Cerebral venous thrombosis (CVT) is usually treated with systemic anticoagulation, but mechanical thrombectomy (MT) and local infusion of a thrombolytic agent have been proposed as an alternative therapy. In this study, we analyze National Inpatient Sample (NIS) to determine the trends of MT including discharge other than home (DOTH) and mortality.Healthcare Utilization Program-NIS (HCUP-NIS) was queried between 2005 and 2018 for CVT and MT. Cochran-Armitage test was conducted to assess linear trend of proportion of utilization and DOTH of MT. Multivariable logistic regression was conducted to assess odds of undergoing MT among CVT admissions, odds of in-hospital mortality, and DOTH for all admissions involving MT for CVT.A total of 1331 (1.56%) admissions involved MT out of 85,370 CVT cases. Utilization of MT had an upward trend of 0.13% (p < 0.001) per year. Trend in proportion of incidence of DOTH among MT admission remained stationary (trend: 0.70%; p = 0.417). Patients with cerebral edema (odds ratio [OR]: 4.34; p < 0.001) or hematological disorders (OR: 2.28; p < 0.001) were more likely to receive MT for CVT. Additionally, patients with coma (OR: 3.17; p = 0.023) or cerebral edema (OR: 4.40; p = 0.001) had higher odds of mortality.There was an increasing trend of utilization of MT. Proportions of DOTH among MT procedures, however, remained stable. Patients with greater risk factors, including hematological disorders and cerebral edema, were more likely to undergo MT. Among patients treated with MT, those with coma or cerebral edema were more likely to die.
Abstract EKG changes are common and vary from simple S-T segment changes to new complex cardiac arrhythmias. New EKG changes in critically ill neurological patients could indicate acute myocardial ischemia or pulmonary emboli. Critically ill patients often have underlying cardiac disease and the most common problem is flaring up of atrial fibrillation, often with a rapid ventricular response. Sudden discontinuation of antiarrhythmic drugs can lead to this response. The pharmacological choices to initially treat the increased heart rate and options for long-term control are discussed in this chapter. Diltiazem infusion may control rapid ventricular response in atrial fibrillation or even convert atrial fibrillation to normal sinus rhythm.
Several randomized controlled trials (RCTs) have compared tenecteplase to alteplase for treatment of acute ischemic stroke (AIS). Yet, there is no meta-analysis that includes the latest published RCTs of 2022. We sought to compare the safety and efficacy of tenecteplase vs. alteplase for the treatment of AIS through a meta-analysis of all published RCTs.A systematic literature review of the English language literature was conducted using PubMed, Web of Science, Scopus, and Embase. We included RCTs that focused on patients with AIS treated with tenecteplase and alteplase. Multiple reviewers screened through potential studies to identify the final papers included in our analysis. Following PRISMA guidelines, multiple authors extracted data to ensure accuracy. Data were pooled using a random-effects model.Nine trials, with 3,706 patients, compared outcomes of patients treated with tenecteplase and alteplase for AIS. Both treatments resulted in comparable rates of modified Rankin Scale (mRS) 0-1 at 90 days (RR = 1.03; 95% CI = 0.97-1.10; P-value = 0.359) and mRS 0-2 at 90 days (RR = 1.03; 95% CI = 0.87-1.22; P-value = 0.749). There was no heterogeneity among included studies regarding mRS 0-1 rates (I2 = 26%; P-value = 0.211); however, there was significant heterogeneity in mRS 0-2 rates (I2 = 71%; P-value = 0.002). Similarly, rates of mortality (RR = 0.97; 95% CI = 0.81-1.16; P-value = 0.746) and symptomatic intracranial hemorrhage (sICH) rates (RR = 1.10; 95% CI = 0.75-1.61; P-value = 0.622) were comparable in both treatment groups. There was no significant heterogeneity among included studies in either mortality (I2 = 30%; P-value = 0.181) or sICH (I2 = 0%; P-value = 0.734) rates. Further analysis comparing dosing of tenecteplase (0.1, 0.25, 0.32, and 0.4 mg/kg) yielded no significant differences for any of the endpoints (mRS 0-1, mRS 0-2, sICH, and mortality) compared to alteplase.Based on available evidence from completed RCTs, tenecteplase has proven similar safety and efficacy to alteplase for treatment of AIS.
