Continuous irrigation with thrombolytics for intraventricular hemorrhage: case-control study

Intraventricular hemorrhage (IVH) is a complication of a spontaneous intracerebral hemorrhage. Standard treatment is with external ventricular drain (EVD). Intraventricular thrombolysis may improve mortality but does not improve functional outcomes. We present our initial experience with a novel irrigating EVD (IRRAflow) that automates continuous irrigation with thrombolysis.Single-center case-control study including patients with IVH treated with EVD compared to IRRAflow. We compared standard demographics, treatment, and outcome parameters between groups. We developed a brain phantom injected with a human clot and assessed clot clearance using EVD/IRRAflow approaches with CT imaging.Twenty-one patients were treated with standard EVD and 9 patients with IRRAflow. Demographics were similar between groups. Thirty-three percent of patients with EVD also had at least one dose of t-PA and 89% of patients with IRRAflow received irrigation with t-PA (p = 0.01). Mean drain days were 8.8 for EVD versus 4.1 for IRRAflow (p = 0.02). Days-to-clearance of ventricular outflow was 5.8 for EVD versus 2.5 for IRRAflow (p = 0.02). Overall clearance was not different. Thirty-seven percent of EVD patients achieved good outcome (mRS ≥ 3) at 90 days versus 86% of IRRAflow patients (p = 0.03). Assessing only t-PA, reduction in mean days-to-clearance (p = 0.0004) and ICU days (p = 0.04) was observed. In the benchtop model, the clot treated with IRRAflow and t-PA showed a significant reduction of volume compared to control.Irrigation with IRRAflow and t-PA is feasible and safe for patients with IVH. Improving clot clearance with IRRAflow may result in improved clinical outcomes and should be incorporated into randomized trials.

Trial Readiness of Cavernous Malformations With Symptomatic Hemorrhage, Part II: Biomarkers and Trial Modeling

BACKGROUND

Quantitative susceptibility mapping (QSM) and dynamic contrast-enhanced quantitative perfusion (DCEQP) magnetic resonance imaging sequences assessing iron deposition and vascular permeability were previously correlated with new hemorrhage in cerebral cavernous malformations. We assessed their prospective changes in a multisite trial-readiness project.

METHODS

Patients with cavernous malformation and symptomatic hemorrhage (SH) in the prior year, without prior or planned lesion resection or irradiation were enrolled. Mean QSM and DCEQP of the SH lesion were acquired at baseline and at 1- and 2-year follow-ups. Sensitivity and specificity of biomarker changes were analyzed in relation to predefined criteria for recurrent SH or asymptomatic change. Sample size calculations for hypothesized therapeutic effects were conducted.

RESULTS

We logged 143 QSM and 130 DCEQP paired annual assessments. Annual QSM change was greater in cases with SH than in cases without SH (P=0.019). Annual QSM increase by ≥6% occurred in 7 of 7 cases (100%) with recurrent SH and in 7 of 10 cases (70%) with asymptomatic change during the same epoch and 3.82× more frequently than clinical events. DCEQP change had lower sensitivity for SH and asymptomatic change than QSM change and greater variance. A trial with the smallest sample size would detect a 30% difference in QSM annual change during 2 years of follow-up in 34 or 42 subjects (1 and 2 tailed, respectively); power, 0.8, α=0.05.

CONCLUSIONS

Assessment of QSM change is feasible and sensitive to recurrent bleeding in cavernous malformations. Evaluation of an intervention on QSM percent change may be used as a time-averaged difference between 2 arms using a repeated measures analysis. DCEQP change is associated with lesser sensitivity and higher variability than QSM. These results are the basis of an application for certification by the US Food and Drug Administration of QSM as a biomarker of drug effect on bleeding in cavernous malformations.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03652181.

HummingFlow: novel single twist-drill access for ventricular drainage, irrigation, monitoring, and automated local drug delivery in subarachnoid hemorrhage

OBJECTIVE

The management of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage (aSAH) remains one of the most important targets for neurocritical care. Advances in monitoring technology have facilitated a more thorough understanding of the pathophysiology and therapeutic approaches, but interventions are generally limited to either systemic therapies or passive CSF drainage. The authors present a novel approach that combines a multimodal monitoring bolt-based system with an irrigating ventricular drain capable of delivering intrathecal medications and describe their early experience in patients with aSAH.

METHODS

The authors performed a retrospective review of cases treated with the combined Hummingbird multimodal bolt system and the IRRAflow irrigating ventriculostomy.

RESULTS

Nine patients were treated with the combined multimodal bolt system with irrigating ventriculostomy approach. The median number of days to clearance of the third and fourth ventricles was 3 days in patients with obstructive intraventricular hemorrhage. Two patients received intrathecal alteplase for intraventricular hemorrhage clearance, and 2 patients received intrathecal nicardipine as rescue therapy for severe symptomatic angiographic vasospasm.

CONCLUSIONS

Combined CSF drainage, irrigation, multimodality monitoring, and automated local drug delivery are feasible using a single twist-drill hole device. Further investigation of irrigation settings and treatment approaches in high-risk cases is warranted.

Non-Invasive Vagus Nerve Stimulation Improves Brain Lesion Volume and Neurobehavioral Outcomes in a Rat Model of Traumatic Brain Injury

Abstract Traumatic brain injury (TBI) continues to be a major cause of death and disability worldwide. This study assessed the effectiveness of non-invasive vagus nerve stimulation (nVNS) in reducing brain lesion volume and improving neurobehavioral performance in a rat model of TBI. Animals were randomized into three experimental groups: (1) TBI with sham stimulation treatment (Control), (2) TBI treated with five lower doses (2-min) nVNS, and (3) TBI treated with five higher doses (2 × 2-min) nVNS. We used the gammaCore nVNS device to deliver stimulations. Magnetic resonance imaging studies were performed 1 and 7 days post-injury to confirm lesion volume. We observed smaller brain lesion volume in the lower dose nVNS group compared with the control group on days 1 and 7. The lesion volume for the higher dose nVNS group was significantly smaller than either the lower dose nVNS or the control groups on days 1 and 7 post-injury. The apparent diffusion coefficient differences between the ipsilateral and contralateral hemispheres on day 1 were significantly smaller for the higher dose (2 × 2 min) nVNS group than for the control group. Voxel-based morphometry analysis revealed an increase in the ipsilateral cortical volume in the control group caused by tissue deformation and swelling. On day 1, these abnormal volume changes were 13% and 55% smaller in the lower dose and higher dose nVNS groups, respectively, compared with the control group. By day 7, nVNS dampened cortical volume loss by 35% and 89% in the lower dose and higher dose nVNS groups, respectively, compared with the control group. Rotarod, beam walking, and anxiety performances were significantly improved in the higher-dose nVNS group on day 1 compared with the control group. The anxiety indices were also improved on day 7 post-injury compared with the control and the lower-dose nVNS groups. In conclusion, the higher dose nVNS (five 2 × 2-min stimulations) reduced brain lesion volume to a level that further refined the role of nVNS therapy for the acute treatment of TBI. Should nVNS prove effective in additional pre-clinical TBI models and later in clinical settings, it would have an enormous impact on the clinical practice of TBI in both civilian and military settings, as it can easily be adopted into routine clinical practice.

Cavernous Angioma Symptomatic Hemorrhage (CASH) Trial Readiness II: Imaging Biomarkers and Trial Modeling

Background

Quantitative susceptibility mapping (QSM) and dynamic contrast enhanced quantitative perfusion (DCEQP) MRI sequences assessing iron deposition and vascular permeability were previously correlated with new hemorrhage in cavernous angiomas. We assessed their prospective changes in cavernous angiomas with symptomatic hemorrhage (CASH) in a multisite trial readiness project ( clinicaltrials.gov NCT03652181 ).

Methods

Patients with CASH in the prior year, without prior or planned lesion resection or irradiation were enrolled. Mean QSM and DCEQP of CASH lesion were acquired at baseline, and at 1- and 2-year follow-ups. Sensitivity and specificity of biomarker changes were analyzed in relation to predefined lesional symptomatic hemorrhage (SH) or asymptomatic change (AC). Sample size calculations for hypothesized therapeutic effects were conducted.

