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PURPOSE OF REVIEW This article reviews the evidence on integrating palliative care into the care of patients with various types of serious neurologic illness, emphasizes the importance of palliative care in the neurocritical care unit, and suggests tools for clinicians to improve their communication skills and decision making. RECENT FINDINGS Palliative care is a holistic approach to medical care that aims to relieve physical, psychological, social, and spiritual suffering. It is both a medical specialty as young as neurocritical care itself and an approach to patient care by all clinicians who manage patients with serious illness. Patients presenting to the neurocritical care unit and their families have unique palliative care needs that challenge communication and shared decision making. SUMMARY Palliative care, effective communication, and shared decision making require a set of core skills that all neurology clinicians should master.

The coronavirus disease 2019 (COVID-19) pandemic is profoundly affecting neurology patients, families, and providers through direct neurologic complications,1 indirect consequences of COVID-19 on healthcare delivery,2 and the consequences of social distancing.3 As frontline providers, neurologists see both the medical consequences of COVID-19 and its toll in heightening personal suffering ranging from interruptions or changes in standard therapies4 to patients facing isolation in the hospital and even the prospect of dying without the family being present.5 Almost instantly, the calculus of risks and benefits have changed to include concerns of COVID-19 during routine office visits, procedures, and hospital admissions. This affects patients desire to seek medical care and may explain the dramatic drop in acute hospitalizations and outpatient referrals. Neurologists also face challenges in providing ongoing care for persons with chronic illness, responding to novel clinical situations and hosting an increasing number of difficult conversations, often via telehealth.6

Strokes remain a leading cause of morbidity and mortality in patients with ventricular assist devices (VADs). Varying study populations, event definitions, and reporting methods make direct comparison of neurologic event risk across clinical trials and registries challenging. We aim to highlight important differences among major VAD studies and standardize rates of neurologic events to facilitate a comprehensive and objective comparison. We systematically identified and analyzed key clinical trials and registries evaluating the HeartMate II (HMII), HeartMate 3 (HM3), and HVAD devices. Reported neurologic events were nonexclusively categorized into ischemic stroke, hemorrhagic stroke, disabling stroke, fatal stroke, and other neurologic events per the studies' definitions. Event rates were standardized to events per patient-year (EPPY) and freedom from event formats. Seven key clinical trials and registries were included in our analysis. There is significant variation and overlap in neurologic event rates for the three VAD platforms across clinical trials (all neurologic events [EPPY]: HM3 0.17-0.21; HMII 0.19-0.26; HVAD 0.16-0.28). None performs consistently better for all types of neurologic events. Furthermore, stroke rates among VAD trials correlated with baseline stroke risk factors including ischemic etiology, history of atrial fibrillation, and history of prior stroke.

Background and ObjectivesNeuropalliative care is an emerging interprofessional field that aims to improve communication and quality of life for all people affected by serious neurologic disease. Teaching neuropalliative care skills is a key objective for neurology residencies, and the Accreditation Council for Graduate Medical Education requires proficiency in palliative care. The objective of this study was to describe a novel longitudinal multimodal curriculum in neuropalliative care communication and evaluate its feasibility and outcomes.Methods and Curriculum DescriptionWe designed a multimodal curriculum focused on neuropalliative care communication skills using as our theoretical foundation transformative learning theory. We implemented this program for neurology residents at a single academic institution over the course of their 3-year training. Residents underwent (1) 3 communication workshops using VitalTalk modules and simulated patient encounters, (2) 3 or more observed clinical encounters with structured faculty feedback, and (3) at least 3 annual neuropalliative care lectures. We evaluated the effect on learners' self-assessed confidence in neuropalliative care skills with preworkshop and postworkshop questionnaires.Results and Assessment DataIn 2021, 14 of 20 eligible residents attended our workshops and completed the preworkshop questionnaire, and 12 of those completed the postworkshop questionnaire. After the workshop, a larger proportion of residents (75%, 9/12) agreed or strongly agreed that they felt confident leading family meetings compared with before the workshop (57%, 8/14). While more than 90% of residents felt confident recognizing patient and family emotions both before and after the workshop, the workshop improved their confidence in responding to such emotions. Still, some residents neither agreed nor disagreed (42%, 5/12) about feeling confident in responding to emotions after the workshop, and many commented on wanting more training in this area.Discussion and Lessons LearnedThe successful implementation and high attendance among eligible participants demonstrate the feasibility of our longitudinal multimodal neuropalliative care curriculum. The evaluation of intervention outcomes suggests that residents' confidence in neuropalliative communication skills improved. Our study shows that VitalTalk is a tool that can be adapted to teach neuropalliative communication skills for neurology residents, and this program can be easily adopted by other neurology training programs.

