Impact of a Neurointensivist on Outcomes in Critically Ill Stroke Patients

Background  

Current guidelines for management of critically ill stroke patients suggest that treatment in a neurocritical care unit (NCCU) and/or by a neurointensivist (NI) may be beneficial, but the contribution of each to outcome is unknown. The relative impact of a NCCU versus NI on short- and long-term outcomes in patients with acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and aneurysmal subarachnoid hemorrhage (SAH) was assessed.     

Early Mobilization in the Neuro-ICU: How Far Can We Go?

Immobility that is frequently encountered in the intensive care unit (ICU) can lead to patient complications. Early mobilization of patients in the ICU has been shown to reduce the complications associated with critical illness; however, early mobilization in the neurological intensive care unit (NICU) presents a unique challenge for the multidisciplinary team. The early mobilization of patients with acute neurologic injuries such as acute ischemic stroke, aneurysmal subarachnoid hemorrhage, intracerebral hemorrhage, and neurotrauma varies because of differing disease processes and management. When developing an early mobility program in the NICU, the following should be considered: the effect of positional changes and exercise, the time from symptom onset to the initiation of early mobilization, and the type and intensity of the exercise prescribed.     

Intensive care management [corrected] of patients with intracerebral hemorrhage

Approximately 10-15% of acute strokes are caused by non-aneurysmatic intracerebral hemorrhage (ICH) and incidences are expected to increase due to an aging population. Studies from the 1990s estimated mortality of ICH to be as high as 50%. However, these figures may partly be attributed to the fact that patients suffering from ICH frequently received only supportive therapy and the poor prognosis may therefore be more a self-fulfilling prophecy. Recently it has been shown that treatment in a specialized neurological intensive care unit alone was associated with better outcomes after ICH. In recent years considerable efforts have been undertaken in order to develop new therapies for ICH and to assess them in randomized controlled trials. Apart from admission status, hemorrhage volume is considered to be the main prognostic factor and impeding the spread of the hematoma is thus a basic therapeutic principle. The use of activated factor VIIa (aFVIIa) to stop hematoma enlargement has been assessed in two large randomized controlled trials, however the promising results of the dose-finding study could not be confirmed in a phase III trial. Although hemostatic therapy with aFVIIa reduced growth of the hematoma it failed to improve clinical outcome. Similar results were found in a randomized controlled trial on blood pressure management in acute ICH. The link between reduction of hematoma growth and improved outcome is therefore still lacking. Likewise the value of surgical hematoma evacuation remains uncertain. In the largest randomized controlled trial on surgical treatment in ICH so far, only a small subgroup of patients with superficial hemorrhages seemed to benefit from hematoma evacuation. Whether improved intensive care can contribute to improved outcome after ICH will be shown by data obtained in the coming years.     

Elevated Neutrophil-Lymphocyte Ratio is Predictive of Poor Outcomes Following Aneurysmal Subarachnoid Hemorrhage

Background Recent studies of patients with intracerebral hemorrhage suggest an association between peripheral blood neutrophil-lymphocyte ratio and neurologic deterioration. We aimed to study the prognostic utility of neutrophil-lymphocyte ratio in predicting inpatient mortality in aneurysmal subarachnoid hemorrhage. Methods We conducted a retrospective electronic medical record review of the clinical, laboratory, and radiographic data of patients with aneurysmal subarachnoid hemorrhage 18 years of age or older presenting to the neuroscience intensive care unit from January 1, 2011, to December 31, 2017. Patients with aneurysmal subarachnoid hemorrhage were divided into 2 groups (group 1, alive at discharge; group 2, deceased prior to discharge), and neutrophil-lymphocyte ratio laboratory mean values were recorded for each patient. Our primary outcome measure was inpatient mortality, and our secondary measure was incidence of pneumonia with hospitalization. Results We identified 403 patients with aneurysmal subarachnoid hemorrhage for the study. After exclusion criteria, 44 eligible patients were divided into the 2 groups (group 1, n = 32; group 2, n = 12). Mean neutrophil-lymphocyte ratio for group 1 was 11.53, and for group 2, 17.85 (P < .01). The mean neutrophil-lymphocyte ratio of those who developed pneumonia compared to those who did not was 15.28 versus 12.81, respectively (P = .39). A Kaplan-Meier plot demonstrated increased mortality among patients with a neutrophil-lymphocyte ratio equal to or greater than 12.5 compared to those with a neutrophil-lymphocyte ratio less than 12.5. Conclusions These preliminary data demonstrate that a neutrophil-lymphocyte ratio equal to or greater than 12.5 at admission predict higher inpatient mortality in patients with aneurysmal subarachnoid hemorrhage.     

