Hypothermia and temperature modulation for intracerebral hemorrhage (ICH): pathophysiology and translational applications

Background

Intracerebral hemorrhage (ICH) still poses a substantial challenge in clinical medicine because of the high morbidity and mortality rate that characterizes it. This review article expands into the complex pathophysiological processes underlying primary and secondary neuronal death following ICH. It explores the potential of therapeutic hypothermia as an intervention to mitigate these devastating effects.

Methods

A comprehensive literature review to gather relevant studies published between 2000 and 2023.

Discussion

Primary brain injury results from mechanical damage caused by the hematoma, leading to increased intracranial pressure and subsequent structural disruption. Secondary brain injury encompasses a cascade of events, including inflammation, oxidative stress, blood-brain barrier breakdown, cytotoxicity, and neuronal death. Initial surgical trials failed to demonstrate significant benefits, prompting a shift toward molecular mechanisms driving secondary brain injury as potential therapeutic targets. With promising preclinical outcomes, hypothermia has garnered attention, but clinical trials have yet to establish its definitive effectiveness. Localized hypothermia strategies are gaining interest due to their potential to minimize systemic complications and improve outcomes. Ongoing and forthcoming clinical trials seek to clarify the role of hypothermia in ICH management.

Conclusion

Therapeutic hypothermia offers a potential avenue for intervention by targeting the secondary injury mechanisms. The ongoing pursuit of optimized cooling protocols, localized cooling strategies, and rigorous clinical trials is crucial to unlocking the potential of hypothermia as a therapeutic tool for managing ICH and improving patient outcomes.

Implementation and impact of a point of care electroencephalography platform in a community hospital: a cohort study

Objective

To determine the clinical and financial feasibility of implementing a poc-EEG system in a community hospital.

Design

Data from a prospective cohort displaying abnormal mentation concerning for NCSE or rhythmic movements due to potential underlying seizure necessitating EEG was collected and compared to a control group containing patient data from 2020.

Setting

A teaching community hospital with limited EEG support.

Patients

The study group consisted of patients requiring emergent EEG during hours when conventional EEG was unavailable. Control group is made up of patients who were emergently transferred for EEG during the historical period.

Interventions

Application and interpretation of Ceribell®, a poc-EEG system.

Measurement and main results

88 patients were eligible with indications for poc-EEG including hyperkinetic movements post-cardiac arrest (19%), abnormal mentation after possible seizure (46%), and unresponsive patients with concern for NCSE (35%). 21% had seizure burden on poc-EEG and 4.5% had seizure activity on follow-up EEG. A mean of 1.1 patients per month required transfer to a tertiary care center for continuous EEG. For the control period, a total of 22 patients or a mean of 2 patients per month were transferred for emergent EEG. Annually, we observed a decrease in the number of transferred patients in the post-implementation period by 10.8 (95% CI: -2.17-23.64, p = 0.1). Financial analysis of the control found the hospital system incurred a loss of $3,463.11 per patient transferred for an annual loss of $83,114.64. In the study group, this would compute to an annual loss of $45,713.05 for an overall decrease in amount lost of $37,401.59. We compared amount lost per patient between historical controls and study patients. Implementation of poc-EEG resulted in an overall decrease in annual amount lost of $37,401.59 by avoidance of transfer fees. We calculated the amount gained per patient in the study group to be $13,936.44. To cover the cost of the poc-EEG system, 8.59 patients would need to avoid transfer annually.

Conclusion

A poc-EEG system can be safely implemented in a community hospital leading to an absolute decrease in transfers to tertiary hospital. This decrease in patient transfers can cover the cost of implementing the poc-EEG system. The additional benefits from transfer avoidance include clinical benefits such as rapid appropriate treatment of seizures and avoidance of unnecessary treatment as well as negating transfer risk and keeping the patient at their local hospital.

Consensus recommendations on therapeutic hypothermia after minimally invasive intracerebral hemorrhage evacuation from the hypothermia for intracerebral hemorrhage (HICH) working group

Background and purpose

Therapeutic hypothermia (TH), or targeted temperature management (TTM), is a classic treatment option for reducing inflammation and potentially other destructive processes across a wide range of pathologies, and has been successfully used in numerous disease states. The ability for TH to improve neurological outcomes seems promising for inflammatory injuries but has yet to demonstrate clinical benefit in the intracerebral hemorrhage (ICH) patient population. Minimally invasive ICH evacuation also presents a promising option for ICH treatment with strong preclinical data but has yet to demonstrate functional improvement in large randomized trials. The biochemical mechanisms of action of ICH evacuation and TH appear to be synergistic, and thus combining hematoma evacuation with cooling therapy could provide synergistic benefits. The purpose of this working group was to develop consensus recommendations on optimal clinical trial design and outcomes for the use of therapeutic hypothermia in ICH in conjunction with minimally invasive ICH evacuation.

Methods

An international panel of experts on the intersection of critical-care TH and ICH was convened to analyze available evidence and form a consensus on critical elements of a focal cooling protocol and clinical trial design. Three focused sessions and three full-group meetings were held virtually from December 2020 to February 2021. Each meeting focused on a specific subtopic, allowing for guided, open discussion.

Results

These recommendations detail key elements of a clinical cooling protocol and an outline for the roll-out of clinical trials to test and validate the use of TH in conjunction with hematoma evacuation as well as late-stage protocols to improve the cooling approach. The combined use of systemic normothermia and localized moderate (33.5°C) hypothermia was identified as the most promising treatment strategy.

Conclusions

These recommendations provide a general outline for the use of TH after minimally invasive ICH evacuation. More research is needed to further refine the use and combination of these promising treatment paradigms for this patient population.

Therapeutic hypothermia for intracerebral hemorrhage: Systematic review and meta-analysis of the experimental and clinical literature

BACKGROUND

Intracerebral hemorrhage remains the deadliest form of stroke worldwide, inducing neuronal death through a wide variety of pathways. Therapeutic hypothermia is a robust and well-studied neuroprotectant widely used across a variety of specialties.

AIMS

This review summarizes results from preclinical and clinical studies to highlight the overall effectiveness of therapeutic hypothermia to improve long-term intracerebral hemorrhage outcomes while also elucidating optimal protocol regimens to maximize therapeutic effect.

SUMMARY OF REVIEW

A systematic review was conducted across three databases to identify trials investigating the use of therapeutic hypothermia to treat intracerebral hemorrhage. A random-effects meta-analysis was conducted on preclinical studies, looking at neurobehavioral outcomes, blood brain barrier breakdown, cerebral edema, hematoma volume, and tissue loss. Several mixed-methods meta-regression models were also performed to adjust for variance and variations in hypothermia induction procedures. Twwenty-one preclinical studies and five human studies were identified. The meta-analysis of preclinical studies demonstrated a significant benefit in behavioral scores (ES = -0.43, p = 0.02), cerebral edema (ES = 1.32, p = 0.0001), and blood brain barrier (ES = 2.73, p ≤ 0.00001). Therapeutic hypothermia was not found to significantly affect hematoma expansion (ES = -0.24, p = 0.12) or tissue loss (ES = 0.06, p = 0.68). Clinical study outcome reporting was heterogeneous; however, there was recurring evidence of therapeutic hypothermia-induced edema reduction.

CONCLUSIONS

The combined preclinical evidence demonstrates that therapeutic hypothermia reduced multiple cell death mechanisms initiated by intracerebral hemorrhage; yet, there is no definitive evidence in clinical studies. The cooling strategies employed in both preclinical and clinical studies were highly diverse, and focused refinement of cooling protocols should be developed in future preclinical studies. The current data for therapeutic hypothermia in intracerebral hemorrhage remains questionable despite the highly promising indications in preclinical studies. Definitive randomized controlled studies are still required to answer this therapeutic question.

Intravenous thrombolysis in the elderly is facilitated by a tele-stroke network: A cross-sectional study

BACKGROUND

Data suggest that elderly patients have less favorable outcomes after ischemic stroke.

