread of an infectious agent would help prevent future similar conflicts.

Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality despite advances in management. We evaluated the prognostic significance of a qualitative score using brain magnetic resonance imaging (MRI) features obtained early after aSAH. Patients with aSAH were enrolled in a prospective observational cohort and underwent brain MRI during their acute hospitalization. MRIs were rated using a scoring system that considers the anatomical location of signal intensity changes on diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) sequences. The relationship between MRI scores and functional outcome defined by modified Rankin scale (mRS) at 6 months was evaluated in uni- and multivariable models. The cohort included 45 aSAH patients (median World Federation of Neurologic Surgeons (IQR) 2 (1–4)) who underwent brain MRI a mean (SD) of 9.0 ± 8.0 days after aSAH. At 6 months after aSAH, 26 patients had achieved a favorable outcome (mRS ≤ 2) while 15 had an unfavorable outcome (mRS > 2). Deep gray nuclei (DGN) score (p = 0.016), cortex + DGN score (p = 0.015), FLAIR score (p = 0.016), DWI score (p = 0.0045), and overall score (p = 0.0081) were significantly lower in patients with favorable outcome compared to those with unfavorable outcome. However, MRI scores were not independent predictors of outcome in multivariable models adjusting for admission Hunt and Hess, Glasgow Coma Scale, or World Federation of Neurologic Surgeons scales. In this pilot study, a qualitative scoring system using anatomically defined MRI FLAIR and DWI signal abnormalities identified in the acute phase of aSAH was linked to 6-month functional outcome. However, these scores did not add prognostic value to established indices of neurological severity.

Objective The aim of this study was to collect and rate Green Flags, that is, symptoms or pieces of information indicating that a patient is more likely to suffer from a primary than from a secondary headache. Background When assessing headaches, a central question to be answered is whether the pain is primary or secondary to another disorder. To maximize the likelihood of a correct diagnosis, relevant signs and symptoms must be sought, identified, and weighed against each other. Methods The project was designed as a Delphi study. In the first round, an expert panel proposed green flags that were rated anonymously in two subsequent rounds. Proposals with an average rating of 4.0 and higher on a scale from 0 to 5 reached consensus. Results Five Green Flags reached consensus: (i) "The current headache has already been present during childhood"; (ii) "The headache occurs in temporal relationship with the menstrual cycle"; (iii) "The patient has headache-free days"; (iv) "Close family members have the same headache phenotype"; and (v) "Headache occurred or stopped more than one week ago." Conclusions We propose five Green Flags for primary headache disorders. None being a pathognomonic sign, we recommend searching for both Green Flags and Red Flags. If both are present, a secondary headache should be suspected. Overall, the application of the Green Flag concept in clinical practice is likely to increase diagnostic accuracy and improve diagnostic resource allocation. Prospective studies in clinical populations should be conducted to validate these Green Flags.

Intracranial hemorrhage (ICH) is a known risk of oral anticoagulation; delineating ICH attributes may provide nuanced guidance regarding atrial fibrillation management. We evaluated ICH characteristics and outcomes from Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48 (ENGAGE AF-TIMI 48), a randomized trial that compared two edoxaban regimens (higher-dose edoxaban regimen 60/30 mg (HDER), lower-dose edoxaban regimen 30/15 mg (LDER)) with warfarin in patients with atrial fibrillation. Patients who suffered ICH vs those who did not were compared and independent predictors of ICH were calculated. We also assessed ICH subtype and etiology. Of 21,105 randomized patients, 322 (1.53%) had ≥ 1 ICH for a total of 368 events. Intraparenchymal hemorrhage (HDER: HR 0.52 [95% CI 0.35-0.77], LDER: HR 0.22 [0.13-0.38]) and subdural hematoma (HDER: HR 0.29 [0.15-0.55], LDER: HR 0.26 [0.13-0.50]) were lower with both HDER and LDER vs warfarin. Subarachnoid hemorrhage frequency was similar in the HDER vs warfarin groups but lower in LDER. Compared to warfarin, edoxaban was associated with lower risk of spontaneous ICH (HDER: HR 0.47 [0.31-0.69], LDER: HR 0.34 [0.22-0.53]) and traumatic ICH (HDER: HR 0.32 [0.17-0.61], LDER: HR 0.31 [0.16-0.59]). In multivariable analysis, randomization to warfarin, increased age, and risk of falling remained independent predictors of ICH. In ENGAGE AF-TIMI 48, ICH was decreased in edoxaban-treated patients compared to warfarin-treated patients, including ICH of both spontaneous and traumatic causes. Both edoxaban regimens lowered intraparenchymal and subdural hemorrhages compared to warfarin. Patient characteristics and medical history may help guide anticoagulation management.

