In this episode of Hot Topics, Dr. Nicholas Morris interviews Dr. Giuseppe Citerio, professor of anesthesia and intensive care at Milano-Bicocca University, about the ORANGE study, which investigated the neurological pupil index (NPI) for prognosticating outcomes in patients with acute brain injury. The study, involving 13 centers in Europe and North America, found that repeat abnormal NPI values, including zero, were predictors of poor outcomes. The study collected data every four hours for seven days and used a sophisticated statistical model to account for longitudinal changes. Despite initial expectations, the study did not find a strong correlation between the NPI and ICP, suggesting NPI should not be used as a surrogate for ICP. Future research may focus on developing a standardized response to low NPI values.

Show Notes:

https://doi.org/10.1016/S1474-4422(23)00271-5

Oddo M, Taccone FS, Petrosino M, Badenes R, Blandino-Ortiz A, Bouzat P, Caricato A, Chesnut RM, Feyling AC, Ben-Hamouda N, Hemphill JC. The Neurological Pupil index for outcome prognostication in people with acute brain injury (ORANGE): a prospective, observational, multicentre cohort study. The Lancet Neurology. 2023 Oct 1;22(10):925-33.

On September 2022, Cameron Kuklick fell from a motorized rental scooter while returning to his hotel after celebrating his brother’s wedding in Harrisonburg, Virginia. Cameron experienced a severe traumatic brain injury (TBI) at the age of 30. Cameron and his family hope that by sharing their story and experiences, they too can provide hope and healing for others. In this week’s episode, Cameron joins Dr. Lauren Koffman and Dea Mahanes, DNP, APRN, CCNS, HEC-C, FNCS, who was on Cameron's care team, to discuss his Story of Hope.

You can read Cameron's story in Currents at https://currents.neurocriticalcare.org/Stories-of-Hope/Article/unbroken-stride-camerons-story-of-hope-overcoming-brain-injury-to-cross-the-finish-line.

In this week's episode of Perspectives, Dr Nicholas Morris is joined by NCS Past President, Dr Gretchen Brophy, Professor of Pharmacotherapy & Outcomes Sciences and Neurosurgery with Virginia Commonwealth University (VCU) School of Pharmacy, Medical College of Virginia Campus, in Richmond.

Electroencephalography (EEG) is an important and relatively inexpensive tool that allows intensivists to monitor cerebral activity of critically ill patients in real time. Seizure detection in patients with and without acute brain injury is the primary reason to obtain an EEG in the Intensive Care Unit (ICU); and in response to the increased demand for EEG, advances in quantitative EEG (qEEG) created an approach to review large amounts of data instantly. Today, rapid response EEG is now available to reduce the time to detect electrographic seizures in limited-resource settings. In this week's MasterClass, our hosts Dr Jon Rosenberg and Dr Stephan Mayer are joined by Dr Lawerence Hirsch, Co-Director of the Critical Care EEG Monitoring Program at Yale School of Medicine to discuss the evolution, value, and impact of brain monitoring with EEG in the critically ill. 

The purpose of informed consent, as it exists now, is primarily to maintain patient autonomy, but additional benefits include the protection of patients, avoidance of fraud, and promotion of rational decisions, amongst others. It is now considered both an ethical and legal obligation which should, at a minimum, always include: 1) the nature of the procedure, 2) the risks and benefits of the procedure, 3) reasonable alternatives, and 4) risks and benefits of alternatives, with an assessment of comprehension of these elements (1). This week Dr Lauren Koffman is joined by Clotilde Balucani, MD and Julia Durrant, MD two of the authors of the recent Currents article Consent for Brain Death Determination - the ends justify the means... or it does not.

It is unknown whether decompressive craniectomy improves clinical outcome for people with spontaneous severe deep intracerebral haemorrhage. The SWITCH trial aimed to assess whether decompressive craniectomy plus best medical treatment in these patients improves outcome at 6 months compared to best medical treatment alone. The SWITCH Trial has come to an end and the findings published in The Lancet and in this week's HOT TOPICS episode, Dr. Nicholas Morris is joined by two of the lead authors, Prof. Jürgen Beck, MD and Prof. Urs Fischer, MD to discuss the trial.

Patients with acute intracerebral hemorrhage who are receiving factor Xa inhibitors have a risk of hematoma expansion. The effect of andexanet alfa, an agent that reverses the effects of factor Xa inhibitors, on hematoma volume expansion had not been well studied, until the ANNEXA-I Trial. To discuss this week's Hot Topic, Nicholas Morris, MD is joined by one of the trial's collaborators, Ashkan Shoamanesh, MD as well as clincial pharmacist Andrew Webb, PharmD, BCCCP. 

Listeners can also join the NCS Journal Club which will be discussing the ANNEXA-I Trial on "X" / Twitter on Tuesday, July 16th starting at 9am CT.

In this week's episode of Perspectives, Dr Nicholas Morris is joined by Dr Monisha Kumar, FNCS, Professor of Neurology at the Hospital of the University of Pennsylvania to discuss the threats to diversity, equity, and inclusion in neurocritical care.

As clinicians working with patients who have sustained an acute brain injury, we are naturally focused on caring for the injury itself. Until recent years, the clinical severity of brain injury was regarded as the main driver of prognosis and outcomes. However, we are beginning to understand how non-clinical factors, including the social determinants of health (SDOH), contribute to differential risk for all brain injuries including hemorrhagic stroke, and continue to impact our patients’ recovery even after injury. In this week's episode Dr Lauren Koffman is joined by Dr Nirupama Yechoor and Dr Rachel Forman to discuss how understanding the complex interplay between clinical and social determinants of health is crucial for clinicians caring for hemorrhagic stroke survivors, not only for recovery and secondary prevention, but also to effectively counsel families on primary prevention. Lauren is also joined by Mike Foster, a member of Yale's Stroke Patient Advisory Board who talks about his experience as a stroke survivor.

You can read the Currents article at https://currents.neurocriticalcare.org/Leading-Insights/Article/innovation-for-health-disparities-research-in-hemorrhagic-stroke. 

Stroke survivors or those who care for loved ones who have had a stroke can sign-up for Dr Yechoor's study at https://rally.massgeneralbrigham.org/study/strokewellbeing. 

For the latest episode in our Hot Topics series, Dr Nicholas Morris, FCNS is joined by Dr Jennifer Frontera, FNCS to discuss the NCS Guidelines for Seizure Prophylaxis in Adults Hospitalized with Moderate-Severe Traumatic Brain Injury. 

Download the guidelines at https://link.springer.com/article/10.1007/s12028-023-01907-x. 

In this week's PERSPECTIVES episode, Dr Nicholas Morris is joined by Dr Daryl Gress, Professor of Neurological Sciences at the University of Nebraska to discuss Dr Gress' lessons learned while building a new neurocritical care unit and training program at UCSF.