Acute Neurological Emergencies Research Articles

Quantitative EEG in the neonatal intensive care unit: Current application and future promise

AbstractImportanceQuantitative electroencephalography (qEEG) has been used in the neonatal intensive care unit (NICU) for several decades. Recent innovations have led to renewed interest in expanding its role in the NICU with the goal of improving both acute care of neonates in the NICU and longer‐term outcomes.ObservationsEEG in the NICU is primarily used to identify neonatal seizures. Sophisticated analysis of EEG can detect other acute neurological emergencies and provide additional information about short‐ and long‐term neurodevelopmental and epileptic prognosis. Using EEG for these additional findings may be limited by access to EEG resources and a constrained supply of neonatal neurophysiologists who can consistently evaluate unique neonatal EEG patterns.RelevanceQuantitative EEG analysis is a rapidly developing technology with the potential to augment and support the interpretation of neonatal EEGs. This review focuses on the status of qEEG use in the NICU for identification and prediction of seizures and use in neuroprognostication. It also examines areas of promise for bedside qEEG applications.

T817MA Regulates Mitochondrial Dynamics via Sirt1 and Arc Following Subarachnoid Hemorrhage.

Spontaneous subarachnoid hemorrhage (SAH) is an acute neurologic emergency with poor outcomes, and mitochondrial dysfunction is known as one of the key pathological mechanisms underlying the SAH-induced early brain injury (EBI). 1-{3-[2-(1-benzothiophen-5-yl)ethoxy]propyl} azetidin-3-ol maleate (T817MA) is a newly synthesized neurotrophic compound that has been demonstrated to exert protective effects against brain injury. Here, we investigated the effect of T817MA in neuronal injury following experimental SAH both in vitro and in vivo. Primary cultured cortical neurons were treated with oxyhemoglobin (OxyHb) to mimic SAH in vitro, and T817MA at concentrations higher than 0.1μM reduced OxyHb-induced neuronal injury. T817MA treatment significantly inhibited lipid peroxidation, reduced neuronal apoptosis and attenuated mitochondrial fragmentation. The results of western blot showed that T817MA markedly reduced the expression of mitochondrial fission proteins, fission protein 1 (Fis-1) and dynamin-related GTPase-1 (Drp-1), but prolonged the expression of the postsynaptic protein activity-regulated cytoskeleton-associated protein (Arc). In addition, T817MA significantly increased the expression of sirtuin 1 (Sirt1), which was accompanied by preserved enzymatic of isocitrate dehydrogenase (IDH2) and superoxide dismutase (SOD). Knockdown of Sirt1 and Arc via small interfere RNA (siRNA) transfection partially prevented the T817MA-induced protection in cortical neurons. Furthermore, treatment with T817MA in vivo significantly reduced brain damage and preserved neurological function in rats. The decreased expression of Fis-1 and Drp-1, as well as the increased expression of Arc and Sirt1 were also observed in vivo. Taken together, these data indicate that the neuroprotective agent T817MA protects against SAH-induced brain injury via Sirt1- and Arc-mediated regulation of mitochondrial dynamics.

Epidemiology and disease burden of patients requiring neurocritical care: a Brazilian multicentre cohort study

Acute neurological emergencies are highly prevalent in intensive care units (ICUs) and impose a substantial burden on patients. This study aims to describe the epidemiology of patients requiring neurocritical care in Brazil, and their differences based on primary acute neurological diagnoses and to identify predictors of mortality and unfavourable outcomes, along with the disease burden of each condition at intensive care unit admission. This prospective cohort study included patients requiring neurocritical care admitted to 36 ICUs in four Brazilian regions who were followed for 30 days or until ICU discharge (Aug-Sep in 2018, 1 month). Of 4245 patients admitted to the participating ICUs, 1194 (28.1%) were patients with acute neurological disorders requiring neurocritical care and were included. Patients requiring neurocritical care had a mean mortality rate 1.7 times higher than ICU patients not requiring neurocritical care (17.21% versus 10.1%, respectively). Older age, emergency admission, higher number of potential secondary injuries, and worse APACHE II, SAPS III, SOFA, and Glasgow coma scale scores on ICU admission are independent predictors of mortality and poor outcome among patients with acute neurological diagnoses. The estimated total DALYs were 4482.94 in the overall cohort, and the diagnosis with the highest DALYs was traumatic brain injury (1634.42). Clinical, epidemiological, treatment, and ICU outcome characteristics vary according to the primary neurologic diagnosis. Advanced age, a lower GCS score and a higher number of potential secondary injuries are independent predictors of mortality and unfavourable outcomes in patients requiring neurocritical care. The findings of this study are essential to guide education policies, prevention, and treatment of severe acute neurocritical diseases.