Results

We logged 143 QSM and 130 DCEQP paired annual assessments. Annual QSM change was greater in cases with SH than in cases without SH (p= 0.019). Annual QSM increase by ≥ 6% occurred in 7 of 7 cases (100%) with recurrent SH and in 7 of 10 cases (70%) with AC during the same epoch, and 3.82 times more frequently than clinical events. DCEQP change had lower sensitivity for SH and AC than QSM change, and greater variance. A trial with smallest sample size would detect a 30% difference in QSM annual change in 34 or 42 subjects (one and two-tailed, respectively), power 0.8, alpha 0.05.

Conclusions

Assessment of QSM change is feasible and sensitive to recurrent bleeding in CASH. Evaluation of an intervention on QSM percent change may be used as a time-averaged difference between 2 arms using a repeated measures analysis. DCEQP change is associated with lesser sensitivity and higher variability than QSM. These results are the basis of an application for certification by the U.S. F.D.A. of QSM as a biomarker of drug effect in CASH.

Abstract 121: Prospective Symptomatic Hemorrhage Rates And Functional Outcomes In Trial Eligible Cavernous Angiomas With Symptomatic Hemorrhage

Background: Cerebral cavernous angiomas with symptomatic hemorrhage (CASH) carry highest rebleed rates and are targeted for novel interventions. A multisite clinical trial readiness project (clinicaltrials.gov NCT03652181) aims to identify clinical and functional changes over time in trial eligible CASH patients.

Methods: Adult patients from 5 high volume centers with a CASH in the prior year and no planned surgical intervention were enrolled. In addition to demographic, clinical, and imaging review, patients underwent baseline, 1 year and 2 year NIH-stroke scale (NIHSS), modified Rankin scale (mRS), Euro-QOL 5D-3L (EQ-5D-3L) and EQ VAS (visual analog score), and PROMIS 29 assessments. Recurrent symptomatic hemorrhages (SH) were verified. We assessed the hemorrhage rate, change in scores/scales over time, and determined which scales/scores were most affected in patients with SH.

Results: 123 patients completed baseline assessments and were prospectively followed (60.9% female; mean age 44.1 years; 39.1% familial; 41.5% brainstem location). As of reporting date, 89 of 104 (86%) and 58 of 76 (76%) cases have completed assessments. There were 16 SHs during 147 patient-years of follow up (10.9% per patient year). At baseline, 111 (90.2%) of patients had NIHSS 0-2 and 77 (62.6%) patients had mRS baseline 0-1 which improved to 40 (95.2 %) and 43 (75.4%) at 2 years. At baseline, 54 (43.9%) of patients had at least one moderate to severely abnormal PROMIS-29 domain compared to 13 (26.5%) at 2 years. EQ-5D-3L baseline demonstrated a moderate proportion of patients reporting some difficulty with pain (48.8%), anxiety (41.5%), and activity (41.5%) which improved to 28%, 30%, and 34% respectively at 2 years. Patients with a prospective SH were more likely than those without recurrent SH at 2 years to display mild functional decline (0.5 SD) of most PROMIS-29 domains, a mRS of 2 or higher and an abnormal EQ- self-care (P<0.05). Other scales/scores were not significantly different between the groups.

Conclusion: We report SH rate and functional outcome at baseline and rates of changes during 2 years in trial eligible CASH patients. The PROMIS-29, mRS, and EQ-self-care domains were most discriminative in patients with recurrent SH. No test was 100% specific.

Abstract WP18: Association Of Quality Of Life Domains And Clinical Symptoms In Familial Cerebral Cavernous Malformation Patients

Background: Familial cerebral cavernous malformation (FCCM) is characterized by multiple brain lesions at risk for intracranial hemorrhage (ICH) and neurological morbidity, affecting quality of life (QoL). PROMIS-29 is a QoL survey validated in some neurological diseases but has not yet been evaluated for FCCM. We aimed to assess whether PROMIS-29 health domains are associated with clinical symptoms in FCCM patients.

Methods: PROMIS-29 surveys assessing seven QoL domains were completed by 198 FCCM patients >=18 years either at a baseline or follow-up visit in the Brain Vascular Malformation Consortium CCM study. Raw PROMIS-29 domain scores were converted to T scores that are standardized to a reference population with mean 50 and SD 10, and oriented so that higher scores are unfavorable. One-sample t-tests and p-values assessed whether mean T-scores were significantly different from 50 (p<0.05). Multivariable linear regression was used to test whether domain scores were associated with history of ICH, seizures, or headaches at time of survey, adjusting for age and sex.

Results: Compared to a reference population, FCCM patients had significantly higher anxiety (52.7, 95% CI: 51.3-54.2, p<0.001), pain (52.5, 95% CI: 51.0-54.0, p=0.002), and physical functioning scores (52.0, 95% CI: 51.4-54.5, p<0.001), but lower social participation scores (46.9, 95% CI: 45.4-48.5, p<0.001). History of ICH and headaches were significantly associated with 4 domains each (all >3 points, p<0.05, Table), while seizures were not associated. Fatigue was the only affected domain in common.

Conclusion: FCCM patients differed significantly from the reference population on anxiety, pain, physical functioning, and social participation domains. These same domains were significantly associated with history of ICH or headaches in patients. Further studies will determine whether changes in health domains are associated with changes in clinical symptoms.

Intensive Versus Standard Treatment of Hyperglycemia in Acute Ischemic Stroke Patient: A Randomized Clinical Trial Subgroups Analysis

Benefit from blood glucose (BG) control during acute ischemic stroke may depend on glycemic parameters. We evaluated for associations between the SHINE (Stroke Hyperglycemia Insulin Network Effort) randomized treatment group and the SHINE predefined 90-day functional outcome, within-patient subgroups defined by various glycemic parameters.

Delayed Cerebral Ischemia after Subarachnoid Hemorrhage

Delayed cerebral ischemia (DCI) is the most feared complication of aneurysmal subarachnoid hemorrhage (aSAH). It increases the mortality and morbidity associated with aSAH. Previously, large cerebral artery vasospasm was thought to be the sole major contributing factor associated with increased risk of DCI. Recent literature has challenged this concept. We conducted a literature search using PUBMED as the prime source of articles discussing various other factors which may contribute to the development of DCI both in the presence or absence of large cerebral artery vasospasm. These factors include microvascular spasm, micro-thrombosis, cerebrovascular dysregulation, and cortical spreading depolarization. These factors collectively result in inflammation of brain parenchyma, which is thought to precipitate early brain injury and DCI. We conclude that diagnostic modalities need to be refined in order to diagnose DCI more efficiently in its early phase, and newer interventions need to be developed to prevent and treat this condition. These newer interventions are currently being studied in experimental models. However, their effectiveness on patients with aSAH is yet to be determined.

Decision-making for decompressive craniectomy in traumatic brain injury aided by multimodality monitoring: illustrative case

BACKGROUND

Severe traumatic brain injury (TBI) requires individualized, physiology-based management to avoid secondary brain injury. Recent improvements in quantitative assessments of metabolism, oxygenation, and subtle examination changes may potentially allow for more targeted, rational approaches beyond simple intracranial pressure (ICP)-based management. The authors present a case in which multimodality monitoring assisted in decision-making for decompressive craniectomy.

OBSERVATIONS

This patient sustained a severe TBI without mass lesion and was monitored with a multimodality approach. Although imaging did not seem grossly worrisome, ICP, pressure reactivity, brain tissue oxygenation, and pupillary response all began worsening, pushing toward decompressive craniectomy. All parameters normalized after decompression, and the patient had a satisfactory clinical outcome.

LESSONS

Given recent conflicting randomized trials on the utility of decompressive craniectomy in severe TBI, precision, physiology-based approaches may offer an improved strategy to determine who is most likely to benefit from aggressive treatment. Trials are underway to test components of these strategies.

Abstract P46: Baseline Characteristics of Patients With Cerebral Cavernous Angiomas With Symptomatic Hemorrhage in a Multisite Trial Readiness Study

Background: Patients with cerebral cavernous angiomas with symptomatic hemorrhage (CASH) have high risk of disability from recurrent bleeding. Candidate medications to prevent rebleeding in CASH lesions will require multisite clinical trials with standardized data collection.

Objective: To report the prevalence and baseline cohort features in CASH patients and establish a research network infrastructure for trials.