Objectives Treatment decisions following severe acute brain injury need to consider patients' goals-of-care and long-term outcomes. Using family members as respondents, we aimed to assess patients' goals-of-care in the ICU and explore the impact of adaptation on survivors who did not reach the level of recovery initially considered acceptable. Design Prospective, observational, mixed-methods cohort study. Setting Comprehensive stroke and level 1 trauma center in Pacific Northwest United States. Participants Family members of patients with severe acute brain injury in an ICU for greater than 2 days and Glasgow Coma Scale score less than 12. Measurements and main results At enrollment, we asked what level of physical and cognitive recovery the patient would find acceptable. At 6 months, we assessed level of recovery through family surveys and chart review. Families of patients whose outcome was below that considered acceptable were invited for semistructured interviews, examined with content analysis. Results For 184 patients, most family members set patients' minimally acceptable cognitive recovery at "able to think and communicate" or better (82%) and physical recovery at independence or better (66%). Among 170 patients with known 6-month outcome, 40% had died in hospital. Of 102 survivors, 33% were able to think and communicate, 13% were independent, and 10% died after discharge. Among survivors whose family member had set minimally acceptable cognitive function at "able to think and communicate," 64% survived below that level; for those with minimally acceptable physical function at independence, 80% survived below that. Qualitative analysis revealed two key themes: families struggled to adapt to a new, yet uncertain, normal and asked for support and guidance with ongoing treatment decisions. Conclusions and relevance Six months after severe acute brain injury, most patients survived to a state their families initially thought would not be acceptable. Survivors and their families need more support and guidance as they adapt to a new normal and struggle with persistent uncertainty.

Background: Management of intracranial hemorrhage (ICH) in patients with left ventricular assist devices (LVADs) is complicated by the competing concerns of hematoma expansion and the risk of thrombotic events. Strategies include reversal or withholding of anticoagulation (AC) and neurosurgical (NSG) interventions. The consequences of these decisions can significantly impact both short- and long-term survival. Currently no guidelines on management exist. We reviewed medical and NSG practices and subsequent outcomes at a single academic center. Methods: We retrospectively identified all patients within our institutional LVAD database who developed ICH between 2012-2018. Demographic, clinical, and outcome data were analyzed. Results: Of 283 LVAD patients, 32 (11%) had 34 ICHs: 16 intraparenchymal (IPH, 47%), 4 subdural (SDH, 12%), and 14 subarachnoid (SAH, 41%). IPH occurred sooner than other subtypes (median 138 [48 - 258]) days post-LVAD placement vs SDH (431 [22 - 915] days) and SAH (484 [272 - 990] days). Mean GCS was 12.9 (3.7). All patients were on AC with a mean INR of 3.3 (range 1.2 - 7.0). AC was reversed in 27 (79%) patients, most frequently with a combination of Vit K (56%), FFP (47%), or PCC (26%). AC was held in 31 patients a median of 4 (2.0 - 9.0) days; 1 thrombotic event occurred while off AC (spinal cord infarct). After AC resumption, 16 thrombotic events occurred a median of 15 (8.0-37.0) days post-ICH and led to death in most (79%) by 6 months. Five patients underwent NSG intervention: 1 hemicraniectomy, 3 EVDs, and 1 aneurysm coiling. Six patients (18%) went on to receive heart transplant. Overall, 30-day mortality was 26%. IPH had the highest 30-day mortality (38% vs SDH, 0% and SAH, 29%). At 6 months, overall mortality was 44%. Conclusion: ICH is a common post-LVAD complication with high short- and long-term mortality. Of the subtypes, IPH was the most common, most deadly and occurred the earliest following LVAD placement. At our institution, most patients underwent AC reversal but AC was also resumed rapidly. Delayed thrombotic complications nearly doubled 6-month mortality. The development of ICH did not preclude successful heart transplant. Further research in the care of LVAD patients with ICH may help improve these short- and long-term outcomes.