The Completion of a PGY-1 Neurology Bootcamp Leads to Increased Trainee Knowledge and Confidence in Neurologic Emergencies Management and Procedural Skills (P2-2.001)

<h3>Objective:</h3> To evaluate the impact of an end-of-the-year, post-graduate year 1 (PGY-1) simulation-based neurology bootcamp on trainee knowledge, self-confidence, and skill independence regarding acute neurologic emergencies management and bedside procedural skills. <h3>Background:</h3> The post-graduate year 2 (PGY-2) neurology resident is often the first line of triage for evaluation of acute neurologic deterioration on the inpatient neurology service, requiring autonomy and responsibility. We implemented and evaluated a bootcamp prior to this critical training period. <h3>Design/Methods:</h3> In this prospective cohort study, 14 rising PGY-2 neurology residents attended a two-day bootcamp with a simulation-based curriculum led by neurology faculty practicing cerebrovascular, critical care, and inpatient neurology medicine. Pre- and postbootcamp, trainees completed multiple-choice knowledge assessments and via Likert scales, self-reported confidence in managing neurologic emergencies. Faculty observed and rated trainee ability to independently perform five neurologic procedures (lumbar puncture, external ventricular drain [EVD] management, botulinum toxin injection for migraine, digital fundoscopy, and pupillometry), with residents additionally reporting their own perceived degree of independence. <h3>Results:</h3> Proportion of trainees demonstrating independence per faculty rating significantly increased for all five procedural skills post-bootcamp (for all, p &lt; .05). Trainee self-reported independence of EVD management, pupillometry, and fundoscopy skills also increased postbootcamp (for all, p &lt; .05), with &lt; 25% of trainees reporting total independence pre-bootcamp to 50%, 86%, and 79% post-bootcamp, respectively. Knowledge assessment scores increased from a pre-bootcamp mean of 54% of questions correct to mean 70% correct (p = 0.002), driven by increases in vascular neurologic emergency and procedural knowledge. On a 5-point Likert scale, trainee self-reported confidence in emergency management increased from median 2.5 (a little confident) to median 4 (fairly confident) (p &lt; .001) <h3>Conclusions:</h3> A simulation-based, two-day bootcamp with focus on acute cerebrovascular neurologic emergencies and neurologic procedural skills showed significant improvements in trainee knowledge along with faculty-observed and self-reported confidence and independence. <b>Disclosure:</b> An immediate family member of Dr. Swetlik has received personal compensation for serving as an employee of Pfizer. Dr. Buletko has nothing to disclose. Dr. Marquardt has nothing to disclose. Dr. Higgins has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Organon. Ms. Hassett has nothing to disclose.