Methods: This prospective observational cohort study includes adults with radiologically verified CASH lesion within 1-year of consent. Exclusions include prior or planned surgical intervention, spinal location, or prior brain irradiation. Six sites enrolled patients into the screening and clinical assessment portion of the study starting July 2018. Patients also had the option to participate in the follow up biomarker validation at 4 sites. Baseline demographics, clinical and imaging information, and outcomes (mRS, PROMIS-29, NIHSS, and EuroQol-5D) were collected. Biomarker imaging included dynamic contrast enhanced quantitative perfusion (DCEQP) and quantitative susceptibility mapping (QSM) that correlated with symptomatic bleeding. Descriptive statistics were performed and one-sample t-test was used to compare whether mean T-scores for PROMIS-29 domains differed significantly from a reference population.

Results: As of May 2020, 849 CASH patients were screened of whom 110 (13%) were eligible and enrolled; 73 also enrolled into the biomarker validation study. Average age at enrollment was 46±16 years at a mean of 4.4 months after symptom onset; 53% were female, 41% were familial, and 43% of CASH lesions were brainstem location. At enrollment, 90% of the cohort had independent functional outcome (mRS ≤ 2 and NIHSS <5). Perceived health problems affecting QoL were reported in >30% (EuroQol-5D). CASH cases had significantly worse anxiety but better depression and social satisfaction scores compared to a general population (all P<0.01). Baseline DCEQP and QSM measures did not differ significantly across sites.

Conclusion: We demonstrate feasibility of multisite recruitment of CASH patients and report prevalence of baseline features that will aid in design of clinical trials and inclusion of appropriate outcome measures.

Hyperbaric oxygen therapy after acute ischemic stroke with large penumbra: a case report

Background

Hyperbaric oxygen therapy (HBOT) for the treatment of acute stroke has been under the radar for a long time. Previous studies have not been able to prove efficacy. Several factors might have contributed to such inconsistent results. The timing of delivering the hyperbaric oxygen in relation to the stage of stroke evolution may be an important factor. This was not taken into account in the previous studies as there was no feasible and standardized method to assess the penumbra in the acute phase. Now with the perfusion scan appearing as a key player in the acute stroke management, precise stroke patient selection for hyperbaric oxygen therapy deserves a second chance similar to mechanical thrombectomy.

Case presentation

A 62-year-old female patient who presented with acute large vessel stroke was not eligible for chemical or mechanical thrombectomy. There was a large penumbra on imaging. She got treated with several sessions of hyperbaric oxygen over a 2-week period immediately after stroke. The patient showed significant improvement on the follow-up perfusion imaging as well as some clinical improvement. The more impressive radiological improvement was probably due to the presence of relatively large core infarction at baseline affecting functional brain areas. The patient continued to improve clinically on her 6-month follow up visit.

Conclusion

Our case demonstrates immediate stroke-related penumbra improvement associated with HBOT. Based on that, we anticipate a potential role for HBOT in acute stroke management considering precise patient selection. Future randomized controlled trials are needed and should take that in consideration.

Angiogenesis and Blood-Brain Barrier Permeability in Vascular Remodeling after Stroke

Angiogenesis, the growth of new blood vessels, is a natural defense mechanism helping to restore oxygen and nutrient supply to the affected brain tissue following an ischemic stroke. By stimulating vessel growth, angiogenesis may stabilize brain perfusion, thereby promoting neuronal survival, brain plasticity, and neurologic recovery. However, therapeutic angiogenesis after stroke faces challenges: new angiogenesis-induced vessels have a higher than normal permeability, and treatment to promote angiogenesis may exacerbate outcomes in stroke patients. The development of therapies requires elucidation of the precise cellular and molecular basis of the disease. Microenvironment homeostasis of the central nervous system is essential for its normal function and is maintained by the blood-brain barrier (BBB). Tight junction proteins (TJP) form the tight junction (TJ) between vascular endothelial cells (ECs) and play a key role in regulating the BBB permeability. We demonstrated that after stroke, new angiogenesis-induced vessels in peri-infarct areas have abnormally high BBB permeability due to a lack of major TJPs in ECs. Therefore, promoting TJ formation and BBB integrity in the new vessels coupled with speedy angiogenesis will provide a promising and safer treatment strategy for improving recovery from stroke. Pericyte is a central neurovascular unite component in vascular barriergenesis and are vital to BBB integrity. We found that pericytes also play a key role in stroke-induced angiogenesis and TJ formation in the newly formed vessels. Based on these findings, in this article, we focus on regulation aspects of the BBB functions and describe cellular and molecular special features of TJ formation with an emphasis on role of pericytes in BBB integrity during angiogenesis after stroke.

Covid-19 systemic infection exacerbates pre-existing acute disseminated encephalomyelitis (ADEM)

Acute disseminated encephalomyelitis (ADEM) is an uncommon diagnosis in adults. It is known to be due to an abnormal immune response to a systemic infection rather than direct viral invasion to the central nervous system. There have been few reports of ADEM diagnosed in the setting of COVID-19 systemic infection. However, we report a case of Coxsackie induced ADEM that remitted but got exacerbated by COVID-19 infection. The patient contracted the COVID-19 infection shortly after being discharged to a rehabilitation facility. Direct COVID-19 neuroinvasion was ruled out via CSF PCR testing for the virus. The patient responded well to pulse steroid therapy and plasmapheresis in both occasions. We hypothesize that COVID-19 infection can flare-up a recently remitted ADEM via altering the immune responses. It is known now that COVID-19 infection can produce cytokine storming. Cytokine pathway activation is known to be involved in the pathology of ADEM. Caution regarding discharging immune suppressed patient to the inpatient rehabilitation facility should be made in the era of COVID-19 pandemic.

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COVID-19 infection can exacerbate an acute disseminated encephalomyelitis (ADEM) attack.

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Early recognition of ADEM in the setting of COVID-19 is crucial for early treatment.

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Treated ADEM exacerbated by COVID-19 systemic infection carries a good prognosis.

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Diagnosis of COVID 19-exacerbated ADEM depends on CSF viral testing.

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Alternative methods to inpatient skilled nursing rehabilitation should be considered.

Adenosine Receptor Modulation of Hypoxic-ischemic Injury in Striatum of Newborn Piglets

BACKGROUND

Hypoxic-ischemic encephalopathy (HIE) is a major cause of pediatric and adult mortality and morbidity. Unfortunately, to date, no effective treatment has been identified. In the striatum, neuronal injury is analogous to the cellular mechanism of necrosis observed during NMethyl- D-Aspartate (NMDA) excitotoxicity. Adenosine acts as a neuromodulator in the central nervous system, the role of which relies mostly on controlling excitatory glutamatergic synapses.

OBJECTIVE

To examine the effect of pretreatment of SCH58261, an adenosine 2A (A2A) receptor antagonist and modulator of NMDA receptor function, following hypoxic-ischemia (HI) on sodium- potassium ATPase (Na+, K+-ATPase) activity and oxidative stress.

METHODS

Piglets (4-7 days old) were subjected to 30 min hypoxia and 7 min of airway occlusion producing asphyxic cardiac arrest. Groups were divided into four categories: HI samples were divided into HI-vehicle group (n = 5) and HI-A2A group (n = 5). Sham controls were divided into Sham vehicle (n = 5) and Sham A2A (n = 5) groups. Vehicle groups were pretreated with 0.9% saline, whereas A2A animals were pretreated with SCH58261 10 min prior to intervention. Striatum samples were collected 3 h post-arrest. Sodium-potassium ATPase (Na+, K+-ATPase) activity, malondialdehyde (MDA) + 4-hydroxyalkenals (4-HDA) and glutathione (GSH) levels were compared.

RESULTS

Pretreatment with SCH58261 significantly attenuated the decrease in Na+, K+-ATPase, decreased MDA+4-HDA levels and increased GSH in the HI-A2A group when compared to HIvehicle.

CONCLUSION

A2A receptor activation may contribute to neuronal injury in newborn striatum after HI in association with decreased Na+, K+-ATPase activity and increased oxidative stress.