Background: Intracranial hemorrhage (ICH) has a high mortality rate (up to 40% in some studies) with most deaths occurring after limitation of life-sustaining therapies. ICH is a feared complication of left ventricular assist device (LVADs) and challenges end-of-life decisions for patients, families, and health-care teams. Palliative care (PC) is considered essential for the management of patients who receive an LVAD, yet little is known about the end-of-life course of patients with LVAD-associated ICH. The goal of this single center study was to better understand the impact of PC involvement in post-ICH care in LVAD patients. Methods: We retrospectively identified all patients within our institutional LVAD database who experienced ICH between 2012 - 2018. Demographic, clinical, and outcome data were collected and analyzed using descriptive statistics. Results: Of the 283 patients who underwent LVAD placement, 32 (11%) experienced 34 ICHs: 16 intraparenchymal (IPH, 47%), 4 subdural (SDH, 12%), and 14 subarachnoid (SAH, 41%), a median of 258 (110-526) days post-LVAD. PC was consulted in 23 (68%) cases (69% of IPHs, 75% of SDHs, and 64% of SAHs). The patients who received PC were younger (50.5 [16.5] vs 54.9 [17.1] years) and more neurologically impaired (mean GCS 12.8 [3.6] vs 13.2 [4.0]). Women were referred more frequently than men (80% vs 63%) and White patients more frequently than non-White (74% vs 63%). All patients were full code at the time of their ICH; following PC consult, code status was changed to DNR in 48%. Ten patients (29%) died during their hospitalization. Though most patients in the cohort were referred for PC, only one died on home hospice; the remaining patients died in the hospital setting, 7 (70%) in the intensive care unit (ICU). Conclusions: In this single-center study, the vast majority of LVAD patients who died from their ICH died in the hospital setting, and most in the ICU, despite high numbers of PC consultation. As prior studies have associated in-hospital death with worse end-of-life-care and more physical and emotional distress for terminal patients, the use of hospice services has been increasing in the stroke population. Further work is needed to provide better end-of-life options for LVAD patients following serious neurologic injuries.

Background: Mechanical thrombectomy (MT) is now standard of care for patients with acute large vessel occlusion (LVO) ischemic stroke, after several trials showed significant functional improvement at 90 days. Despite this expected duration for recovery, withdrawal of life sustaining treatment (WLST) often occurs within less than 5 days after MT. We aimed to identify determinants of early WLST and better understand decisions that led to it. Methods: Retrospective chart review at a single academic stroke center from 1/2015 to 8/2020 using mixed methods. We compared patient characteristics and hospital course in those with early WLST (within 5 days) to those without WLST. Six authors conducted in-depth qualitative analysis of family meeting notes among a subgroup of 16 purposively sampled early WLST patients. Results: Among 402 patients (mean age 68.0, SD 14.7 years; 53.7% male) who underwent MT, 88 (21.9%) had WLST, of which 52 (12.9%) were early WLST (mean 2.2, SD 1.3 days). Logistic regression adjusted for sex, race, LVO location, time of MT from last known normal, and post-procedural hemorrhage showed early WLST compared to no WLST was significantly associated with older age, inpatient stroke, increased stroke severity, unsuccessful MT, no tPA given, post-procedural need for craniectomy, and palliative care consultation (p Conclusion: Early WLST after MT occurs frequently in patients with severe stroke and high medical complexity, especially if progression to cerebral herniation. Clear communication before and after MT regarding expected prognosis and trajectory of recovery could allow for improved decision making and prevent potentially premature WLST by providers or families. Prior knowledge of patient’s goals-of-care may also reduce patient or caregiver suffering and improve resource utilization for the healthcare system in patients with severe stroke.

Neuropalliative care is an emerging subspecialty in neurology and palliative care. On April 26, 2017, we convened a Neuropalliative Care Summit with national and international experts in the field to develop a clinical, educational, and research agenda to move the field forward. Clinical priorities included the need to develop and implement effective models to integrate palliative care into neurology and to develop and implement informative quality measures to evaluate and compare palliative approaches. Educational priorities included the need to improve the messaging of palliative care and to create standards for palliative care education for neurologists and neurology education for palliative specialists. Research priorities included the need to improve the evidence base across the entire research spectrum from early-stage interventional research to implementation science. Highest priority areas include focusing on outcomes important to patients and families, developing serious conversation triggers, and developing novel approaches to patient and family engagement, including improvements to decision quality. As we continue to make remarkable advances in the prevention, diagnosis, and treatment of neurologic illness, neurologists will face an increasing need to guide and support patients and families through complex choices involving immense uncertainty and intensely important outcomes of mind and body. This article outlines opportunities to improve the quality of care for all patients with neurologic illness and their families through a broad range of clinical, educational, and investigative efforts that include complex symptom management, communication skills, and models of care.

