Bio


Dr. Venkatasubramanian is a board certified neurologist, vascular neurologist and neurocriticial care physician. She completed her residency training in internal medicine from India and neurology residency and stroke/neurocritical care fellowships at Stanford University Medical Center. She holds a Masters degree in Clinical Trials from University of London. She is a board certified neurosonologist. She has been on faculty since 2007. Her primary focus is the clinical care of critically ill patients in the neurological and other intensive care units and patients with acute stroke and TIA in the inpatient stroke unit. In addition, she sees patients with stroke and neurovascular diseases in her stroke clinic as well as patients discharged from the neurological ICU in the Outcomes clinic. Her main interests are in brain hemorrhage, unusual and rare causes of stroke, cerebral venous thrombosis, anticoagulation management after strokes and use of technology for improving outcomes in the neurological ICU.
Her research focuses on the study of intracerebral hemorrhage using brain imaging with CT and MRI. She is the Stanford prinicipal investigator for several clinical trials in intracerebral hemorrhage and large hemispheric infarction. She oversees guideline development for the Neurocritical Care Society, serves as a voting member for medical school admissions to Stanford and represents the neurology department at the Faculty Senate. She enjoys cooking, yoga, Bollywood fitness.

Clinical Focus


  • Neurocritical Care
  • Stroke
  • Traumatic Brain Injury
  • Intracerebral Hemorrhage
  • Vascular Neurology

Academic Appointments


Administrative Appointments


  • Associate Chair, Faculty Affairs, Neurology, Stanford University (2023 - Present)

Honors & Awards


  • Gold Medal in Pathology, Indian Association of Pathologists and Microbiologists (1993)
  • Gold Medal for "Best Outgoing Student in M.B.B.S", Indian Medical Association (1996)
  • Gold Medal in Cardiology, Cardiological and Electrophysiological Society of India (1999)
  • Fellowship Award for Clinical Research, Neurocritical Care Society (2005)

Professional Education


  • Board Certification: American Board of Psychiatry and Neurology, Neurocritical Care (2021)
  • Board Certification: American Board of Psychiatry and Neurology, Neurology (2018)
  • Board Certification: American Board of Psychiatry and Neurology, Vascular Neurology (2008)
  • Board Certification: United Council for Neurologic Subspecialties, Neurocritical Care (2007)
  • Fellowship: Stanford University Vascular Neurology Fellowship (2006) CA
  • Residency: Stanford University Neurology Residency (2005) CA
  • Internship: Kaiser Permanente Santa Clara Internal Medicine Residency (2002) CA
  • Residency: Coimbatore Medical College (1999) India
  • Board Certification, American Society of Neuroimaging, Neurosonology (2010)
  • Board Certification, United Council of Neurologic Subspecialties, Neurocritical Care (2007)
  • Medical Education: Coimbatore Medical College (1999) India
  • M.B.B.S., Dr MGR Medical University India, Medicine (1996)

Current Research and Scholarly Interests


I care for neurologically critically ill patients in the intensive care unit and patients with acute stroke and TIA in the inpatient stroke unit. I also see outpatients in a stroke clinic and conduct follow-up of patients discharged from the neurological ICU, in the “Outcomes clinic”.
I am interested in the study of the radiological characteristics and temporal profile of edema/ tissue injury in the perihematomal area around spontaneous intracerebral hemorrhage. I am also interested in developing protocols for emergent reversal of anticoagulation in a life-threatening hemorrhage situation.