Standards for Neurologic Critical Care Units: A Statement for Healthcare Professionals from The Neurocritical Care Society

Neurocritical care is a distinct subspecialty focusing on the optimal management of acutely ill patients with life-threatening neurologic and neurosurgical disease or with life-threatening neurologic manifestations of systemic disease. Care by expert healthcare providers to optimize neurologic recovery is necessary. Given the lack of an organizational framework and criteria for the development and maintenance of neurological critical care units (NCCUs), this document is put forth by the Neurocritical Care Society (NCS). Recommended organizational structure, personnel and processes necessary to develop a successful neurocritical care program are outlined. Methods: Under the direction of NCS Executive Leadership, a multidisciplinary writing group of NCS members was formed. After an iterative process, a framework was proposed and approved by members of the writing group. A draft was then written, which was reviewed by the NCS Quality Committee and NCS Guidelines Committee, members at large, and posted for public comment. Feedback was formally collated, reviewed and incorporated into the final document which was subsequently approved by the NCS Board of Directors.

The Role of Mast Cells in Intracerebral Hemorrhage

Mast cells are first responders to intracerebral hemorrhage. They release potent mediators that can disrupt the blood-brain barrier promoting injury, vasogenic edema formation, and hematoma exacerbation. Also, mast cells recruit other inflammatory cells that maintain and amplify brain damage. Given their early role in the cascade of events in intracerebral hemorrhage, mast cells may offer an alternative target for antichemotactic interventions.

Correction to: Standards for Neurologic Critical Care Units: A Statement for Healthcare Professionals from The Neurocritical Care Society

The authors note that there is a discrepancy between the text of the paper and Table 2 regarding physician subspecialty certification requirements in neurocritical care for Level II centers.

Abstract TP572: Electrocardiogram T Wave Abnormalities are Associated With the Total Burden of Cerebral Small Vessel Disease in Patients With Acute Ischemic Stroke or Transient Ischemic Attack

Introduction: Electrocardiogram (ECG) abnormalities are commonly seen in patients with acute ischemic stroke (AIS). We aimed to determine the influence of the underlying brain state as measured by the total cerebral small vessel disease (CSVD) burden on ECG abnormalities in patients with AIS or Transient Ischemic Attack (TIA).

Methods: Patients with AIS and TIA were prospectively enrolled in a hospital-based stroke registry. Total CSVD burden was measured according to Staals et al on the first brain MRI obtained within 48 hours from hospital admission. Stroke volume was measured on the DWI sequences using ABC/2 formula according to Sims et al. ECG abnormalities were noted on the first ECG obtained in the Emergency Department. Additionally, PR and QTC intervals and QRS complex duration were measured. Univariate analysis was used to test the relationships between total CSVD burden and ECG abnormalities. Linear regression and binary logistic regression models were used for the variables that were significant in univariate analysis to adjust for age, sex, race, current smoking, history of atrial fibrillation, coronary artery disease, valvular disease, myocardial infarction, hypertension, diabetes, hyperlipidemia, antihypertensive medications, stroke volume and involvement of the insula by the stroke.

Results: 141 patients (age 64.5±15.3, 49% females, total CSVD burden was 1.6±1.4, stroke volume 21±40.6, heart rate 79.6±16.5, PR interval 168.4±27 ms, QRS complex 94.1±19.2 ms, QTC interval 450±37.1 ms, abnormalities of ST, T wave, right ventricular hypertrophy, left ventricular hypertrophy, bundle branch block and myocardial infarction were seen in 19.8%, 26.5%, 1.7%, 9.2%, 6.7% and 24.2%). Rhythm was sinus in 72.7% and atrial fibrillation in 8.6%. In univariate analysis, there was significant relationship of total CSVD score with QTC interval and T wave abnormalities (P values: 0.01 and 0.0036 respectively). The relationship of T wave abnormality with total CSVD burden remained significant in logistic regression analysis (OR: 2.2, 95% CI: 1-4.8, P: 0.05).

Conclusions: Total CSVD burden is associated with ECG T wave abnormalities in TIA and AIS patients. Further research is required to identify the underlying pathophysiological mechanisms.

Abstract TP563: White Matter Hyperintensities are Associated With Intracranial Internal Carotid Artery Calcifications in a Cohort of Patients With Acute Ischemic Stroke or Transient Ischemic Attack

Introduction: Previous studies of the relationship between cerebral small vessel disease (CSVD) lesions and carotid artery (CA) calcifications have yielded conflicting results.

Hypothesis: We hypothesized that intracranial ICA (ICICA) calcifications are most closely associated with CSVD in comparison to extracranial ICA (ECICA) and common CA (CCA) calcifications.

Methods: Acute ischemic stroke and transient ischemic attack patients were recruited into a hospital-based prospective stroke registry. Total CSVD burden score including white matter hyperintensity (WMH), lacunes, microbleeds (MBs) and enlarged perivascular spaces (PVS) was measured according to Staals et al. Fazekas scale was used to rate the periventricular and deep WMH (PVMH and DWMH respectively). ICICA calcifications were measured on plain head CT scan according to Subedi et al. ECICA and CCA calcifications were measured according to Yamada et al on the neck CT angiography. Univariate analyses were used to test the relationship between CSVD lesions and CA calcifications. Binary and ordered logistic regression analyses were performed to adjust for the effect of age, sex, race, history of hypertension, diabetes and current smoking for the variables that showed significance in the univariate analyses.

Results: 141 patients (age 64.5±15.3, 49% females, total CSVD score 1.6±1.4, ICICA, ECICA and CCA calcification scores were 7.8±9.9, 10.3±13.4 and 2.1±6.9, respectively). In Univariate analyses, ICICA calcification score showed significant relationships with PVMH, DWMH, lacunes, MBs and total CSVD scores ( P values: <0.0001, 0.0005, 0.0078, 0.049 and 0.0026 respectively). ECICA calcification score showed significant relationships with PVWMH and DWMH (P values: 0.0062 and 0.0332, respectively) while CC calcification score showed significant relationships with PVMWH, DWMH, MBs and PVS (P values: 0.0008, 0.034, 0.045 and 0.013). Multivariate analyses showed significant relationships only for PVWMH and DWMH with ICICA calcification (P values: 0.008 and 0.05, respectively).

Conclusions: ICICA calcifications are most closely linked to PVMW and DWMH. Further studies are required to investigate the pathophysiological mechanisms behind this relationship.

Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging

BACKGROUND

Thrombectomy is currently recommended for eligible patients with stroke who are treated within 6 hours after the onset of symptoms.

METHODS

We conducted a multicenter, randomized, open-label trial, with blinded outcome assessment, of thrombectomy in patients 6 to 16 hours after they were last known to be well and who had remaining ischemic brain tissue that was not yet infarcted. Patients with proximal middle-cerebral-artery or internal-carotid-artery occlusion, an initial infarct size of less than 70 ml, and a ratio of the volume of ischemic tissue on perfusion imaging to infarct volume of 1.8 or more were randomly assigned to endovascular therapy (thrombectomy) plus standard medical therapy (endovascular-therapy group) or standard medical therapy alone (medical-therapy group). The primary outcome was the ordinal score on the modified Rankin scale (range, 0 to 6, with higher scores indicating greater disability) at day 90.

RESULTS

The trial was conducted at 38 U.S. centers and terminated early for efficacy after 182 patients had undergone randomization (92 to the endovascular-therapy group and 90 to the medical-therapy group). Endovascular therapy plus medical therapy, as compared with medical therapy alone, was associated with a favorable shift in the distribution of functional outcomes on the modified Rankin scale at 90 days (odds ratio, 2.77; P<0.001) and a higher percentage of patients who were functionally independent, defined as a score on the modified Rankin scale of 0 to 2 (45% vs. 17%, P<0.001). The 90-day mortality rate was 14% in the endovascular-therapy group and 26% in the medical-therapy group (P=0.05), and there was no significant between-group difference in the frequency of symptomatic intracranial hemorrhage (7% and 4%, respectively; P=0.75) or of serious adverse events (43% and 53%, respectively; P=0.18).

CONCLUSIONS

Endovascular thrombectomy for ischemic stroke 6 to 16 hours after a patient was last known to be well plus standard medical therapy resulted in better functional outcomes than standard medical therapy alone among patients with proximal middle-cerebral-artery or internal-carotid-artery occlusion and a region of tissue that was ischemic but not yet infarcted. (Funded by the National Institute of Neurological Disorders and Stroke; DEFUSE 3 ClinicalTrials.gov number, NCT02586415 .).