Acute Neurological Emergencies: Using Neurology-Trained Standardized Patients To Promote Active Learning in a Case-Based Simulation Curriculum for Neurology Clerkship Students (P9-2.004)

<h3>Objective:</h3> To describe the impact of using live, neurology-trained standardized patients (SPs) in a case-based simulation curriculum for clerkship students. <h3>Background:</h3> Simulation in neurology is limited by the inadequacy of manikins to portray neurologic exam findings. We designed a simulation curriculum using live, neurology-trained resident SPs residents for clerkship students to (1) practice taking a neurologic history, (2) perform a neurologic exam, and (3) recognize and triage neurological emergencies. <h3>Design/Methods:</h3> Two scenarios were developed: (1) evaluation of dizziness and management of acute stroke and (2) treatment of new-onset seizure. Monthly sessions involved 4–5 students. Residents SPs mimicked expected exam findings. Pre- and post-session surveys evaluated students’ self-rated knowledge, clinical skills, and confidence in gathering a history, performing a neurological exam, presenting a case, and recognizing, working up, and managing strokes and seizures. Students also rated the overall session quality and provided feedback about the experience. Paired t-tests were performed for quantitative items. <h3>Results:</h3> 54 students participated. Post-session, students reported significantly higher self-confidence in all neurological knowledge domains and clinical skills (p&lt;0.003 for all). Over 90% of students agreed sessions met the learning objectives, the course was valuable, and the simulation was a safe learning environment and would improve their clinical performance. 94% would recommend the session to others. Over 80% agreed the simulation was realistic, well-organized, and an effective way to practice teamwork and clinical skills. In open responses, students reported they appreciated evaluating neurologic emergencies, performing the exam with a trained SP, and making treatment decisions. Students wanted more cases and time; they suggested smaller groups. <h3>Conclusions:</h3> A simulation curriculum with neurology residents portraying the patient increased students’ knowledge, clinical skills, and self-confidence in recognizing and managing acute neurological emergencies. Resident SPs were cited as the most effective educational component. Future research should evaluate the sustainability of benefits gained and assess clinical skills objectively. <b>Disclosure:</b> Dr. Gheihman has nothing to disclose. Dr. Harrold has nothing to disclose. The institution of Dr. Howard has received research support from Genentech. The institution of Dr. Howard has received research support from Novartis. Dr. Howard has received personal compensation in the range of $50,000-$99,999 for serving as a Clinical Fellow with National Multiple Sclerosis Society. Dr. Albin has received personal compensation in the range of $5,000-$9,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Continuum: Life Long Learning in Neurology. Dr. Albin has received research support from American Academy of Neurology. Dr. Albin has received publishing royalties from a publication relating to health care. Dr. Albin has received personal compensation in the range of $500-$4,999 for serving as a Instructor with Resuscitation Leadership Academy. Dr. Kaplan has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Novartis . Dr. Kaplan has received personal compensation in the range of $500-$4,999 for serving as a Consultant for EMD Serono .

Clinical Performance Measures for Emergency Department Care for Adults With Intracranial Hemorrhage

Though select inpatient-based performance measures exist for the care of patients with nontraumatic intracranial hemorrhage, emergency departments lack measurement instruments designed to support and improve care processes in the hyperacute phase. To address this, we propose a set of measures applying a syndromic (rather than diagnosis-based) approach informed by performance data from a national sample of community EDs participating in the Emergency Quality Network Stroke Initiative. To develop the measure set, we convened a workgroup of experts in acute neurologic emergencies. The group considered the appropriate use case for each proposed measure: internal quality improvement, benchmarking, or accountability, and examined data from Emergency Quality Network Stroke Initiative-participating EDs to consider the validity and feasibility of proposed measures for quality measurement and improvement applications. The initially conceived set included 14 measure concepts, of which 7 were selected for inclusion in the measure set after a review of data and further deliberation. Proposed measures include 2 for quality improvement, benchmarking, and accountability (Last 2 Recorded Systolic Blood Pressure Measurements Under 150 and Platelet Avoidance), 3 for quality improvement and benchmarking (Proportion of Patients on Oral Anticoagulants Receiving Hemostatic Medications, Median ED Length of Stay for admitted patients, and Median Length of Stay for transferred patients), and 2 for quality improvement only (Severity Assessment in the ED and Computed Tomography Angiography Performance). The proposed measure set warrants further development and validation to support broader implementation and advance national health care quality goals. Ultimately, applying these measures may help identify opportunities for improvement and focus quality improvement resources on evidence-based targets.