OBJECTIVE

To study the outcomes after intravenous tissue plasminogen activator (tPA) administration in elderly patients with acute ischemic stroke.

METHODS

Cross-sectional study using prospective collected patient data maintained via our "tele-stroke" network, which provides acute care in 29 community hospitals within our region from 2013-2015. Exposure of interest was age divided into >80 years (octogenarian) or younger. Outcomes of interest were rate of intravenous tPA administration, hemorrhagic transformation (ICH), in-hospital neurological deterioration, and poor outcome defined as a composite of hospital discharge to long-term care facility or death.

RESULTS

Mean age 67 ± 16 years, 57 % (743/1317) were women, and median (Md) NIHSS was 4 (Interquartile Range [IQR] 8). The rate of tPA was 20 % (267/1317). Compared to reported rates of tPA administration in the nation, our tPA rate exceeded the one from the literature (20 % v 3%, z = 2.83, SE = 0.04, p = .005). There were no differences in ICH or neurological deterioration. The octogenarian group had a higher proportion of poor-outcome (61 % vs. 23 %, p < 0.001) than the younger group but similar in-hospital case-fatality (25 % v 14 %, p = 0.09). Predictors of poor-outcome were age >80 (OR 4.9; CI, 2.0-12, p < .001) and α-NIHSS>9. (OR 8.7; CI, 3.5-20, p < .001).

CONCLUSION

Our data suggest that in our "tele-stroke" network, rates of tPA administration are higher than those reported in the literature and that this rate was not different in octogenarians compared to younger patients. Octogenarians were not at risk for ICH or neurological deterioration after tPA administration. However, octogenarians had a higher risk of poor outcome.

Status of SARS-CoV-2 in cerebrospinal fluid of patients with COVID-19 and stroke

BACKGROUND

Emergence of the novel corona virus (severe acute respiratory syndrome (SARS)-CoV-2) in December 2019 has led to the COVID-19 pandemic. The extent of COVID-19 involvement in the central nervous system is not well established, and the presence or the absence of SARS-CoV-2 particles in the cerebrospinal fluid (CSF) is a topic of debate.

CASE DESCRIPTION

We present two patients with COVID-19 and concurrent neurological symptoms. Our first patient is a 31-year-old man who had flu-like symptoms due to COVID-19 and later developed an acute-onset severe headache and loss of consciousness and was diagnosed with a Hunt and Hess grade 3 subarachnoid haemorrhage from a ruptured aneurysm. Our second patient is a 62-year-old woman who had an ischaemic stroke with massive haemorrhagic conversion requiring a decompressive hemicraniectomy. Both patients' CSF was repeatedly negative on real-time PCR analysis despite concurrent neurological disease.

CONCLUSION

Our report shows that patients' CSF may be devoid of viral particles even when they test positive for COVID-19 on a nasal swab. Whether SARS-CoV-2 is present in CSF may depend on the systemic disease severity and the degree of the virus' nervous tissue tropism and should be examined in future studies.

Tele-Critical Care: An Update From the Society of Critical Care Medicine Tele-ICU Committee

OBJECTIVES

In 2014, the Tele-ICU Committee of the Society of Critical Care Medicine published an article regarding the state of ICU telemedicine, one better defined today as tele-critical care. Given the rapid evolution in the field, the authors now provide an updated review.

DATA SOURCES AND STUDY SELECTION

We searched PubMed and OVID for peer-reviewed literature published between 2010 and 2018 related to significant developments in tele-critical care, including its prevalence, function, activity, and technologies. Search terms included electronic ICU, tele-ICU, critical care telemedicine, and ICU telemedicine with appropriate descriptors relevant to each sub-section. Additionally, information from surveys done by the Society of Critical Care Medicine was included given the relevance to the discussion and was referenced accordingly.

DATA EXTRACTION AND DATA SYNTHESIS

Tele-critical care continues to evolve in multiple domains, including organizational structure, technologies, expanded-use case scenarios, and novel applications. Insights have been gained in economic impact and human and organizational factors affecting tele-critical care delivery. Legislation and credentialing continue to significantly influence the pace of tele-critical care growth and adoption.

CONCLUSIONS

Tele-critical care is an established mechanism to leverage critical care expertise to ICUs and beyond, but systematic research comparing different models, approaches, and technologies is still needed.

Abstract TP449: Hypertonic Saline Solution After Aneurysmal Subarachnoid Hemorrhage Does Not Affect Sodium Balance

Background: Euvolemic hyponatremia is prevalent in patients with aneurysmal subarachnoid hemorrhages (aSAH) and is associated with poor outcome, gait imbalance, cognitive impairment, and prolonged length of stay. We sought to determine the effect of 3% hypertonic saline (HTS3%) on sodium (Na) trends in an interim analysis of the HS3 clinical trial.

Methods: The “Safety and Feasibility of HTS3% after aSAH Hemorrhage (HS3)” Clinical Trial (ClinicalTrials.gov NCT02432157) is a randomized, safety and efficacy, single center, single blinded clinical trial designed to evaluate if a protocol of volume expansion with HTS3% is safe and effective in patients with aSAH for the prevention of hyponatremia. Within 72 hours of index hemorrhage, aSAH patients were randomized to receive prophylactic intravenous HTS3% bolus injections at a dose of 250ml via central line every 6 hours for 7 days vs. routine fluid management with isotonic fluids as pre-specified by our local management protocol, which is based on multi-professional guidelines for the management of aSAH. We followed serum Na levels from day of admission (D0) to hospital day 10 (D10) and compared them using the Mann-U-Whitney test for non-parametric data.

Results: In total, 22 patients participated in the study. Half of the patients (11) were randomized to the treatment group and 11 were part of the control arm. Mean age was 53±12years, 68.2% (n=15) were female, 54.5% (n=12) were white, and median (Md) Hunt and Hess was 3 (IQR=1), Md-modified-Fisher was 3 (IQR=1). Mean GCS on admission was 10 (SD 4) and mean ICP was 13 (SD 5). There was no significant difference in the demographics between the groups. Md-Na levels from D0-D10 did not differ between the groups and hyponatremia did not occur in either group.

Conclusion: Data from an interim analysis of HS3 clinical trial indicate that both fluid strategies were associated with similar profile in Na balance and no incidence of hyponatremia. Further data is needed to investigate association between HTS3% and mortality, clinical outcome, delayed cerebral ischemia and vasospasms.

Self-Reported Muscle Strength As A Strategy For The Prevention Of Non-Communicable Diseases

Background

Muscle strength is considered as a health indicator and an independent predictor of future disease. For this reason, the evaluation of this component in the young population is recognised as a fundamental strategy for the prevention of non-communicable diseases. Field tests are the techniques most commonly used to evaluate muscle strength. However, an alternative method that could be applied in epidemiological studies is self-report questionnaires. The aim of this research was to evaluate the ability of a self-report questionnaire to correctly rank the levels of muscle strength in college students.

Methods

A cross-sectional study was developed in 135 students from the Areandina University in Bogota, Colombia. For the evaluation of muscle strength, two tests were applied. The first was the application of the handgrip protocol using an adjustable handle Digital Grip Strength Dynamometer. The second was the application of protocols to a maximum repetition in 6 different exercises. For the assessment of self-perceived strength, the third question of the International Scale Fitness Questionnaire (IFIS) was applied. The IFIS response options are presented on a Likert scale with five possible answers: “very poor”, “poor”, “average”, “good” or “very good”. An analysis of variance (ANOVA) was applied to evaluate the ability of the IFIS questionnaire to rank muscle strength levels correctly.

Results

Overall, 70.3% of the participants were men, and 29.7% were women. The results of the field tests and the self-perception of muscle strength were significantly higher in the male group than in the female group (P &lt; 0.001). Students who reported having good or very good muscle strength in the questionnaire had a better result in the field tests compared to those who reported average, poor or very poor muscle strength levels (P &lt; 0.005).

Conclusions

The IFIS questionnaire was able to rank real muscle strength in university students correctly.