Abstract WP414: Total Burden Of Magnetic Resonance Imaging Load Of Cerebral Small Vessel Disease Features And Outcome Of Acute Ischemic Stroke

Introduction: Age is a major risk factor for Cerebral Small Vessel Disease (CSVD) and poor functional outcome following acute ischemic stroke (AIS). Recently, white matter hyperintensity (WMH), a surrogate for CSVD has been associated with AIS poor functional outcome. We aimed to investigate the effect of the total MRI load of CSVD features on AIS functional outcome and their relationship to age.

Methods: Patients presenting with AIS were prospectively recruited. Baseline characteristics, in-hospital complications, acute therapies and discharge dispositions were collected. Total CSVD disease burden (WMH, lacunes, microbleed (MB) and enlarged perivascular space (PVS)) was measured on the first MRI within 24 hour of hospital admission using (0-4) scale according to Staals et al, Neurology 2014. Univariate analysis was completed using t-test, Mann-Whitney Rank Sum test, Chi square test or Spearman correlation as appropriate. Multivariate logistic regression analysis was performed to adjust for the effect of age, stroke volume and CSVD score on the functional outcome of AIS.

Results: 99 subjects with AIS were analyzed (age 65.4±13.7, 52.5% females). 68.4% of patients had favorable discharge outcome (home or acute rehabilitation). CSVD features were present in the cohort as the following: 41.2% had lacunes, 26.4% had MBs, 70.1% had more than 10 PVS in the basal ganglia and 42.4% had Fazekas score of periventricular WMH of 3 or deep WMH of 2 or above. Total CSVD score was 1.6±1.4, and correlated with age (p=0.0015) but not with stroke volume (p=0.71). Unfavorable stroke outcome was associated with higher stroke volume, CSVD score and age (p =0.0005, 0.003 and 0.012, respectively). This relationship remained significant in multivariate analysis for CSVD (p=0.008) and stroke volume (p=0.004) but not for age (p=0.72).

Conclusions: CSVD burden on MRI is associated with worse functional outcome of AIS. This effect appears to be independent of the effect of age on AIS outcome. These results need to be validated in larger cohorts.

Abstract TP424: Automated Detection of Lacunes in a Cohort of Patients Presenting With Transient Ischemic Attack or Acute Ischemic Stroke

Introduction: Cerebral Small Vessel Disease (CSVD) impacts the functional outcome of acute ischemic stroke (AIS) patients. The majority of the available tools to quantify its burden relies on visual categorical scales, which is labor intensive and subject to inter- and intra-reader variability. Fully automated tools are rare and mostly focus on white matter hyperintensity (WMH) as a surrogate for CSVD. We aimed to develop a novel software that simulates the clinicians’ rational to detect lacunes on clinical MRI scans of patients presenting with acute AIS or transient ischemic attack (TIA).

Methods: Patients presenting with symptoms of acute AIS or TIA were prospectively recruited. Lacunes were scored on the first brain MRI collected within 24 hours of hospital admission by a board-certified neuro-intensivist/vascular neurologist according to the Neuroimaging Standards for Research into Small Vessel Disease (STRIVE) criteria. Following standard skull stripping and co-registration, automated software was developed in Matlab by calculating maximal intensity difference of co-registered voxels on FLAIR and T2 MRI sequences. Cerebrospinal fluid was removed by seed-based growing approach and lacunes were subsequently detected based on their size (3-15 mm) and morphological features.

Results: 30 subjects were included (age 61.6±16.1, 30% females); 6 of which had TIA and 23 had AIS (10 acute lacunar stroke, 3 cardioembolic, 10 cryptogenic and 1 stroke of other determined etiology). There were 24 lacunes detected in 12 subjects by the human reader. The automated system accurately identified subjects with lacunes in 91.6% of the cases with 75% specificity. Negative predictive value for subjects without lacunes was 93.7%. At the lesion level, the paradigm identified 62.5% of all lacunes in all subjects with positive predictive value of 78.9%; 67.0% of the missed lacunes were in close proximity to the ventricles.

Conclusions: Automated identification of lacunes is feasible on clinical MRI scans of patients with acute AIS or TIA. Lacunes closer to the ventricles are challenging and may require a separate approach.

Acute Ischemic Stroke After Moderate to Severe Traumatic Brain Injury: Incidence and Impact on Outcome

BACKGROUND AND PURPOSE

Traumatic brain injury (TBI) leads to nearly 300 000 annual US hospitalizations and increased lifetime risk of acute ischemic stroke (AIS). Occurrence of AIS immediately after TBI has not been well characterized. We evaluated AIS acutely after TBI and its impact on outcome.

METHODS

A prospective database of moderate to severe TBI survivors, admitted to inpatient rehabilitation at 22 Traumatic Brain Injury Model Systems centers and their referring acute-care hospitals, was analyzed. Outcome measures were AIS incidence, duration of posttraumatic amnesia, Functional Independence Measure, and Disability Rating Scale, at rehabilitation discharge.

RESULTS

Between October 1, 2007, and March 31, 2015, 6488 patients with TBI were enrolled in the Traumatic Brain Injury Model Systems National Database. One hundred and fifty-nine (2.5%) patients had a concurrent AIS, and among these, median age was 40 years. AIS was associated with intracranial mass effect and carotid or vertebral artery dissection. High-velocity events more commonly caused TBI with dissection. AIS predicted poorer outcome by all measures, accounting for a 13.3-point reduction in Functional Independence Measure total score (95% confidence interval, -16.8 to -9.7; P<0.001), a 1.9-point increase in Disability Rating Scale (95% confidence interval, 1.3-2.5; P<0.001), and an 18.3-day increase in posttraumatic amnesia duration (95% confidence interval, 13.1-23.4; P<0.001).

CONCLUSIONS

Ischemic stroke is observed acutely in 2.5% of moderate to severe TBI survivors and predicts worse functional and cognitive outcome. Half of TBI patients with AIS were aged ≤40 years, and AIS patients more often had cervical dissection. Vigilance for AIS is warranted acutely after TBI, particularly after high-velocity events.

Practice guideline summary: Reducing brain injury following cardiopulmonary resuscitation: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology

OBJECTIVE

To assess the evidence and make evidence-based recommendations for acute interventions to reduce brain injury in adult patients who are comatose after successful cardiopulmonary resuscitation.

METHODS

Published literature from 1966 to August 29, 2016, was reviewed with evidence-based classification of relevant articles.

RESULTS AND RECOMMENDATIONS

For patients who are comatose in whom the initial cardiac rhythm is either pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF) after out-of-hospital cardiac arrest (OHCA), therapeutic hypothermia (TH; 32-34°C for 24 hours) is highly likely to be effective in improving functional neurologic outcome and survival compared with non-TH and should be offered (Level A). For patients who are comatose in whom the initial cardiac rhythm is either VT/VF or asystole/pulseless electrical activity (PEA) after OHCA, targeted temperature management (36°C for 24 hours, followed by 8 hours of rewarming to 37°C, and temperature maintenance below 37.5°C until 72 hours) is likely as effective as TH and is an acceptable alternative (Level B). For patients who are comatose with an initial rhythm of PEA/asystole, TH possibly improves survival and functional neurologic outcome at discharge vs standard care and may be offered (Level C). Prehospital cooling as an adjunct to TH is highly likely to be ineffective in further improving neurologic outcome and survival and should not be offered (Level A). Other pharmacologic and nonpharmacologic strategies (applied with or without concomitant TH) are also reviewed.