Background: Despite reductions in major adverse events with the latest generation of left ventricular assist devices (LVADs), the incidence of thromboembolic complications remains high. Optimal anticoagulation (AC) strategies immediately after an ischemic stroke remain controversial. We aim to explore practices of anticoagulation management following acute ischemic stroke in LVAD patients at our institution and to identify the optimal strategies. Methods: We performed a retrospective analysis of our institutional LVAD database between 11/2012 and 5/2018. Patients were categorized into 3 groups based on the timing of AC post-stroke: (1) AC immediately continued, (2) AC held for 1-4 days, (3) AC held > 4 days. Primary outcome events included recurrent ischemic stroke or TIA, pump thrombosis, systemic thrombosis, hemorrhagic conversion or other intracranial or extracranial bleeding, and death. Other variables collected included age, sex, and year of LVAD placement. Descriptive and nonparametric survival analysis was performed. Results: A total of 39 adult patients met our criteria. Median age was 60 years (IQR 51-68), 18% were women, and 23% non-white. One half (56%) of procedures occurred after 2014 and ischemic stroke occurred a median of 11 days (1-260) after LVAD implantation. We found a total of 48 outcome events among 28 patients including 30 first events (2 ischemic strokes/TIAs, 4 pump thromboses, 7 systemic thrombotic events, 8 intracranial hemorrhages, 1 systemic hemorrhage, and 8 deaths). Kaplan-Meier survival free of a primary outcome was 64%, 49% and 41% at 7, 14 and 30 days post ischemic stroke, respectively. There was no association between survival and timing of anticoagulation, age > 60, sex, or LVAD placement before vs after 2014. Conclusions: We found a high rate of early outcomes after ischemic stroke in LVAD patients, with no evidence of increased risk with continued anticoagulation. Accepting the limitations of a retrospective study, these data suggest that anticoagulation may not need to be held acutely to prevent hemorrhagic conversion. Risk factors for these post ischemic stroke outcomes however were not identified. Further research is needed to identify approaches to decrease these secondary complications.

The past 2 decades have seen remarkable advances in our abilities to treat and prevent stroke. Better vascular risk factor control has led to a decrease in stroke incidence by 50% since the early 90s.1 Improvements in acute stroke care, especially at specialized centers, have led to a decline in overall stroke mortality. Over the past decade, stroke death rate in the United States decreased by one third, and stroke has moved from the third to the fifth leading cause of mortality.2 If a patient with an acute ischemic stroke presents early enough to the hospital, systems should be in place to appropriately administer tissue-type plasminogen activator within less than an hour of arrival, thereby often doubling their chances of achieving future independence.3,4 Some patients may continue on to the angio-suite for mechanical clot retrieval; those who do are twice more likely to be independent at 3 months.5–7 Despite these remarkable advances, only around 5% to 7% of patients with acute ischemic stroke receive tissue-type plasminogen activator.8,9 Mechanical thrombectomy is reserved for an even smaller proportion. Although community education may increase the proportion of patients calling for help sooner10 and mobile CT scanners and prehospital treatment may shorten the time and increase the proportion of patients receiving tissue-type plasminogen activator,11 for most patients, stroke remains disabling and often deadly. For these reasons, palliative care remains an important part of the stroke care that we deliver, especially for patients with severe stroke. Here we provide a contemporary review of the literature and offer some recommendations on how stroke providers may integrate palliative care into the care of their patients with severe ischemic or hemorrhagic stroke, focusing on early interactions. Stroke palliative care is fundamental to high-quality stroke care …

Patients admitted to the neurological or neurosurgical ICU are likely to have palliative care needs. The goals of this project are to encourage the ICU team to identify palliative care needs for patients and their families and potential ways to meet those needs.Quality improvement project using a parallel-group prospective cohort design.Single neuro-ICU at a large, academic medical center.All patients admitted to the neuro-ICU from September 1, 2013, to November 30, 2013.We developed a palliative care needs screening tool consisting of four questions: 1) Does the patient have distressing physical or psychological symptoms? 2) Are there specific support needs for patient or family? 3) Are treatment options matched with patient-centered goals? 4) Are there disagreements among teams and family? We implemented this daily screening tool on morning rounds for one of two neurocritical care services that alternate admitting days to a single neuro-ICU. We examined prevalence and nature of palliative care needs and actions to address those needs, comparing the services with and without screening.Over the 3-month period, 130 patients were admitted to the service with screening and 132 patients to the service without screening. The two groups did not differ with regard to age, gender, Glasgow Coma Scale, or diagnosis. Palliative care needs were identified in 62% of screened patients (80/130). Needs were mainly social support (53%) and establishing goals of care (28%). Screening was associated with more documented family conferences (p = 0.019) and a trend toward more palliative care consultations (p = 0.056).We developed a brief palliative care needs screening tool that identified palliative care needs for 62% neuro-ICU patients. This tool was associated with actions to meet these needs, potentially improving care for patients and their families.