Key messages

The IFIS questionnaire is a valid alternative to detect students with a potential risk of chronic non-communicable diseases. The epidemiology surveillance systems in Colombia should include the application of self-report questionnaires that evaluate potential risk factors.

Continuous Electroencephalographic Monitoring in the Intensive Care Unit: A Cross-Sectional Study

Objective:

Research on continuous electro-encephalographic monitoring (cEEG) in the intensive care unit (ICU) has previously focused on neuroscience ICUs. This study determines cEEG utilization within a sample of specialty ICUs world-wide.

Methods:

A cross-sectional electronic survey of attending level physicians across various intensive care settings. Twenty-five questions developed from consensus statements on the use of cEEG in the critically ill sent as an electronic survey.

Results:

Of all, 9344 were queried and 417 (4.5%) responses were analyzed with 309 (74%) from the United States and 74 (18%) internationally. Intensive care units were: medical (10%), surgical (6%), neurologic/neurosurgical (12%), cardiac (4%), trauma (3%), pediatrics (29%), burn (<1%), multidisciplinary (30%), and other (5%). Intensive care units were: academic (65%), community (18%), public (3%), military (1%), and other (13%). Specialized cEEG teams were available in 71% of ICUs. Rapid 24/7 access and cEEG interpretation was available in 32% of ICUs. Interpretation changed clinical management frequently (28%) and sometimes (45%).

Conclusions:

Despite guideline recommendations for cEEG use, there is a discordance between availability, night coverage, and immediate interpretation. Only 27% have institutional protocols for indications and duration of cEEG monitoring. Furthermore, cEEG may be underutilized in nonneurologic ICUs as well as ICUs in smaller nonacademic affiliated hospitals and those outside of the United States.

The Benefits of Parenteral Nutrition (PN) Versus Enteral Nutrition (EN) Among Adult Critically Ill Patients: What is the Evidence? A Literature Review

Malnutrition is frequently seen among patients in the intensive care unit. Evidence shows that optimal nutritional support can lead to better clinical outcomes. Recent clinical trials debate over the efficacy of enteral nutrition (EN) over parenteral nutrition (PN). Multiple trials have studied the impact of EN versus PN in terms of health-care cost and clinical outcomes (including functional status, cost, infectious complications, mortality risk, length of hospital and intensive care unit stay, and mechanical ventilation duration). The aim of this review is to address the question: In critically ill adult patients requiring nutrition support, does EN compared to PN favorably impact clinical outcomes and health-care costs?

Abstract WP271: A Comparison of Bedside Echocardiography with Point of Care Ultrasound to Standard Transthoracic Echocardiography in the Setting of Acute Stroke and TIA

Background: Transthoracic Echocardiography (TTE) is routinely performed in the setting of acute stroke and transient ischemic attack (TIA) to evaluate for a cardiac source of emboli. Although standard of care, guidelines remain ambiguous on the indications and recommendations for its routine use. Point-of-care ultrasound (POCUS), a quick bedside method of echocardiography using an easily portable, hand-held device, has been studied extensively in the ED, trauma, and ICU settings, but not for acute stroke and TIA. Here, we demonstrate the feasibility of using POCUS for the purpose of screening echocardiography in acute stroke & TIA patients. Additionally, we compare POCUS with TTE in order to evaluate the veracity of the point-of-care method with the gold standard.

Methods: A retrospective comparison was made between routine TTE and POCUS results performed by a cardiologist during consultation. 99 patients were included, each admitted for workup of stroke, TIA, or retinal artery occlusions, and had a cardiology consultation for any reason. Parameters compared included left ventricular (LV) function, left atrial (LA) size, mitral valve (MV) and aortic valve (AV) pathology, and the presence of LA or LV thrombi, masses, or aneurysms.

Results: All 16 cases with significant abnormalities (LV dysfunction, LV thrombi, or AV/MV vegetations) that were found on TTE were also identified by POCUS. Of the 13 patients with severely abnormal LV function on TTE, 12 were identified as severe on POCUS, and one as mild-moderate. Findings in 9 of these 16 patients led to a change in management, including one case where a large LV thrombus requiring a heparin infusion was identified hours earlier by POCUS.

Conclusions: POCUS was comparable and non-inferior to the gold standard TTE for the purpose of screening echocardiography in the workup of acute ischemic stroke & TIA. Significant findings on TTE were all identified by a bedside POCUS (with the only discrepancy in the degree of LV dysfunction in a single case). All TTE findings resulting in management changes were also identified by POCUS. Importantly, POCUS can be used as a quick diagnostic screening tool to help establish an earlier diagnosis of life threatening conditions, and may lead to earlier management and treatment decisions.

Futility and Patients Who Insist on Medically Ineffective Therapy

As medical decisions fall under more scrutiny and society demands increasing transparency of care, it is likely that more opportunities for conflicts will emerge. Similarly, with increasing demand and a static supply, the issue of who receives treatment and for how long naturally will arise. This mismatch leads to discussions of resource utilization and limitation of care in light of patients' values and rights. Clinicians should always be forthcoming with the uncertainty of prognostication while also articulating the severity of a patient's disease in relation to the risk and benefits of an intervention. However, dispute over treatment course and the idea of futile care can arise for in a variety of reasons, both from the clinician and the patient. Without identifying the cause of these conflicts, it is impossible to have effective communication. At times, it is important to utilize various negotiating skills when resolving these disagreements. Regardless of the approach, practitioners need more training in and exposure to these types of conflicts. In this review, we provide a framework for the origins and current state of futility, challenges in the application of the term, and recommendations on how to approach conflict in these situations.

Targeted Temperature Management in Brain Injured Patients

Evidence from animal models indicates that lowering temperature by a few degrees can produce substantial neuroprotection. In humans, hypothermia has been found to be neuroprotective with a significant impact on mortality and long-term functional outcome only in cardiac arrest and neonatal hypoxic-ischemic encephalopathy. Clinical trials have explored the potential role of maintaining normothermia and treating fever in critically ill brain injured patients. This review concentrates on basic concepts to understand the physiologic interactions of thermoregulation, effects of thermal modulation in critically ill patients, proposed mechanisms of action of temperature modulation, and practical aspects of targeted temperature management.

Abstract WP295: Improving Resident Confidence and Efficiency During Stroke Alerts Through Simulation Training

Background: While most institutions have mock simulations for a code blue or rapid response, there is no standard practice for stroke alert simulations to train neurology residents. This causes residents to feel less confident and take longer when responding to stroke alerts and giving tPA.

Objectives: The first objective was to teach incoming neurology residents how to respond efficiently and appropriately to a stroke alert. Second, we wanted to improve the confidence level of residents during stroke alerts.

Methods: The training session began with a one hour didactic session on how to respond to stroke alerts and when to appropriately administer tPA. A second hour of training focused on how to perform the NIH stroke scale (NIHSS). The following day, nine residents each participated in two stroke simulations utilizing standardized patients. They were observed by an attending, fellow, or resident via video monitoring to ensure accurate history taking and correct NIHSS performance. The residents reviewed head CT imaging and determined if tPA would be given. If tPA was deemed appropriate, the residents notified pharmacy and explained the risks and benefits of the medication to the standardized patient. There was then an immediate feedback session to review particular areas for improvement. The residents completed pre- and post- simulation tests to assess stroke knowledge and to determine confidence in responding to stroke alerts.

Results: Prior to the stroke lecture and simulation, 44% of residents reported confidence responding to a stroke alert. After the simulation, 78% of residents felt confident. Only 44% of residents felt confident performing an NIHSS prior to the simulation versus 100% after the simulation. The number of residents who felt confident in their decision-making ability to give tPA increased from 22% to 56% after the simulation.

Conclusion: In conclusion, residents were more confident responding to stroke alerts, performing an NIHSS, and deciding to give tPA after completing both the didactic stroke training and simulation cases. Data is also being analyzed to determine if the simulations had an effect on resident efficiency during stroke alerts by comparing door to needle time before and after the simulations.

