Subarachnoid hemorrhage (SAH) is an acute cerebrovascular event which can have devastating effects on the central nervous system as well as a profound impact on several other organs. SAH patients are ...routinely admitted to an intensive care unit and are cared for by a multidisciplinary team. A lack of high quality data has led to numerous approaches to management and limited guidance on choosing among them. Existing guidelines emphasize risk factors, prevention, natural history, and prevention of rebleeding, but provide limited discussion of the complex critical care issues involved in the care of SAH patients. The Neurocritical Care Society organized an international, multidisciplinary consensus conference on the critical care management of SAH to address this need. Experts from neurocritical care, neurosurgery, neurology, interventional neuroradiology, and neuroanesthesiology from Europe and North America were recruited based on their publications and expertise. A jury of four experienced neurointensivists was selected for their experience in clinical investigations and development of practice guidelines. Recommendations were developed based on literature review using the GRADE system, discussion integrating the literature with the collective experience of the participants and critical review by an impartial jury. Recommendations were developed using the GRADE system. Emphasis was placed on the principle that recommendations should be based not only on the quality of the data but also tradeoffs and translation into practice. Strong consideration was given to providing guidance and recommendations for all issues faced in the daily management of SAH patients, even in the absence of high quality data.
Previous studies of intracerebral hemorrhage (ICH) outcome prediction models have not systematically included adjustment for comorbid conditions. The purpose of this study was to assess whether the ...Charlson Comorbidity Index (CCI) was associated with early mortality and long-term functional outcome in patients with intracerebral hemorrhage.
We performed a retrospective analysis on a prospective observational cohort of patients with ICH admitted to 2 University of California San Francisco hospitals from June 1, 2001 to May 31, 2004. Components of the ICH score and use of early care limitations were recorded. Outcome was assessed using the modified Rankin Scale to 12 months. The CCI was derived using hospital discharge International Classification of Diseases, revision 9 codes and patient history obtained from standardized case report forms.
In this cohort of 243 ICH patients, comorbid conditions were common, with CCI scores ranging from 0 to 12. Only 29% of patients with high CCI scores (≥3) achieved a 12-month modified Rankin Scale score of ≥3 compared with 48% of patients with CCI scores of 0 (P=0.02). CCI score was independently predictive of 12-month functional outcome, with higher CCI having a greater impact (CCI=2: odds ratio, 2.3; P=0.06; CCI=≥3: odds ratio, 3.5; P=0.001).
Comorbid medical conditions as measured by the CCI independently influence outcome after ICH. Future ICH outcome studies should account for the impact of comorbidities on patient outcome.
Intracerebral hemorrhage (ICH) is a subset of stroke due to spontaneous bleeding within the parenchyma of the brain. It is potentially lethal, and survival depends on ensuring an adequate airway, ...proper diagnosis, and early management of several specific issues such as blood pressure, coagulopathy reversal, and surgical hematoma evacuation for appropriate patients. ICH was chosen as an Emergency Neurological Life Support (ENLS) protocol because intervention within the first hours may improve outcome, and it is critical to have site-specific protocols to drive care quickly and efficiently.
The ICH Score is a commonly used clinical grading scale for outcome after acute intracerebral hemorrhage (ICH) and has been validated for 30-day mortality, but not long-term functional outcome. The ...goals of this study were to assess whether the ICH Score accurately stratifies patients with regard to 12-month functional outcome and to further delineate the pace of recovery of patients during the first year post-ICH.
We performed a prospective observational cohort study of all patients with acute ICH admitted to the emergency departments of San Francisco General Hospital and UCSF Medical Center from June 1, 2001, through May 31, 2004. Components of the ICH Score (admission Glasgow Coma Scale score, initial hematoma volume, presence of intraventricular hemorrhage, infratentorial ICH origin, and age) were recorded along with other clinical characteristics. Patients were then assessed with the modified Rankin Scale (mRS) at hospital discharge, 30 days, and 3, 6, and 12 months post-ICH.
Of 243 patients, 95 (39%) died during initial acute hospitalization. The ICH Score accurately stratified patients with regard to 12-month functional outcome for various dichotomous cutpoints along the mRS (p < 0.05). Many patients continued to improve across the first year, with a small number of patients becoming disabled or dying due to late events unrelated to the initial ICH.
The ICH Score is a valid clinical grading scale for long-term functional outcome after acute intracerebral hemorrhage (ICH). Many ICH patients improve after hospital discharge and this improvement may continue even after 6 months post-ICH.
PURPOSE—The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of spontaneous intracerebral hemorrhage.
METHODS—A formal literature search ...of PubMed was performed through the end of August 2013. The writing committee met by teleconference to discuss narrative text and recommendations. Recommendations follow the American Heart Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Oversight Committee and Stroke Council Leadership Committee.
RESULTS—Evidence-based guidelines are presented for the care of patients with acute intracerebral hemorrhage. Topics focused on diagnosis, management of coagulopathy and blood pressure, prevention and control of secondary brain injury and intracranial pressure, the role of surgery, outcome prediction, rehabilitation, secondary prevention, and future considerations. Results of new phase 3 trials were incorporated.
CONCLUSIONS—Intracerebral hemorrhage remains a serious condition for which early aggressive care is warranted. These guidelines provide a framework for goal-directed treatment of the patient with intracerebral hemorrhage.
...inevitably, I treat reactively, waiting until the neurological examination has worsened to proceed with surgery, allowing the intracranial pressure to become elevated prior to treating brain ...edema, or picking a group-based threshold for a physiological parameter, such as blood pressure or partial pressure of arterial carbon dioxide, and hoping that it is right for my specific patient. Clinical trials that test “one size fits all” approaches may trade a benefit (or harm) in individual patients for the goal of testing generalizability in a large heterogenous population of patients with a common overall condition, such as severe traumatic brain injury or spontaneous intracerebral hemorrhage. What I do not do is step away from the bedside and just provide a set of patient care orders for others (usually nurses and respiratory therapists) to follow similarly to a cookbook recipe. The idea of a dose–response relationship between depth and severity of a physiological event, such as elevated intracranial pressure or low blood pressure, is reasonably well accepted but not reported in most current purportedly advanced standard electronic medical records.
Background
Performance measures are tools to measure the quality of clinical care. To date, there is no organized set of performance measures for neurocritical care.
Methods
The Neurocritical Care ...Society convened a multidisciplinary writing committee to develop performance measures relevant to neurocritical care delivery in the inpatient setting. A formal methodology was used that included systematic review of the medical literature for 13 major neurocritical care conditions, extraction of high-level recommendations from clinical practice guidelines, and development of a measurement specification form.
Results
A total of 50,257 citations were reviewed of which 150 contained strong recommendations deemed suitable for consideration as neurocritical care performance measures. Twenty-one measures were developed across nine different conditions and two neurocritical care processes of care.
Conclusions
This is the first organized Neurocritical Care Performance Measure Set. Next steps should focus on field testing to refine measure criteria and assess implementation.
The article discusses the findings of a study to evaluate the relationship, if any, between surgical hematoma evacuation with clinical outcomes in cerebellar intracerebral hemorrhage (ICH), which ...revealed that among these patients, surgical hematoma evacuation was not associated with improved functional outcome. The need for further research to embrace precision medicine is highlighted.
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