Introduction: Stroke is the 2 nd most common cause of death and the leading cause of disability worldwide. Stroke survivors have high rates of comorbid medical conditions; one in 5 stroke survivors will suffer a recurrent stroke within 5 years, and a TIA doubles the risk for heart attack. In the acute stroke setting, patients are frequently unable to participate in their own medical decision making. Therefore, advanced care planning (ACP) should be a fundamental part of post-stroke care. Methods: We surveyed stroke survivors and stroke physicians in our tertiary care stroke clinic as part of a quality improvement program. All new and follow-up patients were invited to complete a 12 question survey on ACP, including history of relevant discussions and perceived risk of recurrent stroke or disability. Stroke physicians documented demographic data, NIHSS, any acute treatment received, mRS and provided a risk estimate for recurrent stroke or death. Results: Between March and July 2017, 198 surveys were completed. Median age was 61 years (IQR 50-70), 94 (47.5%) were female, and 61% presented to the stroke clinic for the first time after their stroke. The majority (55%) had an initial NIHSS of 5 or less, and 10% had received IV tPA or thrombectomy during their acute stroke care. At the time of follow-up, median mRS was 1 (IQR 0-2). Almost ¾ (n=145) had had a conversation with a physician about ACP, and 110 (56%) wanted to discuss ACP with their stroke physician. Less than one half (n=88) had advance directives (AD) in place. Patients were significantly more likely to have AD if they were white (53% compared to 24% in all other races, p Conclusions: Most patients presenting to stroke clinic do not have advance directives, but a willingness to discuss ACP is common. We identified certain groups who were less likely to have advance care plans. Our findings suggest that the stroke clinic may be an optimal setting for a targeted intervention to increase access to ACP.

Background and Purpose— The purpose of this statement is to delineate basic expectations regarding primary palliative care competencies and skills to be considered, learned, and practiced by providers and healthcare services across hospitals and community settings when caring for patients and families with stroke. Methods— Members of the writing group were appointed by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and the American Heart Association’s Manuscript Oversight Committee. Members were chosen to reflect the diversity and expertise of professional roles in delivering optimal palliative care. Writing group members were assigned topics relevant to their areas of expertise, reviewed the appropriate literature, and drafted manuscript content and recommendations in accordance with the American Heart Association’s framework for defining classes and level of evidence and recommendations. Results— The palliative care needs of patients with serious or life-threatening stroke and their families are enormous: complex decision making, aligning treatment with goals, and symptom control. Primary palliative care should be available to all patients with serious or life-threatening stroke and their families throughout the entire course of illness. To optimally deliver primary palliative care, stroke systems of care and provider teams should (1) promote and practice patient- and family-centered care; (2) effectively estimate prognosis; (3) develop appropriate goals of care; (4) be familiar with the evidence for common stroke decisions with end-of-life implications; (5) assess and effectively manage emerging stroke symptoms; (6) possess experience with palliative treatments at the end of life; (7) assist with care coordination, including referral to a palliative care specialist or hospice if necessary; (8) provide the patient and family the opportunity for personal growth and make bereavement resources available if death is anticipated; and (9) actively participate in continuous quality improvement and research. Conclusions— Addressing the palliative care needs of patients and families throughout the course of illness can complement existing practices and improve the quality of life of stroke patients, their families, and their care providers. There is an urgent need for further research in this area.

Introduction: CT angiography (CTA) is a front-line imaging tool for the evaluation of acute stroke patients in the emergency department. In our experience, however, many CTAs performed for suspected stroke may not be appropriate and patients are found to have alternative diagnoses upon further work-up. We hypothesize that use of an evidence-based imaging guideline such as the American College of Radiology Appropriateness Criteria (ACR-AC) could facilitate more judicious use of CTA by identifying patients who are likely to have alternative diagnoses. Methods: We retrospectively reviewed patients who underwent CTA for stroke workup in the emergency department between January 2014 and January 2015. Patients evaluated for trauma, intracranial hemorrhage and known infarcts were excluded. Through PACS and EMR review, we identified 144 patients. Using a double-reader consensus method, we categorized each patient’s presenting symptoms based on the ACR-AC Neurologic Variants. Categories included: “usually appropriate,” “may be appropriate,” and “usually not appropriate”. We performed contingency table analyses using Fisher’s exact test and calculated odds ratios to correlate ACR-AC categories with CTA findings which explained stroke presentation such as arterial thrombosis, dissection, or high grade stenosis in a relevant vascular distribution. Results: Of the 144 patients who underwent CTA for stroke evaluation, 87 patients fell into the “usually appropriate” ACR-AC category, with 49 “may be appropriate” and 8 “usually not appropriate”. Within the first group, 19/87 CTAs were positive (21.8%) with an odds ratio of 4.98 (p= Conclusion: Our data suggest that ACR-AC correlate with CTA findings relevant to stroke. Specifically, patients in the “usually appropriate” category were more likely to have a positive finding on CTA, while no positive CTAs were seen in the “usually not appropriate” category. These preliminary data suggest that the use of ACR-AC or similar criteria may aid clinical decision making and facilitate evidence-based use of CTA for suspected stroke workup.