Neurological Critical Care Services' Influence Following Large Hemispheric Infarction and Their Impact on Resource Utilization

INTRODUCTION

Acute ischemic stroke (AIS) is the fourth leading cause of death in the US. Numerous studies have demonstrated the use of comprehensive stroke units and neurological intensive care units (NICU) in improving outcomes after stroke. We hypothesized that an expanded neurocritical care (NCC) service would decrease resource utilization in patients with LHI.

METHODS

Retrospective data from consecutive admissions of large hemispheric infarction (LHI) patients requiring mechanical ventilation were acquired from the hospital medical records. Between 2011-2013, there were 187 consecutive patients admitted to the Jefferson Hospital for Neuroscience (Philadelphia, USA) with AIS and acute respiratory failure. Our intention was to determine the number of tracheostomies done over time. The primary outcome measure was the number of tracheostomies over time. Secondary outcomes were, ventilator-free days (Vfd), total hospital charges, intensive care unit length of stay (ICU-LOS), and total hospital length of stay (hospital-LOS), including ICU LOS. Hospital charges were log-transformed to meet assumptions of normality and homoscedasticity of residual variance terms. Generalized Linear Models were used and ORs and 95% CIs calculated. The significance level was set at α = 0.05.

RESULTS

Of the 73 patients included in this analysis, 33% required a tracheostomy. There was a decrease in the number of tracheostomies undertaken since 2011. (OR 0.8; 95% CI 0.6-0.9: p=0.02).Lower Vfd were seen in tracheostomized patients (OR 0.11; 95%CI 0.1-0.26: p<0.0001). The log-hospital charges decreased over time but not significantly (OR 0.9; 95%CI 0.78-1.07: p=0.2) and (OR 0.99; 95%CI 0.85-1.16: p=0.8) from 2012 to 2013 respectively.The ICU-LOS at 23 days vs 10 days (p=0.01) and hospital-LOS at 33 days vs 11 days (p=0.008) were higher in tracheostomized patients.

CONCLUSION

The data suggest that in LHI-patients requiring mechanical ventilation, a dedicated NCC service reduces the overall need for tracheostomy, increases Vfd, and decreases ICU and hospital-LOS.

Secondary Hematoma Expansion and Perihemorrhagic Edema after Intracerebral Hemorrhage: From Bench Work to Practical Aspects

Intracerebral hemorrhages (ICH) represent about 10–15% of all strokes per year in the United States alone. Key variables influencing the long-term outcome after ICH are hematoma size and growth. Although death may occur at the time of the hemorrhage, delayed neurologic deterioration frequently occurs with hematoma growth and neuronal injury of the surrounding tissue. Perihematoma edema has also been implicated as a contributing factor for delayed neurologic deterioration after ICH. Cerebral edema results from both blood–brain barrier disruption and local generation of osmotically active substances. Inflammatory cellular mediators, activation of the complement, by-products of coagulation and hemolysis such as thrombin and fibrin, and hemoglobin enter the brain and induce a local and systemic inflammatory reaction. These complex cascades lead to apoptosis or neuronal injury. By identifying the major modulators of cerebral edema after ICH, a therapeutic target to counter degenerative events may be forthcoming.

Early Ambulation in Patients With External Ventricular Drains: Results of a Quality Improvement Project

INTRODUCTION

Prolonged immobility in patients in the intensive care unit (ICU) can lead to muscle wasting and weakness, longer hospital stays, increased number of days in restraints, and hospital-acquired infections. Increasing evidence demonstrates the safety and feasibility of early mobilization in the ICU. However, there is a lack of evidence in the safety and feasibility of mobilizing patients with external ventricular drains (EVDs). The purpose of this study was to determine the safety and feasibility of early mobility in this patient population.

METHODS

We conducted a prospective, observational study. All patients in the study were managed with standard protocols and procedures practiced in our ICU including early mobility. Patients with an EVD who received early mobilization were awake and following commands, had a Lindegaard ratio <3.0 or middle cerebral artery (MCA) mean flow velocity <120 cm/s, a Mean Arterial Pressure (MAP) > 80 mm Hg, and an intracranial pressure consistently <20 mm Hg. Data were collected by physical therapists at the time of encounter.

RESULTS

Ninety patients with a total of 185 patient encounters were recorded over a 12-month period. The average time between EVD placement and physical therapy (PT) session was 8.3 ± 5.5 days. In 149 (81%) encounters, patients were at least standing or better. Patients were walking with assistance or better in 99 (54%) encounters. There were 4 (2.2%) adverse events recorded during the entire study.

CONCLUSION

This observational study suggests that PT is feasible in patients with EVDs and can be safely tolerated. Further research is warranted in a larger patient population conducted prospectively to assess the potential benefit of early mobility in this patient population.

Beta-blocker therapy and impact on outcome after aneurysmal subarachnoid hemorrhage: a cohort study

OBJECTIVE

Cerebral vasospasm (cVSP) is a frequent complication of aneurysmal subarachnoid hemorrhage (aSAH), with a significant impact on outcome. Beta blockers (BBs) may blunt the sympathetic effect and catecholamine surge associated with ruptured cerebral aneurysms and prevent cardiac dysfunction. The purpose of this study was to investigate the association between preadmission BB therapy and cVSP, cardiac dysfunction, and in-hospital mortality following aSAH.

METHODS

This was a retrospective cohort study of patients with aSAH who were treated at a tertiary high-volume neurovascular referral center. The exposure was defined as any preadmission BB therapy. The primary outcome was cVSP assessed by serial transcranial Doppler with any mean flow velocity ≥ 120 cm/sec and/or need for endovascular intervention for medically refractory cVSP. Secondary outcomes were cardiac dysfunction (defined as cardiac troponin-I elevation > 0.05 μg/L, low left ventricular ejection fraction [LVEF] < 40%, or LV wall motion abnormalities [LVWMA]) and in-hospital mortality.

RESULTS

The cohort consisted of 210 patients treated between February 2009 and September 2010 (55% were women), with a mean age of 53.4 ± 13 years and median Hunt and Hess Grade III (interquartile range III–IV). Only 13% (27/210) of patients were exposed to preadmission BB therapy. Compared with these patients, a higher percentage of patients not exposed to preadmission BBs had transcranial Doppler-mean flow velocity ≥ 120 cm/sec (59% vs 22%; p = 0.003). In multivariate analyses, lower Hunt and Hess grade (OR 3.9; p < 0.001) and preadmission BBs (OR 4.5; p = 0.002) were negatively associated with cVSP. In multivariate analysis, LVWMA (OR 2.7; p = 0.002) and low LVEF (OR 1.1; p = 0.05) were independent predictors of in-hospital mortality. Low LVEF (OR 3.9; p = 0.05) independently predicted medically refractory cVSP. The in-hospital mortality rate was higher in patients with LVWMA (47.4% vs 14.8%; p < 0.001).

CONCLUSIONS

The study data suggest that preadmission therapy with BBs is associated with lower incidence of cVSP after aSAH. LV dysfunction was associated with higher medically refractory cVSP and in-hospital mortality. BB therapy may be considered after aSAH as a cardioprotective and cVSP preventive therapy.

"Cool" Topic: Feeding During Moderate Hypothermia After Intracranial Hemorrhage

BACKGROUND

Therapeutic moderate hypothermia (MH; T _core 33°C-34°C) is being studied for treatment of spontaneous intracerebral hemorrhage (ICH). Nutrition assessment begins with accurate basal metabolic rate (BMR) determination. Although early enteral nutrition (EN) is associated with improved outcomes, it is often deferred until rewarming. We sought to determine the accuracy of predictive BMR equations and the safety and tolerance of EN during MH after ICH.

MATERIALS AND METHODS

Patients were randomized to 72 hours of MH or normothermia (NT; T _core 36°C-37°C). Harris-Benedict (BMR-HB) and Penn-State equation (BMR-PS) calculations were compared with indirect calorimetry (IC) at day (D) 0 and D1-3. Patients with MH received trophic semi-elemental gastric EN. Occurrences of feeding intolerance, gastrointestinal (GI)-related adverse events, and ventilator-associated pneumonia (VAP) were analyzed with a double-sided matched pairs t test.