Hemostasis in Intracranial Hemorrhage

Spontaneous non-traumatic intracerebral hemorrhage (ICH) is associated with high morbidity and mortality throughout the world with no proven effective treatment. Majority of hematoma expansion occur within 4 h after symptom onset and is associated with early deterioration and poor clinical outcome. There is a vital role of ultra-early hemostatic therapy in ICH to limit hematoma expansion. Patients at risk for hematoma expansion are with underlying hemostatic abnormalities. Treatment strategy should include appropriate intervention based on the history of use of antithrombotic use or an underlying coagulopathy in patients with ICH. For antiplatelet-associated ICH, recommendation is to discontinue antiplatelet agent and transfuse platelets to those who will undergo neurosurgical procedure with moderate quality of evidence. For vitamin K antagonist-associated ICH, administration of 3-factor or 4-factor prothrombin complex concentrates (PCCs) rather than fresh frozen plasma to patients with INR >1.4 is strongly recommended. For patients with novel oral anticoagulant-associated ICH, administering activated charcoal to those who present within 2 h of ingestion is recommended. Idarucizumab, a humanized monoclonal antibody fragment against dabigatran (direct thrombin inhibitor) is approved by FDA for emergency situations. Administer activated PCC (50 U/kg) or 4-factor PCC (50 U/kg) to patients with ICH associated with direct thrombin inhibitors (DTI) if idarucizumab is not available or if the hemorrhage is associated with a DTI other than dabigatran. For factor Xa inhibitor-associated ICH, administration of 4-factor PCC or aPCC is preferred over recombinant FVIIa because of the lower risk of adverse thrombotic events.

Utility of CSF Pressure Monitoring to Identify Idiopathic Intracranial Hypertension without Papilledema in Patients with Chronic Daily Headache

The aim of the present study was to report on the utility of continuous Pcsf monitoring in establishing the diagnosis of idiopathic intracranial hypertension without papilledema (IIHWOP) in chronic daily headache (CDH) patients. We report a series of patients ( n = 10) with refractory headaches and suspected IIHWOP referred to us for continuous Pcsf monitoring between 1991 and 2000. Pcsf was measured via a lumbar catheter and analysed for mean, peak, highest pulse amplitude and abnormal waveforms. A 1-2 day trial of continuous controlled CSF drainage (10 cc/h) followed Pcsf monitoring. Response to CSF drainage was defined as improvement in headache symptoms. Patients with abnormal waveforms underwent a ventriculoperitoneal (VPS) or lumboperitoneal (LPS) shunt insertion. All patients had normal resting Pcsf (8 ± 1 mmHg) defined as ICP < 15 mmHg. During sleep, all patients had B-waves and 90% had plateau waves or near plateau waves. All patients underwent either a VPS or LPS procedure. All reported improvement of their headache after surgery. Demonstration of pathological Pcsf patterns by continuous Pcsf monitoring was essential in confirming the diagnosis of IIHWOP, and provided objective evidence to support the decision for shunt surgery. Increased Pcsf was seen mostly during sleep and was intermittent, suggesting that Pcsf elevation may be missed by a single spot-check LP measurement. The similarity between IIHWOP and CDH suggests that continuous Pcsf monitoring in CDH patients may have an important diagnostic role that should be further investigated.

[Intensive care therapy of space-occupying large hemispheric infarction. Summary of the NCS/DGNI guidelines]

Large hemispheric infarction (LHI), synonymously called malignant middle cerebral artery (MCA) infarction, is a severe neurological disease with a high mortality and morbidity. Treating physicians as well as relatives are often faced with few and low quality data when attempting to apply optimal treatment to these patients and make decisions. While current stroke treatment guidelines focus on risk factors, prevention and acute management, they include only limited recommendations concerning intensive care management of LHI. The Neurocritical Care Society (NCS) and the German Society for Neurocritical and Emergency Medicine (DGNI) organized an interdisciplinary consensus conference on intensive care management of LHI to meet this demand. European and American experts in neurology, neurocritical care, neurosurgery, neuroradiology and neuroanesthesiology were selected based on their expertise and research focus. Subgroups for several main topics elaborated a number of central clinical questions concerning this topic and evaluated the quality of the currently available data according to the grading of recommendation assessment, development and evaluation (GRADE) guideline system. Subsequently, evidence-based recommendations were compiled after weighing the advantages against the disadvantages of certain management options. This is a commented abridged version of the results of the consensus conference.

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.

Abstract W P55: Practice Diversity Among US Neurologists with Respect to the 3 to 4.5-Hour Window for Acute Stroke Thrombolysis

BACKGROUND: In 2009, the AHA/ASA endorsed extending the Acute Stroke IV tPA treatment window to 4.5 hours. Four additional exclusionary criteria were advised for treating patients in this extended window. It is unknown how the practice of stroke care has evolved since then. We developed an online survey aimed to evaluate the current practice patterns of neurologists when treating patients in the 3 to 4.5 hour therapeutic window.

METHODS: We developed a survey utilizing SurveyMonkey.com. The survey included 6 questions, 1. Subspecialty, 2. Frequency of informed consent when giving IV tPA in the 3 to 4.5 hour window, 3-6. Frequency excluding patient's from treatment in the 3 to 4.5 hour window for any of the additional exclusionary criteria. Answer options for questions 2-6 included: always, often (>50% of the time), seldom(<50% of the time), and never. The publicly available AHA/ASA online member directory was utilized to identify physicians meeting criteria: Council: Stroke, Specialty: Neuro/Stroke, Country: USA. The electronic survey was sent by email to 1000 identified physicians.

RESULTS: 260 physicians responded, 230 completed the survey in its entirety and were included in our results. Subspecialties were: 83% vascular neurology, 13% general neurology, and 3% other neurology. Informed consent was always obtained by 33%, often by 22%, seldom by 16%, and never by 28%. Responses for specific exclusion criteria for the 3 to 4.5-hour window were as follows: 1) 34% always excluded patients age >80, 23% often, 29% seldom, and 13% never; 2) 31% always excluded patients with concomitant history of diabetes mellitus and stroke, 21% often, 27% seldom, and 22% never; 3) 28% always excluded patients on warfarin with normal INR, 12% often, 15% seldom, and 46% never; 4) 36% always excluded patients with NIHSS >25, 24% often, 28% seldom, and 12% never.

CONCLUSION: Among US neurologists who care for stroke patients, there is notable diversity in practice with respect to IV thrombolysis within the 3 to 4.5-hour window. This may depict disparities in individual interpretation and acknowledgement of the scientific data pertaining to the extended window. There is a tendency towards obtaining informed consent and adherence to all four exclusion criteria, but not universally.

Abstract W P256: Influence of Withdrawal of Care on Spontaneous Intracerebral Hemorrhage Predictive Scales

Background: Various scoring systems combining different predictors have been developed to more accurately predict the short and long-term outcome after ICH. However, these different scoring systems do not take into account the major influence of the primary cause of mortality in ICH, namely the withdrawal of care (WC). We aim to compare the in-hospital mortality prediction performance after accounting for WC of three widely used scoring systems, the original ICH score (oICH), the ICH Grading scale (ICH-GS), and the simplified ICH score (sICH), in a cohort of ICH patients prior to the development of the aforementioned scales.

Methods: Retrospective observational single center cohort study of adult patients presenting a confirmed diagnosis of ICH. Admission clinical and radiological criteria were obtained through review of medical records and CT at admission. In-hospital mortality was selected as a primary outcome and obtained from the medical records. In the event of death, groups weredivided into: ICH-direct cause of death (cardiac arrest or brain death) andneurological devastation leading to WC. Scoring systems were calculated in each individual patient. Receiver operating characteristic (ROC) analysis was used to assess the ability of each score to predict in-hospital mortality and the maximum Youden Index was identified to denote each score’s optimal predictive cutoff point for each scale. The area under the curve (AUC) between groups was compared by using the Delong et al method. P< 0.05 was set as statistically significant.

Conclusion: Performance of ICH scoring systems accurately predicted in-hospital mortalityeven when WC care is taken into account.

Detailed analysis of periprocedural strokes in patients undergoing intracranial stenting in Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS)

BACKGROUND AND PURPOSE

Enrollment in the Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS) trial was halted due to the high risk of stroke or death within 30 days of enrollment in the percutaneous transluminal angioplasty and stenting arm relative to the medical arm. This analysis focuses on the patient and procedural factors that may have been associated with periprocedural cerebrovascular events in the trial.

METHODS

Bivariate and multivariate analyses were performed to evaluate whether patient and procedural variables were associated with cerebral ischemic or hemorrhagic events occurring within 30 days of enrollment (termed periprocedural) in the percutaneous transluminal angioplasty and stenting arm.