Background & PurposePerimesencephalic subarachnoid hemorrhage (PMSAH) is a predominantly benign pattern of subarachnoid hemorrhage.However, in a minority of PMSAH, a posterior circulation aneurysm is causative.Out of concern for missing an aneurysm, many institutions pursue exhaustive imaging.We aimed to design a predictive model, based on radiographic features of admission non-contrast head computerized tomography (NCHCT), to differentiate PMSAH from aneurysmal causes. MethodsWe retrospectively reviewed consecutive patients admitted for suspected aneurysmal SAH (aSAH) to an academic center.Patients with a final diagnosis of PMSAH or posterior circulation aSAH were included.Using NCHCT, thickness (continuous variable) and location of blood in basal cisterns and Sylvian fissures (categorical variables) were compared between groups.Using the statistically significant features, we created a scoring system.Receiver operating characteristics (ROC) were used to measure accuracy of this model in predicting aneurysmal etiology. ResultsOf 420 SAH cases, we identified 56 with PMSAH and 48 with posterior circulation aSAH.Mean age was 54.7 years (SD 12.6) and 58 patients (54%) were female.Blood thickness measurements in the crural and ambient cisterns, interhemispheric and Sylvian fissures, and degree of extension into the Sylvian fissure were all statistically significant (p=0.001,<0.001, <0.001, <0.001, and <0.001, respectively).Using these significant figures, we developed a 10-point scoring model to predict aneurysmal causes with high accuracy (area under the curve [AUC] 0.98; 95% CI 0.96-1.00;odds ratio per point increase: 7.6; 95% CI 2.6-22). ConclusionsIf externally validated, our predictive model may assist clinicians in the risk-stratification of patients presenting with PMSAH.This model could minimize protracted admissions to intensive care units and reduce healthcare resource utilization and costs.

Background Intraventricular hemorrhage occurs due to intracerebral hemorrhage with intraventricular extension or without apparent parenchymal involvement, known as primary intraventricular hemorrhage. Aims We evaluated the prognosis of primary intraventricular hemorrhage patients in the CLEAR III trial (Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage). Methods In patients with primary intraventricular hemorrhage versus those with secondary intraventricular hemorrhage, we compared intraventricular alteplase response and outcomes including modified Rankin Scale, Barthel Index, National Institutes of Health Stroke Scale (NIHSS), and extended Glasgow Outcome Scale (eGOS) at 30, 180, and 365 days. Outcomes were also compared in primary intraventricular hemorrhage patients who received intraventricular alteplase versus placebo (normal saline) and in matched primary and secondary intraventricular hemorrhage patients using inverse-probability-weighted regression adjustment. Results Of 500 patients enrolled in CLEAR III, 46 (9.2%) had primary intraventricular hemorrhage. Combining both treatment groups, primary intraventricular hemorrhage patients had larger intraventricular hemorrhage volumes (median: 34.2 mL vs. 20.8 mL, p < 0.01) but similar intraventricular hemorrhage removal (51.0% vs. 59.0%, p = 0.24) compared to secondary intraventricular hemorrhage patients, respectively. Confirming previous studies, primary intraventricular hemorrhage patients achieved better NIHSS, modified Rankin Scale, Barthel Index, and eGOS scores at days 30, 180, and 365, respectively (all p < 0.01), although mortality was similar to secondary intraventricular hemorrhage patients; matching analysis yielded similar results. Primary intraventricular hemorrhage patients who received intraventricular alteplase ( n = 19) and saline ( n = 27) achieved similar outcomes. Conclusions In CLEAR III, primary intraventricular hemorrhage patients who survived achieved better long-term outcomes than surviving secondary intraventricular hemorrhage patients with similar mortality. Outcomes and safety were similar between primary intraventricular hemorrhage patients receiving alteplase and those receiving saline.

Alcohol withdrawal syndrome (AWS) can range from mild jittery movements, nausea, sweating to more severe symptoms such as seizure and death. Severe AWS can worsen cognitive function, increase hospital length of stay, and in-hospital mortality and morbidity. Due to a lack of reliable history of present illness in many patients with neurological injury as well as similarities in clinical presentation of AWS and some commonly encountered neurological syndromes, the true incidence of AWS in neurocritical care patients remains unknown. This review discusses challenges in the assessment and treatment of AWS in patients with neurological injury, including the utility of different scoring systems such as the Clinical Institute Withdrawal Assessment and the Minnesota Detoxification Scale as well as the reliability of admission alcohol levels in predicting AWS. Treatment strategies such as symptom-based versus fixed dose benzodiazepine therapy and alternative agents such as baclofen, carbamazepine, dexmedetomidine, gabapentin, phenobarbital, ketamine, propofol, and valproic acid are also discussed. Finally, a treatment algorithm considering the neurocritical care patient is proposed to help guide therapy in this setting.