Admitting Low-Risk Patients With Intracerebral Hemorrhage to a Neurological Step-Down Unit Is Safe, Results in Shorter Length of Stay, and Reduces Intensive Care Utilization: A Retrospective Controlled Cohort Study

Safety is not the question to be asking. What is the best procedure that gets these patients 100% recovered? At least try to ask the correct question. THIS IS WHY SURVIVORS NEED TO BE IN CHARGE. They won't lose sight of the only goal in stroke. 100% recovery.  

Admitting Low-Risk Patients With Intracerebral Hemorrhage to a Neurological Step-Down Unit Is Safe, Results in Shorter Length of Stay, and Reduces Intensive Care Utilization: A Retrospective Controlled Cohort Study 

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Lindsay Laws, MD, Flavia Lee, DO, Abhay Kumar, MD, ...

First Published May 20, 2020 Research Article

https://doi.org/10.1177/1941874420926760

Article information

Abstract

Background and Purpose:

Patients suffering intracerebral hemorrhage (ICH) are at risk for early neurologic deterioration and are often admitted to intensive care units (ICU) for observation. There is limited data on the safety of admitting low-risk patients with ICH to a non-ICU setting. We hypothesized that admitting such patients to a neurologic step-down unit (SDU) is safe(For whom?) and less resource-intensive.

Methods:

We performed a retrospective analysis of patients with primary ICH admitted to our SDU. We compared this cohort to a control group of ICH patients admitted to a neurologic-ICU (NICU) at a partner institution. We analyzed patients with supratentorial ICH ≤15 cc, Glasgow Coma Scale ≥ 13, National Institutes of Health Stroke Scale ≤ 10, and no to minimal intraventricular hemorrhage. Primary end points were (re-)admission to an NICU and rates of hematoma expansion (HE). We also compared total NICU days and hospital length of stay (LOS).

Results:

Eighty patients with ICH were admitted to the SDU. Only 2 required transfer to the NICU for complications related to ICH, including 1 for HE.(Have you identified the reasons so you can change the inclusion criteria?) Seventy-four SDU patients met inclusion criteria and were compared to 58 patients admitted to an NICU. There was no difference in rates of NICU (re-)admission (7 vs 2, P = .17) or rates of HE (3 vs 5, P = .28). Median NICU days were 0 versus 1 (P < .001). Step-down unit admission was associated with shorter LOS (3 vs 4 days, P = .05).

Conclusions:

Select patients with ICH can be safely admitted to an SDU. This may reduce LOS and ICU utilization. We also propose criteria for admitting patients with ICH to an SDU.

Keywords intracerebral hemorrhage, step-down unit, transitional care unit, neurologic intensive care unit, intensive care unit utilization

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Large Volumes of Critically Hypoperfused Penumbral Tissue Do Not Preclude Good Outcomes After Complete Endovascular Reperfusion

So you are screwed if you don't fit the inclusion criteria. A great stroke association would leave no survivor behind. We would solve stroke problems for everyone, not just the easy ones.
http://stroke.ahajournals.org/content/47/1/94.abstract?sid=a1b8f447-dbba-4e5d-bcff-f1b5a4849a56

Redefining Malignant Profile

1. Raul G. Nogueira, MD*;
2. Diogo C. Haussen, MD*;
3. Seena Dehkharghani, MD;
4. Leticia C. Rebello, MD;
5. Andrey Lima, MD;
6. Meredith Bowen, BA;
7. Samir Belagaje, MD;
8. Aaron Anderson, MD;
9. Michael Frankel, MD

+ Author Affiliations

1. From the Department of Neurology (R.G.N., D.C.H., L.C.R., A.L., S.B., A.A., M.F.) and the Department of Radiology (S.D., M.B.), Emory University and Grady Memorial Hospital - Marcus Stroke and Neuroscience Center, Atlanta, GA.

1. Correspondence to Raul G. Nogueira, MD, 49 Jesse Hill Jr Dr SE, Room #333, Atlanta, GA 30303. E-mail raul.g.nogueira@emory.edu

1. ↵* Drs Nogueira and Haussen contributed equally and qualify for equal level of authorship.

Abstract

Background and Purpose—Acute ischemic stroke patients with large volumes of severe hypoperfusion (T_max>10 s>100 mL) on magnetic resonance imaging have a higher likelihood of intracranial hemorrhage and poor outcomes after reperfusion. We aim to evaluate the impact of the extent of T_max>10 s CTP lesions in patients undergoing successful treatment.

Methods—Retrospective database review of endovascular acute ischemic stroke treatment between September 2010 and March 2015 for patients with anterior circulation occlusions with baseline RAPID CTP and full reperfusion (mTICI 3). The primary outcome was the impact of the T_max>10 s lesion spectrum on infarct growth. Secondary safety and efficacy outcomes included parenchymal hematomas and good clinical outcomes (90-day modified Rankin Scale score, 0–2).

Results—Of 684 treated patients, 113 patients fit the inclusion criteria. T_max>10 s>100 mL patients (n=37) had significantly higher baseline National Institutes of Health Stroke Scale (20.7±3.8 versus 17.0±5.9; P<0.01), more internal carotid artery terminus occlusions (29% versus 9%; P=0.02), and larger baseline (38.6±29.6 versus 11.7±15.8 mL; P<0.01) and final (60.7±60.0 versus 29.4±33.9 mL; P<0.01) infarct volumes when compared with patients without T_max>10 s>100 mL (n=76); however, the 2 groups were otherwise well balanced. There were no significant differences in infarct growth (22.1±51.6 versus 17.8±32.4 mL; P=0.78), severe intracranial hemorrhage (PH2: 2% versus 4%; P=0.73), good outcomes (90-day mRS score, 0–2: 56% versus 59%; P=0.83), or 90-day mortality (16% versus 7%; P=0.28). On multivariate analysis, only baseline National Institutes of Health Stroke Scale (odds ratio, 1.19; 95% confidence interval, 1.06–1.34; P<0.01) and baseline infarct core volume (odds ratio, 1.05; 95% confidence interval, 1.02–1.08; P<0.01) were independently associated with T_max>10 s>100 mL. There was no association between T_max>10 s>100 mL with any PH, good outcome, or infarct growth.

Conclusions—In the setting of limited baseline ischemic cores, large T_max>10 s lesions on computed tomographic perfusion do not seem to be associated with a higher risk of parenchymal hematomas and do not preclude good outcomes in patients undergoing endovascular reperfusion with contemporary technology.