Stroke demands our attention because it is common, disabling, and deadly. One in 15 patients requires mechanical ventilation on admission, 1 in 20 patients is discharged from the acute care hospital with a feeding tube, and 1 in 5 patients requires institutional care at 3 months after stroke.1 Most patients with severe stroke who die, do so in the setting of withdrawal of life-sustaining treatment (LST),2 and this decision is typically made by physicians who predict a poor outcome and surrogates who are asked to articulate the patient’s preferences3: "she would not want to live like that." When prognosis is certain and the outcome unacceptable, the decision to withdraw or withhold LST may be relatively straightforward, although emotionally challenging. In most severe strokes, however, decisions are made when prognosis is uncertain and when what constitutes an acceptable outcome is unknown. In this article, we explore the uncertainties and biases that influence these life-and-death decisions. Such biases can lead to errors in decision making and ultimately the overuse or underuse of LST. Hence, the need is urgent to understand better the factors that contribute to optimal -decision making.4 Surviving a severe stroke means living with disability. Treatment decisions, thus, frequently involve trade-offs.5 Three typical preference-sensitive decisions after severe stroke are mechanical ventilation, artificial nutrition, and surgical decompression for hemorrhagic or ischemic strokes with life-threatening mass effect. All of these LSTs reduce the risk of death but increase the chance of survival.6–8 Although one individual may choose life at all costs, even when evidence predicts severe disability, another may refuse LSTs despite a prospect of surviving with a modest deficit, trading off the possibility of survival in an undesirable health state for the more desirable outcome of death. In the acute setting, withdrawal …

Background: Patients with stroke have a high risk of death, physical and cognitive impairments and therefore have a high degree of palliative care (PC) needs. The goal of this study is to explore the prevalence of and associations with PC consultation in stroke patients. Methods: Using the administrative hospital discharge database of Washington State, we reviewed all patients discharged with stroke (based on ICD-9 codes) from 2009-2011. Strokes were subclassified as ischemic, intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). We collected information on demographics, outcome and presence of a “Palliative Care encounter” as defined by the ICD-9 code V66.7. Results: Overall, there were 33102 stroke patients with a mean age of 71.1 (SD 16), 52% were female and 49% white. The majority of patients had ischemic strokes (28581, 86%) followed by ICH (9.6%) and SAH (4%). A PC encounter was found in 1682 patients (5%) and was more common in patients with older age, hemorrhagic stroke types, those discharged from larger hospitals and in more recent years (all p Conclusions: PC encounters are becoming more common for stroke patients, especially in larger hospitals and are strongly associated with hospital death (i.e. more commonly used in more severe strokes). The unequal distribution across age, gender, stroke type and race suggests a need for more standardized methods to identify patients’ need for PC consultation such as validated PC consultation triggers.

Background and Objective: In patients with malignant infarction of the middle cerebral artery (MCA), decompressive hemicraniectomy (DHC) reduces mortality and improves outcome but leaves many survivors severely disabled. In deciding whether to undergo this surgery, patients and surrogates look to providers for relevant prognostic information to help make treatment decisions based on their personal values. The goal of this study is to explore whether the way treatment information is framed influences decision-making regarding DHC. Methods: Ambulatory patients and their family members in hospital outpatient waiting rooms were recruited for this voluntary survey. Subjects were randomized to 1 of 5 different videos of a physician discussing treatment options for their loved one with a hypothetical acute malignant MCA ischemic stroke, each video with a different presentation format (positive or negative framing, reporting results in absolute or relative proportions, graphical display). Subjects were then asked to indicate their treatment decisions and to provide basic demographic data. Results: Fifty-three subjects were enrolled in the study, the majority of whom were insured (47; 88.7%), white (40; 78.4%) and independent (33; 64.7%). Half were 51 years or older (27; 50.9%) and had an income less than $50,000 annually (50.9%). Randomization arms did not differ according to age (p=0.5), functional status (p=0.3), income (p=0.9), insurance type (p=0.4) or race (p=0.8). Marital status differed slightly between arms (p=0.06). Controlling for marital status, subjects were most likely to choose surgery for their loved one (OR 6.9, 95% CI: 0.6, 77.8) after viewing video B (positive framing, relative risk reduction) and least likely (OR 0.8, 95% CI: 0.1-5.5) after viewing video C (negative framing, relative risk reduction) compared to those in the graphical group. Conclusions: Information framing may influence surrogate decision-making for DHC after malignant MCA ischemic stroke. Clinicians should consider this influence when counseling patients; formal decision aids or other methods to present results in a more standardized fashion may help mitigate these effects.

