Early ischaemia is related to poor acute neurological status after SAH and predicts future ischaemia and worse functional outcomes. Treatments addressing acute ischaemia should be evaluated for their effect on outcome.

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Objective To quantify in-hospital systolic blood pressure variability among patients with intracerebral hemorrhage, determine the association between high systolic blood pressure variability (HSBPV) and 90-day severe disability or death, and examine the association between pre-hospital factors and HSBPV. Methods Adult, radiologically confirmed, intracerebral hemorrhage patients enrolled in a multi-site cohort were included. Using a semi-automated algorithm, systolic blood pressure values recorded from routine non-invasive systolic blood pressure monitoring in critical and acute care settings were extracted for the duration of hospitalization. Inter and intra-patient systolic blood pressure variability was quantified using generalized estimating equation methods. Modified Poisson and logistic regression models were fit to determine the association between HSBPV and 90-day severe disability or death and between pre-hospital characteristics and HSBPV, respectively. Results A total of 566 patients managed at four certified stroke centers were included. Over 120,000 systolic blood pressure readings were analyzed, and a standard deviation (SD) of 13.0 was parameterized as a cut-off point to categorize HSBPV. Patients with HSBPV had a greater risk of 90-day severe disability or death (relative risk: 1.20, 95% confidence interval: 1.04–1.39), after controlling for age, pre-morbid functional status, and other disease severity measures. Greater likelihood of in-hospital HSBPV was independently observed in elderly, female patients, and in patients with high admission systolic blood pressure. Conclusion Quantification of HSBPV is feasible utilizing routinely collected systolic blood pressure readings, and a singular cut-off parameter for systolic blood pressure variability demonstrated association with 90-day severe disability or death. Elderly, female, and patients with high admission systolic blood pressure may be more likely to demonstrate HSBPV during hospitalization.

This study concludes that there is no significant adverse clinical risk of thyroid function abnormalities to the fetus after IV iodinated contrast material to their mothers.

Background: Standard gamble (SG) directly measures patients’ valuation of their health state. We compare in-hospital and day-90 SG utilities (SGU) among intracerebral hemorrhage patients and report a 3-way association between SGU, EuroQoL-5 dimension, and modified Rankin Scale at day 90. Methods and Results: Patients with intracerebral hemorrhage underwent in-hospital and day-90 assessments for the modified Rankin Scale, EuroQoL-5 dimension, and SG. SG provides patients a choice between their current health state and a hypothetical treatment with varying chances of either perfect health or a painless death. Higher SGU (scale, 0–1) indicates lower risk tolerance and thus higher valuation of the current health state. Logistic regression was used to estimate the likelihood of low SGU (≤0.6), and Wilcoxon paired signed-rank test compared in-hospital and day-90 SGU. In-hospital and day-90 SG was obtained from 381 and 280 patients, respectively, including 236 paired observations. Median (interquartile range) in-hospital and day-90 SGUs were 0.85 (0.40–0.98) and 0.98 (0.75–1.00; P <0.001). In-hospital SGUs were lower with advancing age ( P =0.007), higher National Institutes of Health Stroke Scale, and intracerebral hemorrhage scores ( P <0.001). Proxy-based assessments resulted in lower SGUs; median difference (95% CI), −0.2 (−0.33 to −0.07). After adjustment, higher National Institutes of Health Stroke Scale and proxy assessments were independently associated with lower SGU, along with an effect modification of age by race. Day-90 SGU and modified Rankin Scale were significantly correlated; however, SGUs were higher than the EuroQoL-5 dimension utilities at higher modified Rankin Scale levels. Conclusions: Divergence between directly (SGU) and indirectly (EuroQoL-5 dimension) assessed utilities at high levels of functional disability warrant careful prognostication of intracerebral hemorrhage outcomes and should be considered in designing early end-of-life care discussions with families and patients.

BackgroundIntracerebral hemorrhage is a devastating disease with no specific treatment modalities. A significant proportion of patients with intracerebral hemorrhage are transferred to large stroke treatment centers, such as Comprehensive Stroke Centers, because of perceived need for higher level of care. However, evidence of improvement in patient-centered outcomes for these patients treated at larger stroke treatment centers as compared to community hospitals is lacking.Methods / design“Efficient Resource Utilization for Patients with Intracerebral Hemorrhage (EnRICH)” is a prospective, multisite, state-wide, cohort study designed to assess the impact of level of care on long-term patient-centered outcomes for patients with primary / non-traumatic intracerebral hemorrhage. The study is funded by the Texas state legislature via the Lone Star Stroke Research Consortium. It is being implemented via major hub hospitals in large metropolitan cities across the state of Texas. Each hub has an extensive network of “spoke” hospitals, which are connected to the hub via traditional clinical and administrative arrangements, or by telemedicine technologies. This infrastructure provides a unique opportunity to track outcomes for intracerebral hemorrhage patients managed across a health system at various levels of care. Eligible patients are enrolled during hospitalization and are followed for functional, quality of life, cognitive, resource utilization, and dependency outcomes at 30 and 90 days post discharge. As a secondary aim, an economic analysis of the incremental cost-effectiveness of treating intracerebral hemorrhage patients at higher levels of care will be conducted.DiscussionFindings from EnRICH will provide much needed evidence of the effectiveness and efficiency of regionalized care for intracerebral hemorrhage patients. Such evidence is required to inform policy and streamline clinical decision-making.

Introduction: Dysphagia affects up to 2/3 of stroke patients; however, management practices are widely disparate. Despite lack of evidence for percutaneous endoscopic gastrostomy (PEG) placement, PEGs are placed in up to 23% of stroke patients a mean of 7 days from admission. We surveyed physicians who manage stroke patients in a large network of hospitals to evaluate knowledge and practices around dysphagia management. Methods: A 20 question survey was compiled and included questions regarding provider demographics, clinical experience and practice patterns for dysphagia management, knowledge about clinical variables associated with persistent dysphagia and beliefs about patient and system variables that influence decisions about dysphagia management (Table 1). Results: 171 providers of stroke care in the Memorial Hermann Healthcare System (13 hospitals) were surveyed and 52 (30%) participated (Table 1). Approximately, 67% of providers were extremely or very comfortable with management of post-stroke dysphagia. There was a trend toward an association between provider specialty and comfort, with critical care practitioners likely to feel more comfortable and internal medicine physicians less comfortable (p = 0.07). While 61% of providers recommend PEG placement within 3-7 days of admission, 77% of providers would delay PEG placement if they could. Providers aware of published trials showing poor outcomes after PEG were more likely to want more time (p=0.04). Providers reported that stroke location (86%), dysarthria severity (77%), and age (71%) of patients were most likely to be associated with persistent dysphagia. Conclusions: To our knowledge, this survey represents the first to assess provider practices, knowledge, and beliefs regarding PEG placement and dysphagia management. Most providers in our network would like more time to determine recovery of swallow function prior to placing PEG tubes, if length of stay and other factors were not issues.

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