Abstract WP49: Clinical Performance Measures For Emergency Department Care For Adults With Nontraumatic Intracranial Hemorrhage

Study Objective: Though select inpatient-based performance measures exist for the care of patients with nontraumatic intracranial hemorrhage (ICH), Emergency Departments (EDs) lack measurement instruments designed to support and improve care processes in the hyperacute phase. To address this, we propose a set of measures applying a syndromic (rather than diagnosis-based) approach informed by performance data from a national sample of community EDs participating in the Emergency Quality Network Stroke Initiative (E-QUAL). Methods: We convened a workgroup of experts in acute neurologic emergencies. The group considered the appropriate use case for each proposed measure (internal quality improvement [QI], benchmarking, or accountability) and examined data from E-QUAL-participating EDs to consider the validity and feasibility of proposed measures. The initially conceived set included 14 measure concepts of which 7 were selected for inclusion in the measure set after review of data and further deliberation. To inform the process, we collected data from E-QUAL participating EDs. EDs used a web-based portal to submit data from chart reviews on patients with ICH during 2020-2021. Descriptive statistics characterize performance and identify variation. Results: Proposed measures include 2 for QI, benchmarking, and accountability, 3 for QI and benchmarking and 2 for QI only (Table). Of the E-QUAL participating EDs, 35 had sufficient case volume (≥25) and were included for review of preliminary performance data. Median annual ED volume was 44,000 (IQR 31,337-67,000) and 16 (48%) reported typically transferring patients with ICH. The Table includes available performance data. Conclusion: Application of these measures may identify opportunities for improvement and focus QI resources on evidence-based targets. The proposed measures warrant further development and validation to support broader implementation and advance national healthcare quality goals.

Acute perioperative neurological emergencies.

Lam, Michelle S.H. MBBS, FHKCAa; Luoma, Astri M.V. MBChB, FRCA, FFICMa,b; Reddy, Ugan BSc, MBChB, FRCA, FFICMa,b Author Information

519: ENHANCING NEUROCRITICAL CARE EDUCATION THROUGH MULTIDISCIPLINARY SIMULATION TRAINING

Introduction: Early recognition and response are paramount in treatment of neurologic emergencies. Due to its complexity, neurocritical care continues to provoke unease for practitioners and trainees. A simulation environment can provider a realistic opportunity for learners to detect and make rapid-fire decisions for an acutely deteriorating neurologic patient. A multidisciplinary simulation-based learning environment may improve education and trainee confidence when caring for the neurocritical care patient population. Methods: Three 45-minute simulation lab sessions were performed with a multidisciplinary team including medical students, neurology residents, critical care medicine fellows, advanced practice providers, and a critical care pharmacist. High fidelity manikins capable of reproducing acute neurologic and physiologic emergencies were used. Prior to the simulation, participants received Emergency Neurological Life Support resources. The simulation session lasted 45 minutes with an additional 10-minute debriefing with a neurointensivist and neurocritical care APP. After the simulation, participants were asked to complete a survey utilizing Likert scale responses, containing questions regarding pre- and post-simulation comfort levels managing specific acute neurologic emergencies. Results: Three simulation lab sessions were conducted and thirteen surveys were completed. Mean learner comfort levels in managing patients improved from pre- to post-simulation in patients with coma [3.25 vs 4.25 (p=0.007)], status epilepticus [3.25 vs 4.25 (p=0.007)], and procedures such as central lines [2.2 vs 3.8, p=0.003], intubations [2 vs 3.2, p=0.004], and bronchoscopies [2 vs 3.2, p=0.004]. Consistently, learners strongly agreed that faculty were knowledgeable, and sessions were well informed and thorough. Learners commented that the simulation experiences were realistic and allowed them to identify areas for improvement. Conclusions: Simulation training can be an effective method to improve education of neurocritical care team members by increasing clinician comfort in managing neurologic emergencies and procedures as well as providing opportunities for multidisciplinary collaboration. Further evaluation of the effectiveness of simulation education in this patient care setting is warranted.