RESULTS

Thirteen patients with ICH participated (6 MH, 7 NT). Mean time to initiate EN: 29.9 (MH) vs 18.4 (NT) hours ( P = .046). Average daily EN calories received D0-3: 398 (MH) vs 1006 (NT) ( P < .01). Three patients with MH experienced high gastric residuals prior to prokinetic agents, 1 had mild ileus, and 1 patient with NT vomited. No GI-related adverse events were reported. One patient with MH and 1 patient with NT had VAP. Two patients with MH received IC, and from D0 to D1-3, BMR-HB remained stable (1331 kcal), BMR-PS decreased (1511 vs 1145 kcal, P = .5), and IC decreased (1413 vs 985 kcal, P = .2).

CONCLUSIONS

In patients with ICH undergoing MH, resting energy expenditure is decreased and predictive equations overestimate BMR. EN is feasible, although delayed EN initiation, high gastric residuals, and less EN provision are common. Future studies should focus on EN initiation within 24 hours, advanced EN rates, and postpyloric feeds during hypothermia.

Abstract TP361: Effect of Therapeutic Hypothermia on Innate Immune Responses and Functional Outcome After ICH

Introduction: The objective of this study was to evaluate the effect of therapeutic moderate hypothermia (MH, Tcore33-34°C) compared to normothermia (NT, Tcore36.5-37°C) on innate immune responses and functional outcome.

Methods: In a clinical trial of temperature modulation after ICH, we measured daily levels of cytokine/chemokine TNFα, IL1, IL6 (M1 response), IL10 (M2 response), and CCL2 in peripheral blood of enrolled patients from day (D) 1-7. Levels were log-transformed to meet assumptions of normality. We used mixed models to evaluate the effect of temperature on the expression of cytokine levels, the t-test to determine the association between cumulative CCL2 log-levels and functional outcome, and Cox-regression to determine the impact of MH on long-term functional outcome adjusted for ICH score (median>2), and initial Sequential Organ Failure Assessment Score (iSOFA, median>3). Poor outcome was defined as mRS=5-6.

Results: 10 ICH patients participated in the study (MH=5, NT=5). Median age was 57 years (IQR 22), 55% women, 66% were Black, median GCS was 7 (IQR 4), and median ICH score was 2 (IQR 1). TNFα, IL1, IL6 vs. IL10 log-ratios decreased significantly over time in MH (Fig.1). Mixed models revealed a significant interaction (arm*day) for MH compared to NT for TNFα (β=-0.1, p=.008), IL1 (β=-.01, p=.02), and IL6 (β=-.04, p=.04) (Fig.1). Cumulative CCL2 log-levels at D7 were lower in ICH patients with mRS 0-4 at 6 months as compared to mRS 5-6 (3.7 ± 0.1 Log-pg/mL vs. 4.2 ± 0.1 Log-pg/mL, p=0.02). Adjusting for ICH score (HR 4.0, 95%CI 0.34-97) and iSOFA (HR 8.8, 95%CI 0.9-295), MH was not associated with poor outcome (HR 0.8, 95%CI 0.5-8.9).

Conclusions: This novel data suggest that MH significantly up-regulates the anti-inflammatory M2 response compared to NT after ICH. Higher cumulative log-levels of CCL2 are associated with long-term poor functional outcome. MH was not associated with worst functional outcome.

Evidence-based guidelines for the management of large hemispheric infarction : a statement for health care professionals from the Neurocritical Care Society and the German Society for Neuro-intensive Care and Emergency Medicine

Large hemispheric infarction (LHI), also known as malignant middle cerebral infarction, is a devastating disease associated with significant disability and mortality. Clinicians and family members are often faced with a paucity of high quality clinical data as they attempt to determine the most appropriate course of treatment for patients with LHI, and current stroke guidelines do not provide a detailed approach regarding the day-to-day management of these complicated patients. To address this need, the Neurocritical Care Society organized an international multidisciplinary consensus conference on the critical care management of LHI. Experts from neurocritical care, neurosurgery, neurology, interventional neuroradiology, and neuroanesthesiology from Europe and North America were recruited based on their publications and expertise. The panel devised a series of clinical questions related to LHI, and assessed the quality of data related to these questions using the Grading of Recommendation Assessment, Development and Evaluation guideline system. They then developed recommendations (denoted as strong or weak) based on the quality of the evidence, as well as the balance of benefits and harms of the studied interventions, the values and preferences of patients, and resource considerations.

Dabigatran-Associated Intracranial Hemorrhage: Literature Review and Institutional Experience

Dabigatran etexilate is an oral direct thrombin inhibitor approved for prevention of stroke and systemic embolization in patients with nonvalvular atrial fibrillation and for the treatment of venous thromboembolism. Although dabigatran has a favorable safety profile, predictable pharmacokinetics, fewer drug interactions than warfarin, and does not require monitoring, clinical data regarding dabigatran reversal are limited. In addition, currently available laboratory assays allow measurement of the presence, but not extent, of dabigatran-associated anticoagulation. Patient age, renal function, weight, concurrent drug therapy, adherence, and concomitant disease states can affect dabigatran's efficacy and safety. Management of dabigatran-related intracranial hemorrhage must be approached on a case-by-case basis and include assessment of degree of anticoagulation, severity of hemorrhage, renal function, timing of last dabigatran dose, and risk of thromboembolic events. Initial management includes dabigatran discontinuation and general supportive measures. Oral activated charcoal should be administered in those who ingested dabigatran within 2 hours. Four-factor prothrombin complex concentrates (4PCCs), activated PCC, or recombinant activated factor VII use may be reasonable but is not evidence based. Reserve fresh frozen plasma for patients with dilutional coagulopathy. If readily available, hemodialysis should be considered, particularly in patients with advanced kidney injury or excessive risk of thromboembolic events. More clinical studies are needed to determine a standardized approach to treating dabigatran-associated intracranial hemorrhage. Institutional protocol development will facilitate safe, efficacious, and timely use of the limited management options.

The incidence and risk factors of associated acute myocardial infarction (AMI) in acute cerebral ischemic (ACI) events in the United States

Objectives

To determine the association between myocardial infarction (AMI) and clinical outcome in patients with primary admissions diagnosis of acute cerebral ischemia (ACI) in the US.

Methods

Data from Nationwide Inpatient Sample (NIS) was queried from 2002–2011 for inpatient admissions of patients with a primary diagnosis of ACI with and without AMI using International Classification of Diseases, Ninth Revision, Clinical Modification coding (ICD-9). A multivariate stepwise regression analysis was performed to assess the correlation between identifiable risk factors and clinical outcomes.

Results

During 10 years the NIS recorded 886,094 ACI admissions with 17,526 diagnoses of AMI (1.98%). The overall cumulative mortality of cohort was 5.65%. In-hospital mortality was associated with AMI (aOR 3.68; 95% CI 3.49–3.88, p≤0.0001), rTPA administration (aOR 2.39 CI, 2.11–2.71, p<0.0001), older age (aOR 1.03, 95% CI, 1.03–1.03, P<0.0001) and women (aOR 1.06, 95% CI 1.03–1.08, P<0.0001). Overall, mortality risk declined over the course of study; from 20.46% in 2002 to 11.8% in 2011 (OR 0.96, 95% CI 0.95–0.96, P<0.0001). Survival analysis demonstrated divergence between the AMI and non-AMI sub-groups over the course of study (log-rank p<0.0001).

Conclusion

Our study demonstrates that although the prevalence of AMI in patients hospitalized with primary diagnosis of ACI is low, it negatively impacts survival. Considering the high clinical burden of AMI on mortality of ACI patients, a high quality monitoring in the event of cardiac events should be maintained in this patient cohort. Whether prompt diagnosis and treatment of associated cardiovascular diseases may improve outcome, deserves further study.