Patients admitted to the Neurological intensive care unit (Neuro ICU) face a myriad of difficulties including a high risk of death and severe physical and cognitive impairments. Clinical treatment decisions often have to be made at a time when prognosis is uncertain. Admitted with stroke, head trauma or other severe acute brain injury, these patients are typically immobilized by their illness alone. Add to that intracerebral lines and monitoring devices, bedrest may at first seem not only necessary but also inevitable. The consequences, however, of prolonged immobility are detrimental [1, 2]. Even among critically ill patients without acute brain injury, ICU-acquired weakness is common. At least 25% of patients receiving one week or more of mechanical ventilation develop such significant weakness that they are unable to lift their limbs against gravity [2]. In patients with high severity of illness, such as the acute respiratory distress syndrome, ICU-acquired weakness may be even more common, and persists at hospital discharge [3]. ICU-acquired weakness is associated with poorer hospital outcomes, including death [4, 5], prolonged mechanical ventilation [2], recurrent respiratory failure [6], and delays recovery and return home [2, 7]. Longer term outcomes, such as health-related quality of life and functional status at 12 months, are also adversely affected by ICU-acquired weakness [3]. Patients with ICU-acquired weakness have muscle atrophy and additional pathologic changes of muscle and nerve that are referred to as critical illness myopathy and neuropathy [2, 8, 9]. The most consistent risk factor appears to be severe systemic inflammatory response syndrome and shock [8, 10]. While most risk factors for ICU-acquired weakness may be unavoidable, including age, gender and severity of illness [2], prolonged immobility is a compelling risk factor that can be avoided [3]. Immobility is a known contributor to muscle atrophy, but in the setting of critical illness, immobility increases local and systemic inflammation and escalates the pathogenesis of critical illness neuropathy and myopathy [11]. When patients with severe acute brain injury develop ICU-acquired weakness, physicians’ prognosis becomes overly pessimistic [12]. With prognostic pessimism already so prevalent after severe stroke, especially intraparenchymal hemorrhage [13, 14], the importance of avoiding ICU-acquired weakness can therefore not be overstated. Stroke remains the leading cause of serious, long-term disability in the US, and the number of stroke survivors will continue to increase. In 2010, the total costs for stroke and traumatic brain injury in the US were estimated to be over $35 and $75 billion, respectively, with severe injuries accounting for the majority of these costs [15, 16]. Finding a treatment for our severe acute brain injury patients that would shorten their hospital stay as well as their need for post-hospital institutionalization would save costs and improve quality of life. Early mobility has been shown to improve functional recovery of both the body and brain, with promotion of ambulation, functional independence at hospital discharge, and significant reduction in duration of delirium [17]. Indeed, getting patients out of bed seems to be a potent approach to reducing the negative sequelae of critical illness. In their article “Clinical and Psychological Effects of Early Mobilization in Patients Treated in a Neurological ICU: A Comparative Study” in this week’s Critical Care Medicine, Kate Klein and colleagues introduce an early mobility program to a large Neuro ICU that is created and led by the unit’s nurses. Using a prospective, pre-post-intervention design, the study findings suggest significantly higher mobility levels, lower hospital and ICU length of stay, and a higher likelihood of being discharged home in those patients receiving the early mobility program [18]. Despite the non-randomized design that limits causal inference, this study is an important addition to the (neuro)critical care literature and shows that early mobilization is not only feasible: it can be a standard part of the nurses’ ICU routine, with the help of a lift team as well as the typical rehabilitation program provided by physical and occupational therapists. This study is a real-world application of previous RCTs [17] that gives a practical approach on how to mobilize Neuro ICU patients early, thereby not only improving their mobility but also increasing their chances of doing what every Neuro ICU patient wants most: to go home. As treatments in our intensive care units are becoming more complex and high-tech, this timely study confirms an often forgotten lore: Exercise is the best medicine – even in the Neuro ICU.

Background: Observational reports suggest that a self-fulfilling prognostic pessimism may lead to withdrawal of life support (WOLS) in patients with more severe intracerebral hemorrhages (ICHs) who might otherwise have acceptable clinical outcomes. Our objective was to estimate what outcomes in a cohort of ICH patients might have been if they did not have WOLS. Methods: Multivariate modeling was used to create a propensity score (PS) for WOLS in a Seattle single center cohort of ICH patients with hospital discharge modified Rankin Scale (mRS) as the primary outcome. Using nearest neighbor matching, individual ICH patients with WOLS were matched to individual ICH patients without WOLS and baseline variables and outcome were compared. Results: The cohort comprised 590 ICH patients with mean age of 67 years, 42% women, 76% white and 18% WOLS. Factors used to create the PS for WOLS included age, pre-ICH mRS, GCS, ICH volume, intraventricular hemorrhage, pre-existing hypertension, diabetes and atrial fibrillation, first temperature and intubation. Matches were possible for 78 WOLS/non-WOLS pairs. Groups were well matched on all PS factors, mean age (67 years), GCS (6.4), ICH volume (59cc) and % intubation (59). Discharge mRS in the both groups varied from 3-6 and was for the WOLS group 1.3%, 2.6%, 6.4% and 90% respectively; in the matched non-WOLS group discharge mRS was 6.4%, 32%, 24% and 37% respectively (difference p Conclusions: The proportion of ICH patients with WOLS that might have had an acceptable outcome without WOLS was ~38%. This discharge “acceptable outcome” of mRS