Clinical Trials


  • Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage Phase III Recruiting

    The overall objective of this Phase III clinical trial is to obtain information from a population of 500 ICH subjects with intraventricular hemorrhage (IVH), representative of current clinical practice and national demographics of ICH regarding the benefit (or lack thereof) of IVH clot removal on subject function as measured by modified Rankin Scale (mRS). This application requests funding for five years to initiate a Phase III randomized clinical trial (RCT) testing the benefit of clot removal for intraventricular hemorrhage. The investigators propose to compare extraventricular drainage (EVD) use plus recombinant tissue plasminogen activator (rt-PA; Alteplase; Genentech, Inc., San Francisco, CA) with EVD+ placebo in the management and treatment of subjects with small intracerebral hemorrhage (ICH) and large intraventricular hemorrhage (IVH defined as ICH < 30 cc and obstruction of the 3rd or 4th ventricles by intraventricular blood clot).

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  • High-Dose Deferoxamine in Intracerebral Hemorrhage Recruiting

    The main purpose of this study is to determine whether treatment with deferoxamine mesylate is of sufficient promise to improve outcome before pursuing a larger clinical trial to examine its effectiveness as a treatment for brain hemorrhage.

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  • Minimally Invasive Surgery Plus Rt-PA for ICH Evacuation Phase III Recruiting

    A phase III, randomized, case-controlled, open-label, 500-subject clinical trial of minimally invasive surgery plus rt-PA in the treatment of intracerebral hemorrhage (ICH).

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  • Antihypertensive Treatment of Acute Cerebral Hemorrhage-II Not Recruiting

    The specific aims of this study are to: 1. Definitively determine the therapeutic benefit of the intensive treatment relative to the standard treatment in the proportion of patients with death and disability (mRS 4-6) at 3 months among subjects with ICH who are treated within 4.5 hours of symptom onset. 2. Evaluate the therapeutic benefit of the intensive treatment relative to the standard treatment in the subjects' quality of life as measured by EuroQol at 3 months. 3. Evaluate the therapeutic benefit of the intensive treatment relative to the standard treatment in the proportion of hematoma expansion (defined as increase from baseline hematoma volume of at least 33%) and in the change from baseline peri-hematoma volume at 24 hours on the serial computed tomographic (CT) scans. 4. Assess the safety of the intensive treatment relative to the standard treatment in the proportion of subjects with treatment-related serious adverse events (SAEs) within 72 hours.

    Stanford is currently not accepting patients for this trial. For more information, please contact Rosen Mann, (650) 721-2645.

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  • Computed Tomography Perfusion (CTP) to Predict Response to Recanalization in Ischemic Stroke Project (CRISP) Not Recruiting

    The overall goal of the CTP to predict Response to recanalization in Ischemic Stroke Project (CRISP) is to develop a practical tool to identify acute stroke patients who are likely to benefit from endovascular therapy. The project has two main parts. During the first part, the investigators propose to develop a fully automated system (RAPID) for processing of CT Perfusion (CTP) images that will generate brain maps of the ischemic core and penumbra. There will be no patient enrollment in part one of this project. During the second part, the investigators aim to demonstrate that physicians in the emergency setting, with the aid of a fully automated CTP analysis program (RAPID), can accurately predict response to recanalization in stroke patients undergoing revascularization. To achieve this aim the investigators will conduct a prospective cohort study of 240 consecutive stroke patients who will undergo a CTP scan prior to endovascular therapy. The study will be conducted at four sites (Stanford University, St Luke's Hospital, University of Pittsburgh Medical Center, and Emory University/Grady Hospital). Patients will have an early follow-up MRI scan within 12+/-6 hours to assess reperfusion and a late follow-up MRI scan at day 5 to determine the final infarct.

    Stanford is currently not accepting patients for this trial. For more information, please contact Stephanie M Kemp, BS, 650-723-4481.

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  • Efficacy and Safety Study of Desmoteplase to Treat Acute Ischemic Stroke (DIAS-4) Not Recruiting

    The purpose of the study is to determine whether desmoteplase is effective and safe in the treatment of patients with acute ischaemic stroke when given within 3 to 9 hours from onset of stroke symptoms.

    Stanford is currently not accepting patients for this trial. For more information, please contact Maarten Lansberg, (650) 723 - 4448.