RESULTS

Of 224 patients randomized to percutaneous transluminal angioplasty and stenting, 213 underwent angioplasty alone (n=5) or with stenting (n=208). Of these, 13 had hemorrhagic strokes (7 parenchymal, 6 subarachnoid), 19 had ischemic stroke, and 2 had cerebral infarcts with temporary signs within the periprocedural period. Ischemic events were categorized as perforator occlusions (13), embolic (4), mixed perforator and embolic (2), and delayed stent occlusion (2). Multivariate analyses showed that higher percent stenosis, lower modified Rankin score, and clopidogrel load associated with an activated clotting time above the target range were associated (P ≤ 0.05) with hemorrhagic stroke. Nonsmoking, basilar artery stenosis, diabetes, and older age were associated (P ≤ 0.05) with ischemic events.

CONCLUSIONS

Periprocedural strokes in SAMMPRIS had multiple causes with the most common being perforator occlusion. Although risk factors for periprocedural strokes could be identified, excluding patients with these features from undergoing percutaneous transluminal angioplasty and stenting to lower the procedural risk would limit percutaneous transluminal angioplasty and stenting to a small subset of patients. Moreover, given the small number of events, the present data should be used for hypothesis generation rather than to guide patient selection in clinical practice. Clinical Trial Registration Information- URL: http://clinicaltrials.gov. Unique Identifier: NCT00576693.

Stenting versus aggressive medical therapy for intracranial arterial stenosis

BACKGROUND

Atherosclerotic intracranial arterial stenosis is an important cause of stroke that is increasingly being treated with percutaneous transluminal angioplasty and stenting (PTAS) to prevent recurrent stroke. However, PTAS has not been compared with medical management in a randomized trial.

METHODS

We randomly assigned patients who had a recent transient ischemic attack or stroke attributed to stenosis of 70 to 99% of the diameter of a major intracranial artery to aggressive medical management alone or aggressive medical management plus PTAS with the use of the Wingspan stent system. The primary end point was stroke or death within 30 days after enrollment or after a revascularization procedure for the qualifying lesion during the follow-up period or stroke in the territory of the qualifying artery beyond 30 days.

RESULTS

Enrollment was stopped after 451 patients underwent randomization, because the 30-day rate of stroke or death was 14.7% in the PTAS group (nonfatal stroke, 12.5%; fatal stroke, 2.2%) and 5.8% in the medical-management group (nonfatal stroke, 5.3%; non-stroke-related death, 0.4%) (P=0.002). Beyond 30 days, stroke in the same territory occurred in 13 patients in each group. Currently, the mean duration of follow-up, which is ongoing, is 11.9 months. The probability of the occurrence of a primary end-point event over time differed significantly between the two treatment groups (P=0.009), with 1-year rates of the primary end point of 20.0% in the PTAS group and 12.2% in the medical-management group.

CONCLUSIONS

In patients with intracranial arterial stenosis, aggressive medical management was superior to PTAS with the use of the Wingspan stent system, both because the risk of early stroke after PTAS was high and because the risk of stroke with aggressive medical therapy alone was lower than expected. (Funded by the National Institute of Neurological Disorders and Stroke and others; SAMMPRIS ClinicalTrials.gov number, NCT00576693.).

Diagnosis and management of pediatric arterial ischemic stroke

Pediatric stroke is among the top 10 causes of death in children and an important cause of chronic morbidity, with an incidence of 3.3/100,000 children/year. Risk factors associated with stroke in children include cardiac diseases, hematologic and vascular disorders, and infection. Clinical presentation varies depending on age, underlying cause, and stroke location. Antithrombotics and anticoagulants are used in the treatment of pediatric stroke; however, there are no established guidelines for the use of these agents in children. In this article we review the cause, pathophysiology, clinical presentation, diagnosis, acute management, secondary prevention, and outcome of children with stroke. The approach to patients with sickle cell disease and Moyamoya disease is also discussed. Up to date studies to determine the optimal acute treatment of childhood stroke and secondary prevention and risk factor modification are critically needed.

Management of intracranial pressure

Although intracranial hypertension may arise from diverse pathology, several basic principles remain paramount to understanding its dynamics; however, the management of elevated intracranial pressure (ICP) may be very complex. Initial management of common ICP exacerbants is important, such as addressing venous outflow obstruction with upright midline head positioning and treating agitation and pain with sedation and analgesia. Surgical decompression of mass effect may rapidly improve ICP elevation, but the impact on outcome is unclear. Considerable effort has been put forth to understand the roles of multimodal intensive care monitoring, osmolar therapy, cerebral metabolic suppression, and temperature augmentation in the advanced management of elevated ICP. Establishing a protocol-driven approach to the management of ICP enables the rapid bedside assessment of multiple physiologic variables to implement appropriate treatments, which limit the risk of developing secondary brain injury.

Sigma receptor ligand 4-phenyl-1-(4-phenylbutyl)-piperidine modulates neuronal nitric oxide synthase/postsynaptic density-95 coupling mechanisms and protects against neonatal ischemic degeneration of striatal neurons

In adult stroke models, 4-phenyl-1-(4-phenylbutyl) piperidine (PPBP), a sigma receptor agonist, attenuates activity of neuronal nitric oxide synthase (nNOS), blunts ischemia-induced nitric oxide production, and provides neuroprotection. Here, we tested the hypothesis that PPBP attenuates neuronal damage in a model of global hypoxia-ischemia (H-I) in newborn piglets. Piglets subjected to hypoxia followed by asphyxic cardiac arrest were treated with saline or two dosing regimens of PPBP after resuscitation. Sigma-1 receptors were found in striatal neurons. PPBP dose-dependently protected neurons in putamen at 4 days of recovery from H-I. Immunoblots of putamen extracts at 3 h of recovery showed that PPBP decreased H-I-induced recruitment of nNOS in the membrane fraction and reduced the association of nNOS with NMDA receptor NR2 subunit. The latter effect was associated with changes in the coupling of nNOS to postsynaptic density-95 (PSD-95), but not NR2-PSD-95 interactions. Moreover, PPBP suppressed NOS activity in the membrane fraction and reduced H-I-induced nitrative and oxidative damage to proteins and nucleic acids. These findings indicate that PPBP protects striatal neurons in a large animal model of neonatal H-I and that the protection is associated with decreased coupling of nNOS to PSD-95.

Frequency of sustained intracranial pressure elevation during treatment of severe intraventricular hemorrhage

BACKGROUND

Elevated intracranial pressure (ICP) is an important marker of neurological deterioration. The occurrence and significance of elevated ICP and low cerebral perfusion pressure (CPP) in aggressively treated spontaneous intraventricular hemorrhage (IVH) are not defined.

METHODS

We performed a secondary longitudinal exploratory data analysis of a randomized multicenter trial of urokinase (UK) versus placebo (Pcb) as a treatment for IVH. Eleven IVH patients who required an external ventricular drain (EVD) were randomized to receive either intraventricular UK or Pcb every 12 h until clinical response permitted EVD removal. ICP and CPP were recorded every 4 or 6 h, as well as before and 1 h after EVD closure for administration of study agent. ICP, CPP and the proportion of ICP readings above 20, 30, 40 and 50 mm Hg were analyzed.

RESULTS

Six UK and 5 Pcb patients aged 39-74 years (mean +/- standard deviation; 53 +/- 11 years) were enrolled. Initial ICP ranged from 0 to 38 mm Hg (10.9 +/- 11.0), initial CPP from 65 to 133 mm Hg (100.5 +/- 17.7). We recorded 472 ICP readings over the entire monitoring period. Of these 65 (14%) were >20 mm Hg, 23 (5%) >30 mm Hg, 9 (2%) >40 mm Hg and 3 (<1%) >50 mm Hg. Only 2 of 141 intraventricular injections of study agent with EVD closure were not tolerated and required reopening of the EVD.

CONCLUSIONS

In the intensive care unit, initial ICP measured with an EVD was uncommonly elevated (1/11 patients) in this group of severe IVH patients despite acute obstructive hydrocephalus. Frequent monitoring reveals ICP elevation >20 mm Hg in 14% of observations during use of EVD. ICP elevation, though it can occur, is not routinely associated with EVD closure for thrombolytic treatment with UK.

Interventional acute ischemic stroke therapy with intracranial self-expanding stent

BACKGROUND AND PURPOSE

Rapid and safe recanalization of occluded intracranial arteries in acute ischemic stroke (AIS) is challenging. Newly available self-expanding intracranial atherosclerotic stents (SEIS), which can be deployed rapidly and safely, make acute stenting an option for treating AIS. We present the feasibility of this technique.