Background: The modified Rankin Scale (mRS) is a commonly used instrument to measure outcome in stroke research and is often dichotomized into good and poor outcome. Quality of life (QoL) is likely affected by factors besides level of disability. The goal of this study was to assess the correlation between the mRS and a more patient-centered QOL measure, the European QoL visual analog scale (EQVAS). Methods: The Medic One Stroke Study reviewed pre-hospital and hospital records from 11 acute care hospitals in the Seattle area from June 2000-January 2003. Subjects with a final hospital diagnosis of stroke were telephoned 3-4 months after stroke onset and both mRS (0-6, with 0 the best) and EQ VAS (0-100 with 100 best) were assessed. Results: We identified 574 patients with stroke: 420 ischemic stroke (IS), 121 intraparenchymal hemorrhage (IPH) and 33 subarachnoid hemorrhage (SAH). At three months after discharge, the proportion with mRS of ≤ 3 varied significantly with stroke type: 50% IS, 20% IPH, and 27% SAH (p Conclusion: Following stroke, QoL decreases with increasing mRS, but exceptions exist with good QoL despite high mRS scores. In the endeavor to advance patient-centeredness as a core component of quality health care, factors other than disability need further exploration, both by researchers doing clinical trials as well as by physicians making treatment recommendations.

Background Post-stroke seizures (PSS) have a devastating effect on morale and may further impair an already compromised quality of life. The reported incidence of PSS is 5-12%, but may be higher in patients with malignant MCA stroke requiring decompressive hemicraniectomy. Seizure prophylaxis for stroke survivors is not recommended, and little guidance exists about the use of prophylactic antiepileptic drugs (AEDs) after neurosurgical procedures. We aimed to determine the incidence of seizures after hemicraniectomy in stroke survivors and to identify risk factors for development of seizures after stroke. Via telephone interview, we explored patients own experience after their stroke. Methods We reviewed charts of patients aged 18-99 with malignant MCA infarction who underwent decompressive hemicraniectomy from Jan 1, 2002 to Dec 31, 2008. We looked for seizures that occurred after their stroke and for clinical and imaging factors related to those. All patients who consented to a telephone interview were contacted to inquire about seizure history. Seizure-free survival analysis was used, with log rank testing for associations. Results We identified 38 patients, mean follow-up time was 504 days (IQR 140-857). Nearly half of patients suffered a seizure (18/38) and the seizures were difficult to control in 9/18. Four patients suffered their first seizure during initial hospitalization. For 14/18, the first seizure occurred after or around cranioplasty and mostly at home. Perioperative seizure prophylaxis was variable and did not influence seizure occurrence. Older age showed a trend towards increased seizure risk (log rank p=.09). Neither gender, race, severity, location or hemorrhagic transformation were associated with development of post-stroke seizures. Modified Rankin Scale score (mRS) at discharge was 4 or above in all patients. By last follow-up, 17/38 patients had a mRS of 3 or better. Patients who suffered a seizure did not feel well prepared for the possibility of PSS, and for some the seizures were considered a major setback. Among those who responded to the questionnaire (n=14, 12 had seizures), all would have wanted to know whether or not they were at high risk for developing PSS, and would have opted to take anti-epileptic medications for seizure prophylaxis. Conclusions The frequency of seizures after malignant MCA stroke requiring decompressive hemicraniectomy is higher than expected, and the seizures often difficult to control.

To the Editor: The Cerebral Hematoma And NXY Treatment (CHANT) investigators found no association between the use of antiplatelet therapy (APT) and intraparenchymal hemorrhage (IPH) volume, growth, or outcome. In the paper and accompanying editorial, authors concluded that acute reversal of antiplatelet medications was not justified.1,2⇓ The literature on the topic yields conflicting results with some papers3–6⇓⇓⇓ supporting an association between APT and outcome from IPH and others not.1,7–9⇓ …

> The left side of my body, > > It feels as if it's dead. > > My right side says it's time to go, > > But I say, …