The epidemiology of spontaneous fever and hypothermia on admission of brain injury patients to intensive care units: a multicenter cohort study

OBJECTIVES

Fever and hypothermia (dysthermia) are associated with poor outcomes in patients with brain injuries. The authors sought to study the epidemiology of dysthermia on admission to the intensive care unit (ICU) and the effect on in-hospital case fatality in a mixed cohort of patients with brain injuries.

METHODS

The authors conducted a multicenter retrospective cohort study in 94 ICUs in the United States. Critically ill patients with neurological injuries, including acute ischemic stroke (AIS), aneurysmal subarachnoid hemorrhage (aSAH), intracerebral hemorrhage (ICH), and traumatic brain injury (TBI), who were older than 17 years and consecutively admitted to the ICU from 2003 to 2008 were selected for analysis.

RESULTS

In total, 13,587 patients were included in this study; AIS was diagnosed in 2973 patients (22%), ICH in 4192 (31%), aSAH in 2346 (17%), and TBI in 4076 (30%). On admission to the ICU, fever was more common among TBI and aSAH patients, and hypothermia was more common among ICH patients. In-hospital case fatality was more common among patients with hypothermia (OR 12.7, 95% CI 8.4-19.4) than among those with fever (OR 1.9, 95% CI 1.7-2.1). Compared with patients with ICH (OR 2.0, 95% CI 1.8-2.3), TBI (OR 1.5, 95% CI 1.3-1.8), and aSAH (OR 1.4, 95% CI 1.2-1.7), patients with AIS who developed fever had the highest risk of death (OR 3.1, 95% CI 2.5-3.7). Although all hypothermic patients had an increased mortality rate, this increase was not significantly different across subgroups. In a multivariable analysis, when adjusted for all other confounders, exposure to fever (adjusted OR 1.3, 95% CI 1.1-1.5) or hypothermia (adjusted OR 7.8, 95% CI 3.9-15.4) on admission to the ICU was found to be significantly associated with in-hospital case fatality.

CONCLUSIONS

Fever is frequently encountered in the acute phase of brain injury, and a small proportion of patients with brain injuries may also develop spontaneous hypothermia. The effect of fever on mortality rates differed by neurological diagnosis. Both early spontaneous fever and hypothermia conferred a higher risk of in-hospital death after brain injury.

Saving the ischemic penumbra: endovascular thrombolysis versus medical treatment

Endovascular thrombolysis may allow rapid arterial recanalization in patients with acute ischemic stroke. We present the first study to our knowledge comparing the ischemic penumbra saved with endovascular versus medical therapy. A retrospective review of 21 patients undergoing endovascular intervention for stroke from 2010 to 2011 was contrasted with 21 consecutive patients treated with antiplatelet agents alone. Immediate computed tomography perfusion (CTP) scan of the head and neck was obtained in all patients. Patients with lacunar and posterior circulation infarcts, and those who were medically unstable for MRI post-operatively were excluded. CTP and MRI underwent volumetric calculation. CTP penumbra was correlated with diffusion restriction volumes on MRI, and an assessment was made on the volume of ischemic burden saved with either endovascular treatment or antiplatelet agents. The median age was 70 years (interquartile range 62-80). Median National Institutes of Health Stroke Scale score was 18 and 14 in the control and endovascular groups, respectively. Intravenous tissue plasminogen activator was administered in 22 of 42 patients (52%). Median penumbra calculated was 32,808 mm(3) in the control group and 46,255 mm(3) in the endovascular group. Median penumbra spared was 9550 mm(3) (4980-18,811) in the control group versus 38,155 mm(3) in the endovascular group (p=0.0001). Endovascular thrombolysis may be more efficient than medical therapy alone in saving ischemic penumbra. Future advances in recanalization techniques will further improve the efficacy of endovascular therapy.

Significance of arterial hyperoxia and relationship with case fatality in traumatic brain injury: a multicentre cohort study

OBJECTIVE

In this retrospective multi-centre cohort study, we tested the hypothesis that hyperoxia was not associated with higher in-hospital case fatality in ventilated traumatic brain injury (TBI) patients admitted to the intensive care unit (ICU).

METHODS

Admissions of ventilated TBI patients who had arterial blood gases within 24 h of admission to the ICU at 61 US hospitals between 2003 and 2008 were identified. Hyperoxia was defined as PaO2 ≥300 mm Hg (39.99 kPa), hypoxia as any PaO2 <60 mm Hg (7.99 kPa) or PaO2/FiO2 ratio ≤300 and normoxia, not defined as hyperoxia or hypoxia. The primary outcome was in-hospital case fatality.

RESULTS

Over the 5-year period, we identified 1212 ventilated TBI patients, of whom 403 (33%) were normoxic, 553 (46%) were hypoxic and 256 (21%) were hyperoxic. The case-fatality was higher in the hypoxia group (224/553 [41%], crude OR 2.3, 95% CI 1.7-3.0, p<.0001) followed by hyperoxia (80/256 [32%], crude OR 1.5, 95% CI 1.1-2.5, p=.01) as compared to normoxia (87/403 [23%]). In a multivariate analysis adjusted for other potential confounders, the probability of being exposed to hyperoxia and hospital-specific characteristics, exposure to hyperoxia was independently associated with higher in-hospital case fatality adjusted OR 1.5, 95% CI 1.02-2.4, p=0.04.

CONCLUSIONS

In ventilated TBI patients admitted to the ICU, arterial hyperoxia was independently associated with higher in-hospital case fatality. In the absence of results from clinical trials, unnecessary oxygen delivery should be avoided in critically ill ventilated TBI patients.

The epidemiology, risk factors, and impact on hospital mortality of status epilepticus after subdural hematoma in the United States

Introduction

Subdural hematoma (SDH) is a well described risk factor in the development of Status Epilepticus (SE), however the epidemiology of SE after SDH is unknown. In this study, we sought to determine the epidemiology of SE, the prevalence of risk factors, and impact on hospital mortality using a large administrative dataset.

Methods

Data was derived from the Nationwide Inpatient Sample from 1988 through 2011. We queried the NIS database for patients older than 18 years, with a diagnosis of SDH and SE. Diagnoses were defined by ICD 9 CM codes 432.1, 852.2, 852.3 and 345.3 for SE. Adjusted incidence rates of admission and prevalence proportions were calculated. Multivariate logistic models were then fitted to assess for the impact of status epilepticus on hospital mortality.

Results

Over the 23-year period, we identified more than 1,583,255 admissions with a diagnosis of SDH. The prevalence of SE in this cohort was 0.5% (7,421 admissions). The population adjusted incidence rate of admissions of SDH increased from 13/100,000 in 1988 to 38/100,000 in 2011. The prevalence of SE in SDH, increased from 0.5% in 1988 to 0.7% in 2011. In hospital mortality of patients with SDH and without SE decreased from 17.9% to 10.3% while in hospital mortality of patients with SDH and SE did not statistically change. Mortality increased over the same period (2.3/100,000 in 1988 to 3.9/100.000 in 2011) and the diagnosis of SE increased mortality in this cohort (OR 2.17, p < 0.0001). The risk of SE remained stable throughout the study period, but was higher among older patients, blacks, and in those with respiratory, metabolic, hematological, and renal system dysfunction.

Conclusion

Our study demonstrates that the incidence of admissions of SDH is increasing in the United States. Despite a decline in the overall SDH related mortality, SE increased the risk of in-hospital death in patients with a primary diagnosis of SDH.

The epidemiology of admissions of nontraumatic subarachnoid hemorrhage in the United States

BACKGROUND

Subarachnoid hemorrhage (SAH) is the cause of 5% to 10% of strokes annually in the United States.

OBJECTIVE

To study the incidence and mortality trends of admissions of SAH from 1979 to 2008 using a nationally representative sample of all nonfederal acute-care hospitals in the United States: The National Hospital Discharge Survey.

METHODS

The sample was obtained from the hospital discharge records according to the International Classification of Disease, 9th Revision, Clinical Modification code 430.