Curriculum Innovations: High-Fidelity Simulation of Acute Neurology Enhances Rising Resident Confidence

Introduction &amp; Problem Statement The matriculation from internal medicine to neurology residency can be challenging. The most cogent approach to address this transition has yet to be identified. Studies show that simulation is highly effective at reinforcing knowledge and skills while improving learner confidence. We present the design and outcomes of an annual acute neurology simulation program. Objectives We hypothesized that incoming neurology residents would (1) report improved confidence with managing acute neurologic emergencies, (2) cite a high degree of educational value with the program, and (3) demonstrate improvement in their technical knowledge. Methods &amp; Curriculum Description Our military, level 1 trauma institution's simulation laboratory and staff were used to develop and execute simulations for rising neurology residents based on the Accreditation Council for Graduate Medical Education neurology milestones. Three simulations were designed including a case of acute ischemic stroke (AIS), status epilepticus (SE) in an austere environment, and brain death evaluation with family counseling. Residents completed matched pre‐ and post assessments to gauge confidence, technical knowledge, and perceived educational value. Results &amp; Assessment Data Over 3 years, 15 rising neurology residents from 2 training programs completed 3 high-fidelity acute neurology cases. Self-reported confidence with acute neurology skills improved after each simulation. Confidence ratings included assessing for and identifying contraindications to tissue plasminogen activator, identifying AIS, identifying clot retrieval candidates, identifying clinical and electrographic SE, diagnosing and treating SE, identifying contraindications to and confounders of brain death diagnosis, performing the examination, and delivering bad news to families (all p &lt; 0.05). Technical knowledge also statistically improved in the stroke (p = 0.046) and brain death simulation (p = 0.039), but not the SE simulation (p = 0.296). Participants reported an average perceived personal value of 4.8, 4.3, and 4.7 (out of a maximum of 5) for AIS, SE, and brain death simulations, respectively. Discussion &amp; Lessons Learned High-fidelity simulation of neurologic emergencies enhances confidence and knowledge of rising neurology residents. Satisfaction with the simulation cases was high. Academic hospitals can consider incorporating acute neurology simulations into their residency training.

Impact of COVID-19 on neurocritical care delivery and outcomes in patients with severe acute brain injury – Assessing the initial response in the first US epicenter

To investigate the pandemic’s impact on critically ill patients with neurological emergencies, we compared care metrics and outcomes of patients with severe acute brain injury (SABI) before and during the initial COVID-19 surge at our institution. We included adult patients with SABI during two separate three-month time periods: 'pre-COVID vs COVID'. We further stratified the COVID cohort to characterize outcomes in patients requiring COVID-19 precautions (Patient Under Investigation, ‘PUI’). The primary endpoint was in-hospital mortality; secondary endpoints included length of stay (LOS), diagnostic studies performed, time to emergent decompressive craniectomies (DCHC), ventilator management, and end-of-life care. We included 394 patients and found the overall number of admissions for SABI declined by 29 % during COVID (pre-COVID n = 231 vs COVID, n = 163). Our primary outcome of mortality and most secondary outcomes were similar between study periods. There were more frequent extubation attempts (72.1 % vs 76 %) and the mean time to extubation was shorter during COVID (55.5 h vs 38.2 h). The ICU LOS (6.10 days vs 4.69 days) and hospital LOS (15.32 days vs 11.74 days) was shorter during COVID. More PUIs died than non-PUIs (51.7 % vs 11.2 %), but when adjusted for markers of illness severity, this was not significant. We demonstrate the ability to maintain a consistent care delivery for patients with SABI during the pandemic at our institution. PUIs represent a population with higher illness severity at risk for delays in care. Multicenter, longitudinal studies are needed to explore the impact of the pandemic on patients with acute neurological emergencies.

Reversal of Advanced Directives in Neurologic Emergencies.