Intensive Care Unit Management of Aneurysmal Subarachnoid Hemorrhage

The emergence of dedicated neurologic-neurosurgical intensive care units, advancements in endovascular therapies, and aggressive brain resuscitation and monitoring have contributed to overall improved outcomes for patients with aneurysmal subarachnoid hemorrhage (aSAH) over the past 20 to 30 years. Still, this feared neurologic emergency is associated with substantial mortality and morbidity. Emergency care for patients with aSAH focuses on stabilization, treatment of the aneurysm, controlling intracranial hypertension to optimize cerebral perfusion, and limiting secondary brain injury. This complex disorder can be associated with many neurologic complications such as acute hydrocephalus, rebleeding, global cerebral edema, seizures, vasospasm, and delayed cerebral ischemia in addition to systemic complications such as electrolyte imbalances, cardiopulmonary injury, and infections. Background routine intensive care practices such as avoidance of hyperthermia, venous thromboembolism prophylaxis, and avoidance of severe blood glucose derangements are additional important elements of care.     

Intensive care management of ischemic stroke

The practice of neurointensive care was initially developed to manage postoperative neurosurgical patients and expanded thereafter to the management of patients with primary head trauma, intracranial hemorrhage, vasospasm after subarachnoid hemorrhage, elevated intracranial pressure, and unstable pulmonary or cardiovascular medical conditions in neurologic patients. Can neurointensive care with its advanced medical and neurologic resources improve the outcome of the ischemic stroke patient? This review discusses selection of patients appropriate for admission to the neurologic intensive care unit (NICU) and current options for the intensive care management of severe ischemic stroke and its attendant complications. We propose that the NICU team is well suited to acute stroke management if they apply their advanced skills and technologic resources to manage the severe stroke patient from the time of presentation to the emergency ward. Study is needed to determine the effect that a critical care level of service has on functional outcome.     

Medical Complications Drive Length of Stay After Brain Hemorrhage: A Cohort Study

Introduction  Longer length of stay (LOS) is associated with higher complications and costs in ICU patients, while hospital protocols may decrease complications and LOS. We hypothesized that medical complications would increase LOS after spontaneous subarachnoid (SAH) and intracerebral (ICH) hemorrhage after accounting for severity of neurologic injury in a cohort of consecutively admitted patients. Methods  We prospectively recorded admission characteristics, hospital complications, and LOS for 122 patients with SAH and 56 patients with ICH from February 2006 through March 2008. A multidisciplinary Neuro-ICU team included a dedicated pharmacist and intensivist on daily rounds. Hospital protocols set glucose control with intravenous insulin, ventilator bundles, pharmacist involvement, and hand hygiene. Associations were explored with univariate statistics (t-tests, ANOVA, or non-parametric statistics as appropriate) and linear regression (repeated after log transformation of ICU and hospital LOS). Results  Factors associated with longer LOS after SAH and ICH were similar. In both SAH and ICH the strongest drivers of LOS were infection, fever, and acute lung injury. For SAH, vasospasm and Glasgow Coma Scale were also significant in some models, while in patients with ICH the volume of the initial bleed was significant in some models. Conclusion  LOS after spontaneous brain hemorrhage is driven by medical complications even after the adoption of dedicated intensive care medical staff, pharmacist involvement, and evidence-based protocols for ICU care. Further alterations in care will be necessary to eliminate “preventable” complications and minimize LOS after brain hemorrhage.     