RESULTS

We reviewed data on approximately 1 billion hospitalizations in the United States over a 30-year study period and identified 612,500 cases of SAH, which was more common in women (relative risk 1.71, 95% confidence interval 1.7-1.72) and nonwhite persons than white persons (relative risk 1.46, 95% confidence interval 1.4-1.5). The estimated incidence rate of admission after SAH was 7.2 to 9.0 per 100,000/year and did not significantly change over the study period. Overall, in-hospital mortality after SAH fell from 30% during the period from 1979 to 1983 to 20% during the subperiod from 2004 to 2008 (P = .03) and was lower in larger treating hospitals. The average days of care for SAH hospitalizations decreased, but the rate of discharge to long-term care facilities increased.

CONCLUSION

The incidence rate of admission after SAH has remained stable over the past 30 years. Total deaths and in-hospital mortality after SAH have decreased significantly. In-hospital mortality after SAH is lower in larger treating hospitals.

Current pathophysiological concepts in cerebral small vessel disease

The association between cerebral small vessel disease (SVD) - in the form of white matter lesions, infarctions, and hemorrhages - with vascular cognitive impairment (VCI), has mostly been deduced from observational studies. Pathological conditions affecting the small vessels of the brain and leading to SVD have suggested plausible molecular mechanisms involved in vascular damage and their impact on brain function. However, much still needs to be clarified in understanding the pathophysiology of VCI, the role of neurodegenerative processes such as Alzheimer's disease, and the impact of aging itself. In addition, both genetic predispositions and environmental exposures may potentiate the development of SVD and interact with normal aging to impact cognitive function and require further study. Advances in technology, in the analysis of genetic and epigenetic data, neuroimaging such as magnetic resonance imaging, and new biomarkers will help to clarify the complex factors leading to SVD and the expression of VCI.

Acute lung injury in patients with subarachnoid hemorrhage: a nationwide inpatient sample study

OBJECTIVE

To determine national trends for patients with subarachnoid hemorrhage (SAH) and pulmonary complications including acute respiratory distress syndrome (ARDS).

METHODS

The Nationwide Inpatient Sample database was used to sample 193,209 admissions for SAH with and without ARDS during the period 1993-2008 using International Classification of Diseases, Ninth Revision, Clinical Modification coding. A multivariate stepwise regression analysis was performed.

RESULTS

The incidence of ARDS in patients with SAH increased from 35.51% in 1993 to 37.60% in 2008. However, the overall mortality in patients with SAH and in patients with SAH and ARDS decreased in the same period, from 42.30% to 31.99% and from 75.13% to 60.76%, respectively. Multivariate analysis showed that the predictors of developing ARDS in patients with SAH include older age; larger hospital size; and comorbidities such as epilepsy, cardiac arrest, sepsis, congestive heart failure, hypertension, chronic obstructive pulmonary disease, hematologic dysfunction, renal dysfunction, and neurologic dysfunction. Predictors of mortality in patients with SAH include age and hospital complications, such as coronary artery disease, ARDS, cancer, hematologic dysfunction, and renal dysfunction.

CONCLUSIONS

Patients with SAH are at increased risk of developing ARDS. The identification of certain risk factors may alert and aid practitioners in preventing worsening disease.

Abstract W P127: Epidemiology of Cerebrovascular Disease: Association Between Geographic Location and In-Hospital Mortality

Background: Extant literature suggests that the South has the lowest ground and air access to Neurocritical Care Units (NCUs) and has the highest number of admissions for subarachnoid hemorrhages (SAH) and intracerebral hemorrhages (ICH) than in other regions. NCUs have been shown to improve outcomes for patients with SAH and ICH, and delayed access may be potentially harmful. Evaluating for in-hospital mortality after SAH or ICH in regions with less access to NCUs may prove useful in determining the need for adequate access.

Objectives: We sought to determine the in-hospital mortality trends for SAH and ICH from 1979 to 2008 per geographic region in relation to the US 2000 standard death rate to derive adjusted comparisons.

Methods: The sample was obtained from the National Hospital Discharge Survey (NHDS) and cases were identified using the ICD-9-CM codes 430 for SAH and 431 for ICH. Age and geographic regions were divided into subgroups according to NHDS recommendations. Annual data was divided into 6 epochs for analysis of temporal changes.

Results: We identified 612,600 cases of SAH and 1,530,613 cases of ICH in the US over a 30-year study period. Overall, crude in-hospital mortality after SAH or ICH was highest in the South [32% (95% CI, 29-35%) and 34% (95% CI, 32-35%), respectively] ( p = 0.001). Crude in-hospital mortality after SAH and ICH per epoch demonstrated a positive temporal trend supported by the Cochran-Armitage trend test (p < 0.0001) and was highest in the South during the sixth epoch (2004-2008) at 24% (95% CI, 22-26%) ( p = 0.001). After adjusting to the US 2000 standard death rate, there was excess mortality in the South with a standard mortality ratio of 1.25 (99% CI, 1.24-1.26) ( p < 0.01) as compared to other regions except for in the Northeast, which was an unanticipated finding.

Conclusions: In-hospital mortality specific to SAH and ICH is higher in US regions identifiable with less access to NCUs when adjusted for all-cause mortality in the US. This study raises numerous questions regarding impact of NCU access and highlights the need for additional data and efforts to maximize access in an efficient manner.

Abstract T P120: Clinical Demographic Effects on Functional Outcome in Patients Following Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction

Background: Malignant MCA infarction is a devastating disease representing 1-10% of strokes. Evidence from recent randomized controlled trials show improved survival and functional outcomes following decompressive hemicraniectomy (DHC) compared with optimal medical. Ideal patient selection remains somewhat controversial. The current study examines the effects of demographic and clinical variables on functional outcomes in patients surviving one or more years following DHC.

Methods: We retrospectively reviewed patients who underwent DHC for malignant MCA infarction at our institution from 03/2006 to 04/2012. We collected and compared demographic and clinical variables including age, gender, race, timing of DHC, side of infarction, IV TPA administration, and additional cerebral territorial involvement (ACA or PCA). The mean mRs was calculated for each group and the Wilcoxon-Mann-Whitney two tailed test was used to calculate statistical significance.

Results: A total of 32 patients met inclusion/exclusion criteria. There was no statistical difference in functional outcomes between patients ≤60 years of age and those >60 years (p=0.51). No statistical difference was observed between males and females (p=0.84)). Patients who received their DHC within 48 hours of their stroke were more likely to have a better outcome than patients who received DHC after 48 hours (p=0.024). Other variables including race, cerebral dominance involvement, IV TPA administration, or additional cerebral territory involvement did not show statistical significance with respect to functional outcomes (p=0.22, p=0.462, p=0.597, and p=0.614 respectively).

Conclusion: In this retrospective study, early DHC done within 48 hours of stroke was the only clinical variable shown to improve functional outcomes 1 year or more later among survivors of patients receiving DHC for malignant MCA infarction. No difference in functional outcome was seen based on age, gender, race, IV TPA administration, dominant MCA involvement, and additional cerebral territorial co infarction. Patient selection should be individualized and larger studies are needed to better assess this patient population, especially in the elderly.

Targeted temperature management after intracerebral hemorrhage (TTM-ICH): methodology of a prospective randomized clinical trial

RATIONALE

Intracerebral hemorrhage causes 15% of strokes annually in the United States, and there is currently no effective therapy.

AIMS AND HYPOTHESIS

This is a clinical trial designed to study the safety, feasibility, and efficacy of a protocol of targeted temperature management to moderate hypothermia in intracerebral hemorrhage patients.

METHODS

The targeted temperature management after intracerebral hemorrhage trial is a prospective, single-center, interventional, randomized, parallel, two-arm (1:1) phase-II clinical trial with blinded end-point ascertainment. Intracerebral hemorrhage patients will be randomized within 18 h of symptom onset to either 72 h of targeted temperature management to moderate hypothermia (32-34°C) followed by a controlled rewarming at of 0·05-0·1°C per hour or 72 h of targeted temperature management to normothermia (36-37°C) using endovascular or surface cooling.