Introduction: In the past 20 years, the concept of the digital twin has been utilized in other fields to track the operations of wind turbines, monitor the status of spacecraft, and even create a model of the Earth for climate research While artificial intelligence holds much promise for the neurocritical care unit, these models should be clearly based on an understanding of underlying physiological variables rather than be opaque “black box” models. Our group has previously created such a digital twin model to predict acute response to treatment of sepsis. This project expands on our previous work by developing a similar model for the critical care of acute ischemic stroke. Methods: A panel of 18 experts in the field of critical care reviewed the clinical practice and pathophysiological statements related to neurology critical care. The core group of investigators developed statements based on a Directed Acyclic Graph (DAG) describing pathophysiology surrounding acute neurological issues encountered in the practice of Neurocritical Care (NCC). A modified Delphi method (3 rounds) was used to gauge agreement on 20 statements (120 sub statements) using a 7-point Likert scale. Agreement was defined a-priori by >80% selection of a 6 (“agree”) or 7 (“strongly agree”). Results: Consensus was achieved on 58 (48.3%) expert statements after completion of 2 rounds. After completion of 3rd round, the level of consensus increased to 93 (77.5%) expert statements. Some statements garnered 100% consensus in the first round of DELPHI such as “Reperfusion of ischemic stroke can lead to improvement of stroke.” Other statements required revision to capture the nuances of clinical practice before gaining consensus. For example, when the severity of infection was incorporated into the statement “Infection can lead to low blood pressure.” consensus increased from 56% to 100%. Conclusions: Our study demonstrated the feasibility of application of the DELPHI process to generate consensus among experts for use in development of a “digital twin” artificial intelligence model for use in the Neuro ICU. Compared to other models which rely on “black-box” associative artificial intelligence, our proposed causal AI model is based on a solid foundation of expert rules and casual mechanisms.
'/%3e%3c/defs%3e%3cpath fill='%23012169' d='M0 0h10080v5040H0z'/%3e%3cpath stroke='%23fff' stroke-width='.6' d='m0 0 6 3m0-3L0 3' clip-path='url(%23b)' transform='scale(840)'/%3e%3cpath stroke='%23e4002b' stroke-width='.4' d='m0 0 6 3m0-3L0 3' clip-path='url(%23c)' transform='scale(840)'/%3e%3cpath stroke='%23fff' stroke-width='840' d='M2520 0v2520M0 1260h5040'/%3e%3cpath stroke='%23e4002b' stroke-width='504' d='M2520 0v2520M0 1260h5040'/%3e%3cg fill='%23fff'%3e%3cuse xlink:href='%23d' x='2520' y='3780'/%3e%3cuse xlink:href='%23a' x='7560' y='4200'/%3e%3cuse xlink:href='%23a' x='6300' y='2205'/%3e%3cuse xlink:href='%23a' x='7560' y='840'/%3e%3cuse xlink:href='%23a' x='8680' y='1869'/%3e%3cuse xlink:href='%23e' x='8064' y='2730'/%3e%3c/g%3e%3c/svg%3e)
'/%3e%3cuse xlink:href='%23a' transform='rotate(23.036 .093 25.536)'/%3e%3cuse xlink:href='%23a' transform='rotate(45.87 1.273 16.18)'/%3e%3cuse xlink:href='%23a' transform='rotate(69.945 .996 12.078)'/%3e%3cuse xlink:href='%23a' transform='rotate(20.66 -19.689 31.932)'/%3e%3c/svg%3e)