Primary intracerebral and subarachnoid hemorrhage. An approach to diagnosis and therapy.

The diagnosis of primary intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) has become easier with the advent of modern imaging techniques. The incidence of ICH has declined, while SAH has remained relatively constant. The prognosis for both disorders remains dismal and the mortality rate is substantially higher than that observed with ischemic stroke. Early imaging with CT or MRI is important for rapid and accurate diagnosis. General medical management in a skilled nursing facility should be available for patients who are not moribund. Therapy for ICH is predominantly supportive and effective medical and surgical intervention remains elusive. For SAH, calcium channel blockers may reduce cerebral ischemic complications related to vasospasm, but effective medical therapy to prevent rebleeding has not been established. Early surgery after SAH should be considered in clinically stable patients. Many challenges remain regarding the prevention and treatment of both these cerebral hemorrhage subtypes.     

Magnesium therapy within 48 hours of an aneurysmal subarachnoid hemorrhage: neuro-panacea

Whereas advances in neurosurgical treatment and intensive care management improve the results from many of the devastating complications associated with aneurysmal subarachnoid hemorrhage, cerebral vasospasm remains a major cause of neurological morbidity and mortality. Experimental studies suggested that MgSO(4) inhibits excitatory amino acid release, blocks N-methyl-D-aspartate (NMDA) receptors and prevents calcium entry into the cell. Magnesium also increases red blood cell deformability. These changes may reduce the occurrence of cerebral vasospasm and minimize neuronal injury during episodes of cerebral vasospasm. Our group is currently hosting the intravenous magnesium sulfate to improve outcome after aneurysmal subarachnoid hemorrhage (IMASH) trial, which is a randomized, placebo-controlled, double-blinded, multicentered trial to evaluate the effect of magnesium sulfate infusion on the clinical outcome of patients with aneurysmal subarachnoid hemorrhage since 2002. The pilot result showed a trend towards decreased clinical vasospasm and better patient outcome. Magnesium sulfate infusion may prove to be an effective and inexpensive way to reduce the morbidity and mortality associated with aneurysmal subarachnoid hemorrhage, which is a major breakthrough in the current management.     

Prognostic significance of initial clinical and instrumental parameters in spontaneous intracerebral hemorrhages

We retrospectively analyzed the records of 63 consecutive patients with spontaneous intracerebral hemorrhage (ICH) who had been treated in our neurological intensive care unit from 1981 to 1985 (aged 17 to 84 years). In this sample, the prognostic value of initial clinical and laboratory findings was studied. The following factors were significantly correlated with mortality: concomitant cardiac failure, general atherosclerosis, and chronic obstructive pulmonary disease; coma or deranged brainstem reflexes on admission; concomitant intraventricular or subarachnoid hemorrhage, hydrocephalus and midline shift on CT scan. ICH location did not significantly correlate with outcome. Among lobar ICH occipital hematomas carried the best prognosis. No prognostic importance was detected for age and gender, initial blood pressure, time interval between ICH and admission, ECG or angiographic findings, or laboratory values.     

Critical care management of subarachnoid hemorrhage

Successful critical care management of patients with aneurysmal subarachnoid hemorrhage requires a thorough understanding of the disease and its complications and a familiarity with modern multimodality neuromonitoring technology. This article reviews the natural history of aneurysmal subarachnoid hemorrhage and strategies for disease management in the acute setting. Available tools for monitoring brain function are discussed.     