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  • Efficacy and Safety Trial of Transcranial Laser Therapy Within 24 Hours From Stroke Onset (NEST-3) Not Recruiting

    The purpose of this pivotal study is to demonstrate safety and efficacy of transcranial laser therapy (TLT) with the NeuroThera® Laser System in the treatment of subjects diagnosed with acute ischemic stroke. The initiation of the TLT procedure must be feasible for each subject between 4.5 and 24 hours of stroke onset.

    Stanford is currently not accepting patients for this trial. For more information, please contact Stephanie Kemp, (650) 723 - 4481.

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  • Imaging Collaterals in Acute Stroke (iCAS) Not Recruiting

    Stroke is caused by a sudden blockage of a blood vessel that delivers blood to the brain. Unblocking the blood vessel with a blood clot removal device restores blood flow and if done quickly may prevent the disability that can be caused by a stroke. However, not all stroke patients benefit from having their blood vessel unblocked. The aim of this study is to determine if special brain imaging, called MRI, can be used to identify which stroke patients are most likely to benefit from attempts to unblock their blood vessel with a special blood clot removal device. In particular, we will assess in this trial whether a noncontrast MR imaging sequence, arterial spin labeling (ASL), can demonstrate the presence of collateral blood flow (compared with a gold standard of the angiogram) and whether it is useful to predict who will benefit from treatment.

    Stanford is currently not accepting patients for this trial. For more information, please contact Gregory Zaharchuk, MD, 650-723-4448.

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  • Insulin Resistance Intervention After Stroke Trial Not Recruiting

    The purpose of this study is to determine if pioglitazone is effective in preventing future strokes or heart attacks among non-diabetic persons who have had a recent ischemic stroke.

    Stanford is currently not accepting patients for this trial. For more information, please contact Madelleine Garcia, (650) 725 - 2326.

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  • Progesterone for the Treatment of Traumatic Brain Injury III Not Recruiting

    The ProTECT study will determine if intravenous (IV) progesterone (started within 4 hours of injury and given for a total of 96 hours), is more effective than placebo for treating victims of moderate to severe acute traumatic brain injury.

    Stanford is currently not accepting patients for this trial. For more information, please contact Rosen Mann, (650) 721 - 2645.

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  • Transient Ischemic Attack (TIA) Triage and Evaluation of Stroke Risk Not Recruiting

    Transient ischemic attack (TIA) is a transient neurological deficit (speech disturbance, weakness…), caused by temporary occlusion of a brain vessel by a blood clot that leaves no lasting effect. TIA diagnosis can be challenging and an expert stroke evaluation combined with magnetic resonance imaging (MRI) could improve the diagnosis accuracy. The risk of a debilitating stroke can be as high as 5% during the first 72 hrs after TIA. TIA characteristics (duration, type of symptoms, age of the patient), the presence of a significant narrowing of the neck vessels responsible for the patient's symptoms (symptomatic stenosis), and an abnormal MRI are associated with an increased risk of stroke. An emergent evaluation and treatment of TIA patients by a stroke specialist could reduce the risk of stroke to 2%. Stanford has implemented an expedited triage pathway for TIA patients combining a clinical evaluation by a stroke neurologist, an acute MRI of the brain and the vessels and a sampling of biomarkers (Lp-PLA2). The investigators are investigating the yield of this unique approach to improve TIA diagnosis, prognosis and secondary stroke prevention. The objective of this prospective cohort study is to determine which factors will help the physician to confirm the diagnosis of TIA and to define the risk of stroke after a TIA.

    Stanford is currently not accepting patients for this trial. For more information, please contact Stephanie Kemp, BS, 650-723-4481.

