Chitra Venkatasubramanian

BACKGROUND: Optimal secondary stroke prevention remains uncertain for patients with intracerebral hemorrhage (ICH) and atrial fibrillation (AF). Anticoagulation reduces ischemic stroke in AF but increases hemorrhage. Left atrial appendage (LAA) occlusion is emerging as an alternative to anticoagulation, but few data exist on its safety in patients with ICH. Amid this uncertainty, little is known about US practice patterns in this scenario. METHODS: We performed a study using linked electronic health record, pharmacy, and insurance claims data on >11 million patients at 29 US healthcare organizations, each with multiple hospital sites, in the TriNetX Linked platform. Validated International Classification of Diseases, Tenth Revision codes were used to identify adults with AF hospitalized for ICH during 2016 to 2024. To identify antiplatelet and anticoagulant prescriptions, we used RxNorm codes, a standardized drug naming system from the National Library of Medicine. LAA occlusion was defined using validated Current Procedural Terminology codes. Kaplan-Meier statistics were used to calculate cumulative rates of therapy utilization from discharge through 5 years. We created 3 mutually exclusive treatment groups with censoring at LAA occlusion for analyses of antiplatelet and anticoagulant therapy and at anticoagulation for analyses of antiplatelet therapy. RESULTS: We identified 2276 patients with AF hospitalized with ICH. Their mean age was 65.4 (±12.8) years, 40.6% were female, median CHA ₂ DS ₂ -VASc score was 5 (interquartile range, 5–6), 19.6% had Medicare, 26.9% received an anticoagulant prescription within 90 days before ICH, and half were discharged home or to an acute rehabilitation facility. Cumulative 5-year rates were 59.8% (95% CI, 55.5%–64.2%) for anticoagulation, 39.9% (95% CI, 34.1%–46.3%) for antiplatelet therapy, and 4.5% (95% CI, 2.6%–7.6%) for LAA occlusion. LAA occlusion rates did not differ by index ICH date ( P =0.88). CONCLUSIONS: In a contemporary, multicenter US cohort of patients with ICH and AF, 60% were prescribed anticoagulation after discharge, and the remainder were mostly treated with antiplatelet therapy only. These findings suggest widespread use of different secondary stroke prevention strategies in patients with AF and ICH.

Background and Purpose: Teleneurocritical care (TeleNCC) provides virtual neurocritical care in emergency departments and intensive care units that do not have continuous in-person coverage. However, there is limited evidence upon which to apply standards, benchmarks, and best practice. The scope of TeleNCC practice is beyond that of Telestroke and Telecritical Care, both of which have existing guidelines. Here, an international authorship group was convened to prepare a consensus statement on both the minimal requirements and optimal conditions for effective adult and pediatric TeleNCC. Methods: A panel consisting of 22 multidisciplinary experts in TeleNCC reviewed the available published literature, held ten virtual meetings between April 2023 and June 2024, used a modified Delphi consensus method, and voted on recommendations for best practices of TeleNCC. In two phases, a total of 13 sections on specific components of TeleNCC were written, reviewed, revised, and finalized following authorship group consensus. Specific expert rationale and applicable supportive evidence, when available, were included and integrated into each section following the recommendation(s). Results: Authorship consensus was achieved. For any disagreement exceeding 15%, there was additional group discussion and addition of explanatory text. Recommendations encompassed the following 13 sections, grouped by structure, operations, and quality; TeleNCC sections: (1) models, (2) organization in health system, (3) structural elements, (4) staffing and engagement, (5) clinical roles and responsibilities, (6) activation and communication, (7) afterhours and anticipatory guidance, (8) regulatory and credentialing, (9) finance, (10) pharmacy, (11) quality, (12) outcomes, and (13) the research gaps, training, and education. We recommend that TeleNCC: be available 24/7, though it may be utilized on a part time basis, use a reliable two-way audio-visual telecommunication system with backup options, allow for the hub TeleNCC provider to have real-time access to patient data contained in an electronic health record, as well as the original, nonprocessed raw electroencephalogram and direct diagnostic radiological imaging data. We suggest that phone-only interactions do not meet the minimum requirements for TeleNCC. The health care system should have defined roles and responsibilities for TeleNCC at the hub and spoke sites, including: a spoke site in-person provider(s) one of which is able to perform critical care procedures, clearly defined daytime and afterhours communication protocols, and have streamlined credentialing and financial arrangements. We recommend that regular continuous measurement of quality and outcome tracking is an essential component of TeleNCC practice. We review additional optimal components in well-resourced centers including the integration of advanced digital technology. Conclusion: TeleNCC may be an effective method to deliver neurocritical care in acute care environments lacking applicable in-person expertise provided the minimum requirements for standard practice and operations are met.