急性出血和缺血性脑卒中高血压控制的研究进展

从长期来看,高血压病患者的降压治疗可以显著降低出血性和缺血性脑卒中的发生和复发。对于蛛网膜下腔出血、脑出血或急性缺血性脑卒中的患者,在发病后的急性期,血压控制的最佳目标血压水平是不确定的。关于脑卒中后立即行血压控制的最佳血压水平的临床试验证据是有限和有争议的。脑卒中患者的血压控制主要是依据普通人群血压控制的指南,辅以基于小样本病例研究的专家建议。脑卒中是一种异质性疾病,适当的血压控制,其效果因不同类型脑卒中的发病机制不同而异。     

Spontaneous intracerebral hemorrhage

Spontaneous intracerebral hemorrhage (sICH) is defined as bleeding within the brain parenchyma, and occurs twice as commonly as subarachnoid hemorrhage, but is equally as deadly. Risk factors for sICH include hypertension, advanced age, leukoaraiosis, prior ICH, renal failure, use of anticoagulant drugs, and cerebral amyloid angiopathy. When a patient is clinically suspected of having sICH, head computed tomography scan is the standard diagnostic tool. However, newer magnetic resonance neuroimaging techniques may aid in determining the underlying pathology and aid in prognosis. Supportive care and blood pressure management are important in the care of patients with sICH. Ongoing research is aimed at determining a safe blood pressure goal that may also prevent expansion of hemorrhage. Hemostatic medications and neuroprotectants have thus far not shown clinical improvement. Although several neurosurgical trials have failed to demonstrate benefit for surgical evacuation of sICH, multiple research trials are ongoing investigating acute blood pressure control, deep or basal ganglionic hemorrhage evacuation via minimally invasive approach (MISTIE; http://mistietrial.com/default.aspx), lobar ICH evacuation (STICH; II http://research.ncl.ac.uk/stich/), and intraventricular thrombolysis with tissue plasminogen activator (tPA) (CLEAR III; http://biosgroup-johnshopkinsmedicine.health.officelive.com/default.aspx).     

Long-term cost of stroke subtypes among Medicare beneficiaries

BACKGROUND AND PURPOSE: The economic impact of hemorrhagic stroke, including subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH), has not been well characterized compared to the more prevalent ischemic stroke (IS). METHODS: Patients diagnosed with SAH, ICH or IS in 1997 were identified in a 5% national random sample of all Medicare beneficiaries. Medical care patterns and associated Medicare reimbursements were analyzed from one year prior to the index event through four years following that event. RESULTS: 11,430 patients were identified with SAH (n = 342), ICH (n = 1,957) or IS (n = 9,131). Average Medicare expenditures, from the initial event through four years, were USD 48,327 for SAH, USD 38,023 for ICH and USD 39,396 for IS. CONCLUSIONS: Long-term healthcare costs of SAH and ICH are substantial. With the expected increase in the elderly population over the coming decades, these results emphasize the need for effective preventive and acute medical care.     

Early seizures following intracerebral hemorrhage: implications for therapy

Seizures occurred in 19 of 112 patients (17%) with nontraumatic, supratentorial intracerebral hemorrhage (ICH). All seizures occurred at ICH onset; patients without seizures at hemorrhage onset remained seizure-free until the last recorded follow-up. Seizures were significantly associated with extension of blood into the cerebral cortex. We found no association between seizures and hemorrhage size or the presence of subarachnoid or intraventricular blood. These data suggest that (1) seizures, in ICH, occur at hemorrhage onset, (2) patients without seizures at hemorrhage onset are at very low risk for subsequent seizures during their hospitalization, (3) hemorrhage involving the cerebral cortex, regardless of site of origin, predisposes to seizures, and (4) the prophylactic use of anticonvulsants in the acute management of these patients appears unwarranted, especially in patients without cortical extension.     

Patterns of prophylactic anticonvulsant use in spontaneous intracerebral and subarachnoid hemorrhage: results of a practitioner survey

Neurological Sciences - The use of prophylactic anti-seizure medications (ASMs) in the management of patients with spontaneous intracerebral hemorrhage (sICH) and aneurysmal subarachnoid hemorrhage...     