METHODS

A retrospective analysis evaluated procedural protocols and clinical response to treatment in patients with AIS treated with SEIS. Descriptive statistics are presented with initial and follow-up National Institutes of Health Stroke Scale and modified Rankin Score.

RESULTS

Nine patients with AIS underwent acute SEIS placement. There was successful deployment of the Neuroform (n=4) and Wingspan (n=4/5) stents in the M1/M2 (n=5) and M3 (n=1) middle cerebral artery segments, intracranial internal carotid artery (one of 2), and intracranial vertebrobasilar junction (one). Mean time of SEIS deployment from AIS onset was 5.1 hours. Complete (Thrombolysis in Cerebral Ischemia/Thrombolysis in Myocardial Ischemia 3) and partial/complete (Thrombolysis in Cerebral Ischemia/Thrombolysis in Myocardial Ischemia 2 or 3) recanalization occurred in 67% and 89%, respectively. One intracranial hemorrhage (11%) and one acute in-stent thrombosis (successfully treated with abciximab and balloon angioplasty) occurred. Stroke-related mortality occurred in 3 of 9 (33%) patients and survivors had modified Rankin Score < or = 2. Follow-up angiography (mean, 8 months; range, 2 to 14 months) in 4 of 9 patients showed no stent restenosis.

CONCLUSIONS

This preliminary experience with SEIS in refractory AIS demonstrated the technical feasibility and high rate of recanalization with acute stenting. Long-term safety and strategies to limit in-stent thrombosis and optimize periprocedural management are crucial before initiating future randomized efficacy studies with SEIS in AIS refractory to standard therapy.

Platelet count and function in spontaneous intracerebral hemorrhage

Impaired platelet function has been associated with an increased propensity for intracerebral hemorrhage (ICH). The role of platelet count and dysfunction in spontaneous ICH (SICH) is poorly understood. We tested the hypotheses that patients with SICH have subtle platelet dysfunction associated with ICH progression and larger ICH size. In a retrospective case series, we compared platelet counts in patients with SICH with age-matched controls with neuromuscular disorders admitted to a Neurosciences Critical Care Unit (NCCU). In a subset of patients, platelet function was measured within one week of ICH. Computerized tomography (CT) scans were performed within 24 hours of the event and ICH volume determined by the ABC/2 method. Comparison of 43 patients with SICH and 35 age-matched controls with neuromuscular disease demonstrated significant decreases in platelet counts over the first few days of admission to the NCCU (Nadir: 149 +/- 9 vs 202 +/- 12 IU/mm3; P = .001). There was a significant correlation between a fall in platelet count and change in hematoma size in 28 patients (P = .01). Seventeen patients were enrolled prospectively to study platelet function. Patients were divided into 2 groups based on ICH volume: < or = 30 cc and > 30 cc. There was an association of low platelet count at a median of 4 days with larger ICH volume (P = .01). Platelet function abnormalities, including aggregation to arachidonic acid, collagen, and ADP and ATP release reactions to thrombin and collagen, and a prolonged bleeding time were common findings in ICH patients compared to standardized controls. Platelet dysfunction was more common in large versus small ICH (80% vs 50%). Two patients with significant (>15%) hematoma enlargement within the first 24 hours had significant early decreases in platelet counts and extensive platelet dysfunction. In conclusion, platelet dysfunction is common among patients with SICH. Low platelet count and platelet dysfunction may be factors in expansion of ICH volume. Further prospective studies with larger sample size are needed to assess this association.

Treatment of unruptured intracranial aneurysms: a nationwide assessment of effectiveness

BACKGROUND AND PURPOSE

With advances in neuroimaging, unruptured cerebral aneurysms are being diagnosed more frequently. Until 1995, surgical clipping of the aneurysm was the only treatment available. Since then, a less invasive endovascular technique has been found effective in a trial of ruptured aneurysms. No efficacy studies comparing the 2 procedures for unruptured aneurysms exist to guide clinical decisions. The objective of this study was to assess effectiveness and outcomes of endovascular versus neurosurgical treatment for unruptured intracranial aneurysms.

METHODS

This was a retrospective cohort study, using data collected over a 1-year time interval (between 1998 and 2000), from 429 hospitals, in 18 states, and representing 58% of the US population. A total of 2535 treated, unruptured cerebral aneurysm cases were evaluated. The measurements used were effectiveness as measured by hospital discharge outcomes: 1) mortality (in-hospital death), 2) adverse outcomes (death or discharge to a rehabilitation or nursing facility), 3) length of stay, and 4) hospital charges. Univariate analyses compared endovascular versus neurosurgical discharge outcomes. Multivariable models were adjusted for age, sex, region, Medicaid insurance status, year, hospital case volume, comorbidity score, and admission source.

RESULTS

Endovascular treatment was associated with fewer adverse outcomes (6.6% versus 13.2%), decreased mortality (0.9% versus 2.5%), shorter lengths of stay (4.5 versus 7.4 days), and lower hospital charges (42,044 dollars versus 47,567 dollars) compared with neurosurgical treatment (P < .05). After multivariable adjustment, neurosurgical cases had 70% greater odds of an adverse outcome, 30% increased hospital charges, and 80% longer length of stay compared with endovascular cases (P < .05).

CONCLUSIONS

The current analysis indicates that endovascular therapy is associated with significantly less morbidity, less mortality, and decreased hospital resource use at discharge, compared with conventional neurosurgical treatment for all unruptured aneurysms. Endovascular therapy, as a treatment alternative to surgical clipping, should be offered as a viable therapeutic option for all patients considering treatment of an unruptured cerebral aneurysm.

Biomarkers and Neuroimaging of Brain Injury after Cardiac Arrest

Unfortunately, it remains a difficult task to predict with certainty which patients will have a poor neurological outcome following cardiac arrest. Finding a quantitative prognostic model of outcome has become the objective of many intensivists to assist grieving families in making early difficult decisions regarding withdrawal of life support. An ideal prognostic test should be readily available, easily reproducible, and associated with a high degree of specificity for poor outcome. The goal is not to define which patients may recover, but rather which patients have no likelihood of meaningful neurological recovery at all to justify early withdrawal of support. The literature and the role of biochemical markers in the blood and in the cerebrospinal fluid will be evaluated as prognosticators following cardiac arrest. Radiological indicators of anoxic cerebral damage are reviewed. Each serum or radiological marker has its pros and cons. To accurately prognosticate following cardiac arrest, a multimodal scale or algorithm that incorporates serum markers, radiological markers, and the neurological exam is clearly needed. As these techniques are being evaluated more closely and as imaging modalities increase in sensitivity and portability, physicians will continue to assist families by providing some guidance as to which patients have no chance of meaningful recovery.

Neurologic prognosis and withdrawal of life support after resuscitation from cardiac arrest

OBJECTIVE

To study the impact of neurologic prognostication on the decision to withdraw life-sustaining therapies (LST) in comatose patients resuscitated after cardiac arrest.

METHODS

The authors prospectively studied a consecutive series of post-resuscitation comatose patients referred for neurologic prognostication at a single center for 4 years. For most patients, neurologic prognostication was not sought due to early death or rapid return to consciousness. Prognostication was based on Glasgow Coma Score (GCS) and Brainstem Reflex Score (BRS), with EEG and cortical evoked potentials (CEP), which were graded as benign, uncertain, and malignant. The outcomes were as follows: survivors (Group S), brain or cardiac death (Group D), and death from withdrawal of life sustaining therapy (Group W). In Group W, the time interval to withdrawal of LST was analyzed by EEG and CEP grades.

RESULTS

Of 58 patients studied, 10 were in Group S, 8 in Group D, and 40 in Group W. Initial median GCS and BRS was similar for all groups with significant improvement noted in Group S, but not in Group D or Group W. In Group W, CEP grade correlated with the median duration of continued therapy before a decision to withdraw LST: 7 days for benign CEP, 2 days for uncertain CEP, and 1 day for malignant CEP, p = 0.0004.

CONCLUSION

In patients with poor neurologic recovery early after resuscitation from cardiac arrest, physicians appear to use the cortical evoked potential grade to estimate prognosis. Cortical evoked potential grade correlated with the waiting time until life sustaining therapies were withdrawn after no improvement in neurologic examination was seen.