Patients with advanced directives or Medical Orders for Life-Sustaining Treatment (MOLST), including "Do Not Resuscitate" (DNR) and/or "Do Not Intubate" (DNI), may be candidates for procedural interventions when presenting with acute neurologic emergencies. Such interventions may limit morbidity and mortality, but typically they require MOLST reversal. We investigated outcomes of patients with MOLST reversal for treatment of neurologic emergencies. We conducted a retrospective chart review from July 1, 2019 to April 30, 2021 of patients with MOLST reversal treated in our NeuroMedicine Intensive Care Unit. Variables collected include neurologic disease, MOLST reversal decision maker, procedural interventions, and outcomes. Twenty-seven patients (18 female, median age 78 years (IQR 73-85 years), median baseline modified Rankin score 1 [IQR 0-2.5] were identified with MOLST reversal. The most common pre-procedural MOLST was DNR/DNI (n=22, 81%), and 93% (n=25) pre-procedural MOLSTs were completed by the patient. MOLSTs were reversed by surrogates in n=23 cases (85%). The median time from MOLST completion to MOLST reversal was 603 days (IQR 45 days to 4 years). The most common neurologic emergency was ischemic stroke (n=14, 52%). Most patients died (n=14, 52%), 26% (n=7) were discharged to skilled nursing, and 22% (n=6) returned to home or assisted living. In neurologic emergencies, urgent shared decision making is needed to ensure goal-concordant care, which may result in reversal of existing advanced directives. Outcomes of patients with MOLST reversal were heterogeneous, emphasizing the importance of deliberate patient-centered care weighing the risks and benefits of each intervention.

116  Management of acute neurological conditions: an e-learning course to support clinical pathways

Introduction andAimAcute neurological problems are prevalent, accounting for 10–20% of medical admissions, but management is often challenging and require input from different teams (A&amp;E, acute medicine, neurology). There is no standardised training for staff in the management of acute neurological conditions and existing clinical pathways for these conditions are often underutilised with variable impact on patient outcome. The use of e-learning has gained popularity in the last decade, showing that it can be as effective as conventional didacticism [Warnecke et al, 2011]. Here, we detail the development of an e-learning course on management of acute neurological conditions to support use of integrated clinical pathways and to facilitate self-directed learning.Method andResultsUsing principles of People, Analysis, Content and Technology (PACT), we defined target learners, their learning needs, challenges in assimilating knowledge and the resources required. Topics were derived from three themes: acute neurological emergencies, commonly seen conditions, and ‘lessons from serious incidents’. Each module lasts 10 minutes and is embedded with a pre- and post-course knowledge quiz. In collaboration with the Neurosciences Institute Programme at King’s Health Partners, an academic Health Science Centre, the course will be hosted and supported by the KHP e-learning platform.SummaryThis e-learning course supports the use of clinical pathways and facilitates clinicians in consoli- dating knowledge. It is flexible, highly transferable, and can be integrated into work-based learning for continuous professional development.kitwu@doctors.org.uk

Head CT for the intensivist: 10 tips and pearls.

Head imaging is an essential diagnostic tool for the management of patients with most acute neurological emergencies involving the brain. While numerous modalities including magnetic resonance imaging and catheter angiography play a role, computed tomography (CT) of the brain is far and away the most widely utilized technique because of its widespread availability and the fact that it is usually easier to implement in critically ill and potentially unstable patients. CT is particularly useful in identifying acute intracranial hemorrhage and this makes it often indispensable in the management of patients with traumatic brain injury and hemorrhagic stroke. However, shortcomings in identifying early ischemia on non-contrast CT mean that care must be taken in considering findings early after symptom onset, with newer CT sequences such as CT angiography and CT perfusion adding value. The critical role played by intensivists in managing neurocritical care patients necessitates familiarity and ability with viewing and understanding the advantages and shortcomings of head CT imaging and under which circumstances other modalities may be appropriate to obtain. This manuscript provides ten different circumstances commonly encountered in neurocritical care and how intensivists can use CT for the benefit of their patients.