Routine Management of Volume Status After Aneurysmal Subarachnoid Hemorrhage

Prophylactic use of hypervolemia and hypertension is believed to present an option to decrease the incidence of symptomatic vasospasm after aneurysmal subarachnoid hemorrhage and improve neurologic outcome. A Medline literature search was conducted to review available evidence regarding volume management after subarachnoid hemorrhage. Quality of selected studies was evaluated, using the standardized GRADE system. Eleven studies focused on prophylactic hypervolemic therapy after aneurysmal subarachnoid hemorrhage were identified, including four randomized controlled trials. Available studies showed a large heterogeneity in physiologic treatment goals and interventions applied. The oldest and smallest randomized controlled trial suggested a positive effect, but had severe limitations in trial design. Neither of the other randomized controlled studies showed outcome benefit with hypervolemic therapy. Results from observational studies were not found to support the use of prophylactic hypervolemia and hypertension. Complication frequency was repeatedly reported to be higher with the application of prophylactic hypervolemia. In summary, prophylactic hyperdynamic therapy after subarachnoid hemorrhage has not been adequately shown to effectively raise cerebral blood flow or improve neurological outcome. In contrast, there is evidence for harm using overly aggressive hydration.     

Treatment of intracerebral haemorrhage

Apart from management in a specialised stroke or neurological intensive care unit, until very recently no specific therapies improved outcome after intracerebral haemorrhage (ICH). In a recent phase II trial, recombinant activated factor VII (eptacog alfa) reduced haematoma expansion, mortality, and disability when given within 4 h of ICH onset; a phase III trial (the FAST trial) is now in progress. Ventilatory support, blood-pressure reduction, intracranial-pressure monitoring, osmotherapy, fever control, seizure prophylaxis, and nutritional supplementation are the cornerstones of supportive care in intensive care units. Ventricular drainage should be considered in all stuporous or comatose patients with intraventricular haemorrhage and acute hydrocephalus. Given the lack of benefit seen in a the recent STICH trial, emergency surgical evacuation within 72 h of onset should be reserved for patients with large (>3 cm) cerebellar haemorrhages, or those with large lobar haemorrhages, substantial mass effect, and rapidly deteriorating condition.     

Sources and reasons for delays in the care of acute stroke patients

OBJECTIVE: This study aimed to identify sources and reasons for delays in the care of our acute stroke patients. METHODS: Data on time interval from symptom onset or awareness to initial presentation, to neurology assessment, to performance of cranial CT scan, and demographic and medical factors associated with delays among stroke patients admitted at St. Luke's Medical Center from May to October 2000 were obtained by interview and record review. RESULTS: Of 259 patients (mean age 61.5+/-13.6 years, 43% females), 63% had infarction (INF), 32% intracerebral hemorrhage (ICH) and 5% subarachnoid hemorrhage (SAH). Fifty-nine percent presented within 3 h of symptom onset or awareness, 73% within 6 h (median=2 h). Patients with ICH presented earlier than those with infarction. Reasons for delayed consultation included failure to recognize symptoms as serious and stroke-related. A non-neurologist was initially consulted in 97% of cases. Median delay from presentation to neurology evaluation was 7.5 h. Median time from presentation to brain imaging was significantly shorter for patients brought to CT-equipped facilities (2 h) than for those needing transfer to other hospitals (11.5 h). CONCLUSIONS AND RECOMMENDATIONS: Patient delay in presentation is only one cause of delay in acute stroke care. Longer delays arise from healthcare-related factors such as delays in neurologist referral and neuroradiologic diagnosis. Professional and public education on the necessity of early neurologic evaluation and patient transport to CT-equipped "Stroke Centers" is recommended.     

Intracerebral Hemorrhage in Women: A Review with Special Attention to Pregnancy and the Post-Partum Period

Neurocritical Care - Non-traumatic intracranial hemorrhage includes subarachnoid hemorrhage, subdural hemorrhage, and intracerebral hemorrhage (ICH), which can be classified as primary or...