BACKGROUND: Time-to-treatment goals for acute ischemic stroke (AIS) have substantially improved outcomes, yet similar metrics have not been studied in patients with intracerebral hemorrhage (ICH), where mortality rates are much higher. METHODS: Multicenter, observational retrospective study of patients with ICH and AIS between January 1, 2017, and December 31, 2022, in 11 comprehensive stroke centers across the United States participating in Get With The Guidelines. We included patients with ICH who received antihypertensive therapy and anticoagulation reversal, and patients with AIS requiring intravenous thrombolytic and mechanical thrombectomy. The coprimary outcomes included (1) time-to-treatment and (2) the percentage of patients meeting current national time interval goals. Multivariable logistic regression models controlling for age, sex, race and ethnicity, time to arrival, National Institutes of Health Stroke Scale score, arrival systolic blood pressure, and admission international normalized ratio were constructed to assess the likelihood of patients with ICH being treated within goal compared with patients with AIS. Multivariable logistic regression models were constructed to assess the impact of treatment time on mortality or discharge disposition in patients with ICH. RESULTS: A total of 28 180 patients were identified, of which 7003 patients were included: n=1972 ICH (mean age, 67; 43% female) and n=5031 AIS (mean age, 69; 49% female). The median door-to-first medication was 52 (28–157) minutes for patients with ICH and 42 (30–63) minutes for patients with AIS ( P P P P P 60 minutes. CONCLUSIONS: Time-to-treatment for patients with ICH is significantly longer than for patients with AIS. Faster antihypertensive treatment times are associated with better discharge outcomes in patients with ICH.

Objective: Transcranial direct current stimulation (tDCS) has been advocated for various neurological conditions, including epilepsy. A 1–4‐mA cathodal current applied to the scalp over a seizure focus can reduce spikes and seizures. This series of four patients with focal status epilepticus is among the first case series to demonstrate benefit of tDCS in the critical care setting.Methods: Patients in the intensive care unit were referred for tDCS treatment when focal status epilepticus or clinically relevant lateralized periodic discharges did not resolve with conventional antiseizure medications and anesthetics. Battery‐powered direct cathodal current at 2 mA was delivered by an ActivaDose (Caputron) tDCS device via a saline‐soaked sponge on the scalp over the seizure focus. Anode was on the contralateral forehead or shoulder. Treatment was for 30 min, repeated twice in a day, then again 1–4 times more over the next few days.Results: Three females and one male, aged 34–68 years, were treated. Etiologies of status epilepticus were posterior reversible encephalopathy syndrome in association with immunosuppressants for a liver transplant, perinatal hypoxic–ischemic injury, a prior cardioembolic parietal stroke, and central nervous system lupus. tDCS led to significant reduction of interictal spikes (.78 to .38/s, p < .0001) in three cases and electrographic seizures (3.83/h to 0/h, p < .001) in two cases. Medication reductions were enabled in all cases subsequent to tDCS. The only side effect of tDCS was transient erythema under the sponge in one case. Two patients died of causes unrelated to tDCS, one was discharged to a nursing home, and one became fully responsive as seizures were controlled with tDCS.Significance: Spikes and electrographic seizure frequency significantly improved within 1 day of tDCS. Results are potentially confounded by multiple ongoing changes in medications and treatments. These results might encourage further investigation of tDCS in the critical care setting, but verification by controlled studies will be required.