Prognostication in Acute Neurological Emergencies

BackgroundFor patients with acute, serious neurological conditions presenting to the emergency department (ED), prognostication is typically based on clinical experience, scoring systems and patient co-morbidities. Because estimating a poor prognosis influences caregiver decisions to withdraw life-sustaining therapy, we investigated the consistency of prognostication across a spectrum of neurology physicians. MethodsFive acute neurological presentations (2 with large hemispheric infarction; 1 with brainstem infarction, 1 with lobar hemorrhage, and 1 with hypoxic-ischemic encephalopathy) were selected for a department-wide prognostication simulation exercise. All had presented to our tertiary care hospital's ED, where a poor outcome was predicted by the ED neurology team within 24 hours of onset. Relevant clinical, laboratory and imaging data available before ED prognostication were presented on a web-based platform to 120 providers blinded to the actual outcome. The provider was requested to rank-order, from most to least likely, the predicted 90-day modified Rankin Scale (mRS) score. To determine the accuracy of individual outcome predictions we compared the patient's the actual 90-day mRS score to highest ranked predicted mRS score. Additionally, the group's “weighted” outcomes, accounting for the entire spectrum of mRS scores ranked by all respondents, were compared to the actual outcome for each case. Consistency was compared between pre-specified provider roles: neurology trainees versus faculty; non-vascular versus vascular faculty. ResultsResponses ranged from 106-110 per case. Individual predictions were highly variable, with predictions matching the actual mRS scores in as low as 2% of respondents in one case and 95% in another case. However, as a group, the weighted outcome matched the actual mRS score in 3 of 5 cases (60%). There was no significant difference between subgroups based on expertise (stroke/neurocritical care versus other) or experience (faculty versus trainee) in 4 of 5 cases. ConclusionAcute neuro-prognostication is highly variable and often inaccurate among neurology providers. Significant differences are not attributable to experience or subspecialty expertise. The mean outcome prediction from group of providers (“the wisdom of the crowd”) may be superior to that of individual providers.

Comparison of Intravenous Antihypertensives on Blood Pressure Control in Acute Neurovascular Emergencies: A Systematic Review.

Acute blood pressure (BP) management in neurologic patients is paramount. Different neurologic emergencies dictate various BP goals. There remains a lack of literature determining the optimal BP regimen regarding safety and efficacy. The objective of this study was to identify which intravenous antihypertensive is the most effective and safest for acute BP management in neurologic emergencies. Ovid EBM (Evidence Based Medicine)Reviews, Ovid Embase, Ovid Medline, Scopus, and Web of Science Core Collection were searched from inception to August 2020. Randomized controlled trials or comparative observational studies that evaluated clevidipine, nicardipine, labetalol, esmolol, or nitroprusside for acute neurologic emergencies were included. Outcomes of interest included mortality, functional outcome, BP variability, time to goal BP, time within goal BP, incidence of hypotension, and need for rescue antihypertensives. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to evaluate the degree of certainty in the evidence available. A total of 3878 titles and abstracts were screened, and 183 articles were selected for full-text review. Ten studies met the inclusion criteria; however, the significant heterogeneity and very low quality of studies precluded a meta-analysis. All studies included nicardipine. Five studies compared nicardipine with labetalol, three studies compared nicardipine with clevidipine, and two studies compared nicardipine with nitroprusside. Compared with labetalol, nicardipine appears to reach goal BP faster, have less BP variability, and need less rescue antihypertensives. Compared with clevidipine, nicardipine appears to reach goal BP goal slower. Lastly, nicardipine appears to be similar for BP-related outcomes when compared with nitroprusside; however, nitroprusside may be associated with increased mortality. The confidence in the evidence available for all the outcomes was deemed very low. Because of the very low quality of evidence, an optimal BP agent for the treatment of patients with neurologic emergencies was unable to be determined. Future randomized controlled trials are needed to compare the most promising agents.

Pediatric Patient with Ischemic Stroke: Initial Approach and Early Management.