OUTCOMES

The primary outcome is the development of serious adverse events possibly and probably related to treatment. Secondary outcomes include in-hospital neurological deterioration between day 0-7, in-hospital mortality, functional outcome measured by the modified Rankin scale at discharge and 90 days, and effect of treatment allocation on cerebral edema and hematoma volume.

DISCUSSION

Intracerebral hemorrhage remains the most severe form of stroke with limited options to improve survival. As the early resuscitation phase in the intensive care unit represents the greatest opportunity for impact on clinical outcome, it also appears to be the most promising window of opportunity to demonstrate a benefit when investigating aggressive treatments.

CONCLUSION

More research of novel therapies to improve outcomes after intracerebral hemorrhage is desperately needed. The results of the targeted temperature management after intracerebral hemorrhage clinical trial may provide additional information on the applicability of targeted temperature management after intracerebral hemorrhage.

Brain Injury as a Risk Factor for Fever Upon Admission to the Intensive Care Unit and Association With In-Hospital Case Fatality

Purpose:

To test the hypothesis that fever was more frequent in critically ill patients with brain injury when compared to nonneurological patients and to study its effect on in-hospital case fatality.

Methods:

Retrospective matched cohort study utilizing a single-center prospectively compiled registry. Critically ill neurological patients ≥18 years and consecutively admitted to the intensive care unit (ICU) with acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and traumatic brain injury (TBI) were selected. Patients were matched by sex, age, and Acute Physiology and Chronic Health Evaluation II (APACHE-II) to a cohort of nonneurological patients. Fever was defined as any temperature ≥37.5°C within the first 24 hours upon admission to the ICU. The primary outcome measure was in-hospital case fatality.

Results:

Mean age among neurological patients was 65.6 ± 15 years, 46% were men, and median APACHE-II was 15 (interquartile range 11-20). There were 18% AIS, 27% ICH, and 6% TBI. More neurological patients experienced fever than nonneurological patients (59% vs 47%, P = .007). The mean hospital length of stay was higher for nonneurological patients (18 ± 20 vs 14 ± 15 days, P = .007), and more neurological patients were dead at hospital discharge (29% vs 20%, P < .0001). After risk factor adjustment, diagnosis (neurological vs nonneurological), and the probability of being exposed to fever (propensity score), the following variables were associated with higher in-hospital case fatality: APACHE-II, neurological diagnosis, mean arterial pressure, cardiovascular and respiratory dysfunction in ICU, and fever (odds ratio 1.9, 95% confidence interval 1.04-3.6, P = .04).

Conclusion:

These data suggest that fever is a frequent occurrence after brain injury, and that it is independently associated with in-hospital case fatality.

Ethical considerations in consenting critically ill patients for bedside clinical care and research

Care of critically ill patients, as in any other field, demands the exercise of ethical principles related to respect of patient's autonomy, beneficence, nonmaleficence, and distributive justice. Professional duty and the common law require doctors to obtain consent before giving treatment or for requesting participation in clinical research. A procedure or research study must be adequately explained, and the patient must have the capacity to consent. If a patient does not have decision-making capacity, treatment must be given using alternative forms of consent or using principles of implied consent in emergency or life-threatening situations. In the case of clinical research, informed consent must always be sought. Exemptions to this rule are morally justified in circumstances related to research in life-threatening conditions or life-saving interventions in which the investigator departs from sound principles of equipoise. This usually implies the imposition of safeguards such as consultation with the community in which the study were to take place, oversight in patient screening and recruitment process by institutional review boards, special study designs, retrospective and prospective consent processes, and independent safety monitoring.

Relationship between temperature, hematoma growth, and functional outcome after intracerebral hemorrhage

BACKGROUND

Fever and hematoma growth are known to be independent predictors of poor outcome after intracerebral hemorrhage (ICH). We sought to assess the distribution of temperature at different stages in relation to hematoma growth and functional outcome at 90 days in a cohort of ICH patients.

METHODS

Data of patients registered in the Virtual International Stroke Trials Archive--ICH were analyzed. Temperatures at baseline, 24, 48, 72, and 168 h were assessed in relation to the hematoma growth and functional outcome at 90 days. We calculated the daily linear variation of each subject's temperature by subtracting 37 °C from the maximal daily recorded temperature (delta-temperature). We used logistic regression and mixed-effects models to identify factors associated with hematoma growth, poor outcome, and temperature elevation after ICH.

RESULTS

303 patients were included in the analysis. The average age was 66 ± 12 years, 200 (66 %) were males, median admission NIHSS was 13 [Interquartile range (IQR), 9-18), median GCS was 15 (IQR, 14-15). Hematoma growth occurred in 22 % and poor functional outcome at 90-days occurred in 41 % of the patients. Cumulative delta-temperature at 72 h was associated with hematoma growth; age, ICH score, hematoma growth, and cumulative delta-temperature at 168 h were associated with poor outcome at 90 days. Factors associated with fever in mixed-models were day after onset of ICH, hypertension, base hematoma volume, intraventricular-hemorrhage, pneumonia, and hematoma growth.

CONCLUSIONS

There is a temporal and independent association between fever and hematoma growth. Fever after ICH is associated with poor outcome at 90 days. Future research is needed to study the mechanisms of this phenomenon and if early protocols of temperature modulation would be associated with improved outcomes after ICH.

The prevalence and impact of mortality of the acute respiratory distress syndrome on admissions of patients with ischemic stroke in the United States

PURPOSE

To determine the epidemiology of the acute respiratory distress syndrome (ARDS) and impact on in-hospital mortality in admissions of patients with acute ischemic stroke (AIS) in the United States.

METHODS

Retrospective cohort study of admissions with a diagnosis of AIS and ARDS from 1994 to 2008 identified through the Nationwide Inpatient Sample.

RESULTS

During the 15-year study period, we found 55 58 091 admissions of patients with AIS. The prevalence of ARDS in admissions of patients with AIS increased from 3% in 1994 to 4% in 2008 (P < .001). The ARDS was more common among younger men, nonwhites, and associated with history of congestive heart failure, hypertension, chronic obstructive pulmonary disease, renal failure, chronic liver disease, systemic tissue plasminogen activator, craniotomy, angioplasty or stent, sepsis, and multiorgan failures. Mortality due to AIS and ARDS decreased from 8% in 1994 to 6% in 2008 (P < .001) and 55% in 1994 to 45% in 2008 (P < .001), respectively. The ARDS in AIS increased in-hospital mortality (odds ratio, 14; 95% confidence interval, 13.5-14.3). A significantly higher length of stay was seen in admissions of patients with AIS having ARDS.

CONCLUSION

Our analysis demonstrates that ARDS is rare after AIS. Despite an overall significant reduction in mortality after AIS, ARDS carries a higher risk of death in this patient population.

Rate of change of carotid intima-media thickness with magnesium administration in Abcc6⁻/⁻ mice

Pseudoxanthoma elasticum (PXE), caused by mutations in the ABCC6 gene, demonstrates progressive build-up of calcium phosphate and proteoglycans in the skin, eye, and arteries, and is associated to myocardial infarctions, stroke, blindness, and elevated carotid intima-media thickness (CIMT). Although CIMT reduction with magnesium (Mg) has been documented in a mouse model for PXE (Abcc6(-/-) ), it is not clear if Mg is effective in humans with PXE to reduce CIMT. To examine this, we calculated the rate of change of CIMT (washout) in 15- and 12-month-old Abcc6(-/-) mice fed standard rodent diet with or without Mg supplementation for 2 months. Using means in untreated 15- and 12-month-old Abcc6(-/-) mice (145 and 120 μm, respectively), the rate of change was 8.3 μm/month. Using means in treated 15- and 12-month-old Abcc6(-/-) mice (118 and 104.6 μm, respectively), the rate of change was 4.5 μm. Compared to normal progression of CIMT in humans without PXE, PXE has advanced atherosclerosis and possibly a higher CIMT rate of change. This experiment may portend, at least in PXE, the rationale for a 1-year oral Mg CIMT clinical trial and may be useful for application in other progressive mineralizing disorders like atherosclerosis.