Background Predictions of functional outcome in neurocritical care (NCC) patients impact care decisions. This study compared the predictive values (PVs) of good and poor functional outcome among health care providers with and without NCC training. Methods Consecutive patients who were intubated for ≥ 72 h with primary neurological illness or neurological complications were prospectively enrolled and followed for 6-month functional outcome. Medical intensive care unit (MICU) attendings, NCC attendings, residents (RES), and nurses (RN) predicted 6-month functional outcome on the modified Rankin scale (mRS). The primary objective was to compare these four groups’ PVs of a good (mRS score 0–3) and a poor (mRS score 4–6) outcome prediction. Results Two hundred eighty-nine patients were enrolled. One hundred seventy-six had mRS scores predicted by a provider from each group and were included in the primary outcome analysis. At 6 months, 54 (31%) patients had good outcome and 122 (69%) had poor outcome. Compared with other providers, NCC attendings expected better outcomes (p < 0.001). Consequently, the PV of a poor outcome prediction by NCC attendings was higher (96% [95% confidence interval [CI] 89–99%]) than that by MICU attendings (88% [95% CI 80–93%]), RES (82% [95% CI 74–88%]), and RN (85% [95% CI 77–91%]) (p = 0.047, 0.002, and 0.012, respectively). When patients who had withdrawal of life-sustaining therapy (n = 67) were excluded, NCC attendings remained better at predicting poor outcome (NCC 90% [95% CI 75–97%] vs. MICU 73% [95% CI 59–84%], p = 0.064). The PV of a good outcome prediction was similar among groups (MICU 65% [95% CI 52–76%], NCC 63% [95% CI 51–73%], RES 71% [95% CI 55–84%], and RN 64% [95% CI 50–76%]). Conclusions Neurointensivists expected better outcomes than other providers and were better at predicting poor functional outcomes. The PV of a good outcome prediction was modest among all providers.

Automated software used to detect anterior circulation large vessel occlusion had high performance across subgroups and imaging systems. Background Identification of large vessel occlusion (LVO) is critical to the management of acute ischemic stroke and prerequisite to endovascular therapy in recent trials. Increasing volumes and da...

BACKGROUND AND PURPOSE: Intracranial hemorrhage (ICH) is an important event that is diagnosed on head NCCT. Increased NCCT utilization in busy hospitals may limit timely identification of ICH. RAPID ICH is an automated hybrid 2D–3D convolutional neural network application designed to detect ICH that may allow for expedited ICH diagnosis. We determined the accuracy of RAPID ICH for ICH detection and ICH volumetric quantification on NCCT. MATERIALS AND METHODS: NCCT scans were evaluated for ICH by RAPID ICH. Consensus detection of ICH by 3 neuroradiology experts was used as the criterion standard for RAPID ICH comparison. ICH volume was also automatically determined by RAPID ICH in patients with intraparenchymal or intraventricular hemorrhage and compared with manually segmented ICH volumes by a single neuroradiology expert. ICH detection accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratios by RAPID ICH were determined. RESULTS: We included 308 studies. RAPID ICH correctly identified 151/158 ICH cases and 143/150 ICH-negative cases, which resulted in high sensitivity (0.956, CI: 0.911–0.978), specificity (0.953, CI: 0.907–0.977), positive predictive value (0.956, CI: 0.911-0.978), and negative predictive value (0.953, CI: 0.907–0.977) for ICH detection. The positive likelihood ratio (20.479, CI 9.928–42.245) and negative likelihood ratio (0.046, CI 0.023–0.096) for ICH detection were similarly favorable. RAPID ICH volumetric quantification for intraparenchymal and intraventricular hemorrhages strongly correlated with expert manual segmentation (correlation coefficient r = 0.983); the median absolute error was 3 mL. CONCLUSIONS: RAPID ICH is highly accurate in the detection of ICH and in the volumetric quantification of intraparenchymal and intraventricular hemorrhages.