Acute Ischemic Stroke (AIS) in children is an acute neurologic emergency associated with significant morbidity and mortality. Although the incidence of AIS in pediatric patients is considerably lower than in adults, the overall cumulative negative impact of the quality of life could be even higher in children. The age-related variable clinical presentation could result in a delay in diagnosis and could negatively influence the overall outcome. The early management should be based on early recognition, acute transfer to pediatric AIS centre, standardised approach (ABCDE), early neurologic examination together with neuroimaging (preferable Magnetic Resonance Imaging—MRI). The treatment is based on supportive therapy (normoxemia, normocapnia, normotension and normoglycemia) in combination with intravenous/intraarterial thrombolytic therapy and/or mechanical thrombectomy in selected cases. Pediatric stroke centres, together with the implementation of local stroke management protocols, could further improve the outcome of pediatric patients with AIS.

Improving the Identification of Acute Neurological Emergencies in the University Pediatric Hospital Emergency Room: A Quality Improvement Project (2480)

Improving the Identification of Acute Neurological Emergencies in the University Pediatric Hospital Emergency Room: A Quality Improvement Project (2480)

Critically ill neurologic patients during the COVID-19 pandemic: A short communication

PurposeWe aimed to evaluate utilization of inpatient hospital and critical care services among critically ill neurologic patients during the COVID-19 pandemic. We hypothesized, based on prior observations among ischemic stroke patients, that there would be significant decline in critically ill neurologic patients presenting to hospitals during the pandemic which may impact outcomes. MethodsWe used TriNetX, a large research network, collecting real-time electronic medical records data. We extracted data on utilization of critical care and hospital inpatient services among cohorts of patients with common neurocritical conditions between January–June 2020 and compared it to data from similar time-frames in previous years. We also compared clinical outcomes, comprising need for intubation and 30-day mortality, among these cohorts. ResultsWe found a 28.1% reduction in intensive care unit (ICU) admissions with critical neurologic illnesses in 2020 when compared to 2019 (8568 vs. 11,917 patients, p ​< ​0.0001) and a 34.4% reduction compared to 2018 (8568 vs. 13,064 patients, p ​< ​0.0001). However, there was no statistically significant difference in mortality (2020: 12.2 vs. 2019: 12.4%; p ​= ​0.7; vs. 2018: 12.6%; p ​= ​0.62) or intubation rates across the years among patients using critical care services. There was 1% increase in mortality among non-ICU patients with similar diagnoses in 2020 compared to previous years (2020: 3.9% vs. 2019: 2.9% vs. 2018: 3.1%; p ​< ​0.0001, p ​= ​0.0001), but no difference in intubation rates. ConclusionThere was a significant reduction in hospital and ICU admissions among patients with acute neurologic emergencies in 2020, after onset of COVID-19 pandemic, compared to previous years. While we did not find a significant difference in mortality among patients admitted to the ICU, there was slightly higher mortality among non-ICU patients with same diagnoses in 2020 compared to previous years. Prospective evaluation and further investigation into the reasons for these trends is needed.

Perioperative Management of Aneurysmal Subarachnoid Hemorrhage.

Aneurysmal subarachnoid hemorrhage is an acute neurologic emergency. Prompt definitive treatment of the aneurysm by craniotomy and clipping or endovascular intervention with coils and/or stents is needed to prevent rebleeding. Extracranial manifestations of aneurysmal subarachnoid hemorrhage include cardiac dysfunction, neurogenic pulmonary edema, fluid and electrolyte imbalances, and hyperglycemia. Data on the impact of anesthesia on long-term neurologic outcomes of aneurysmal subarachnoid hemorrhage do not exist. Perioperative management should therefore focus on optimizing systemic physiology, facilitating timely definitive treatment, and selecting an anesthetic technique based on patient characteristics, severity of aneurysmal subarachnoid hemorrhage, and the planned intervention and monitoring. Anesthesiologists should be familiar with evoked potential monitoring, electroencephalographic burst suppression, temporary clipping, management of external ventricular drains, adenosine-induced cardiac standstill, and rapid ventricular pacing to effectively care for these patients.