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2023-24 Courses


All Publications


  • Automated cerebral hemorrhage volume calculation and stability detection using automated software. Research square Sreekrishnan, A., Venkatasubramanian, C., Heit, J. J. 2023

    Abstract

    The measurement of intracerebral hemorrhage (ICH) volume is important for management, particularly in evaluating expansion on subsequent imaging. However manual volumetric analysis is time-consuming, especially in busy hospital settings. We aimed to use automated Rapid Hyperdensity software to accurately measure ICH volume across repeated imaging.We identified ICH cases, with repeat imaging conducted within 24 hours, from two randomized clinical trials where enrollment was not based on ICH volume. Scans were excluded if there was (1) severe CT artifacts, (2) prior neurosurgical procedures, (3) recent intravenous contrast, or (4) ICH < 1 ml. Manual ICH measurements were conducted by one neuroimaging expert using MIPAV software and compared to the performance of automated software.127 patients were included with median baseline ICH volume manually measured at 18.18 cc (IQR: 7.31 - 35.71) compared to automated detection of 18.93 cc (IQR: 7.55, 37.88). The two modalities were highly correlated (r = 0.994, p < 0.001). On repeat imaging, the median absolute difference in ICH volume was 0.68cc (IQR: -0.60-4.87) compared to automated detection at 0.68cc (IQR: -0.45-4.63). These absolute differences were also highly correlated (r = 0.941, p < 0.001), with the ability of the automated software to detect ICH expansion with a Sensitivity of 94.12% and Specificity 97.27%.In our proof-of-concept study, the automated software has high reliability in its ability to quickly determine IPH volume with high sensitivity and specificity and to detect expansion on subsequent imaging.

    View details for DOI 10.21203/rs.3.rs-2944493/v1

    View details for PubMedID 37292654

    View details for PubMedCentralID PMC10246251

  • Transcranial Direct Current Stimulation for Focal Status Epilepticus or Lateralized Periodic Discharges in Four Patients in a Critical Care Setting. Epilepsia Fisher, R. S., McGinn, R. J., Von Stein, E. L., Wu, T. Q., Qing, K. Y., Fogarty, A., Razavi, B., Venkatasubramanian, C. 2023

    Abstract

    OBJECTIVE: Transcranial direct current stimulation (tDCS) has been advocated for various neurological conditions, including epilepsy. A 1-4 mA cathodal current applied to the scalp over a seizure focus can reduce spikes and seizures. This series of four patients with focal status epilepticus is among the first case series to demonstrate benefit of tDCS in the critical care setting.METHODS: Patients in the intensive care unit were referred for tDCS treatment when focal status or clinically-relevant lateralized periodic discharges did not resolve with conventional anti-seizure medications and anesthetics. Battery-powered direct cathodal current at 2 mA was delivered by an ActivaDose (Caputron) tDCS device via a saline soaked sponge on the scalp over the seizure focus. Anode was on the contralateral forehead or shoulder. Treatment was for 30 minutes, repeated twice in a day, then again 1-4 times more over the next few days.RESULTS: Three females and one male, ages 34-68 were treated. Etiologies of status were PRES in association with immunosuppressants for a liver transplant, perinatal hypoxic-ischemic injury, a prior cardioembolic parietal stroke and CNS lupus. tDCS led to significant reduction of interictal spikes (0.78/s to 0.38/s, p<0.0001) in 3 cases and electrographic seizures (3.83/hr to 0/hr, p<0.001) in two cases. Medication reductions were enabled in all cases subsequent to tDCS. The only side effect of tDCS was transient erythema under the sponge in one case. Two patients died of causes unrelated to tDCS, one was discharged to a nursing home and one became fully responsive as seizures were controlled with tDCS.SIGNIFICANCE: Spikes and electrographic seizure frequency significantly improved within a day of tDCS. Results are potentially confounded by multiple ongoing changes in medications and treatments. These results might encourage further investigation of tDCS in the critical care setting, but verification by controlled studies will be required.

    View details for DOI 10.1111/epi.17514

    View details for PubMedID 36661376

  • Prognostication of ICU Patients by Providers with and without Neurocritical Care Training. Neurocritical care Finley Caulfield, A., Mlynash, M., Eyngorn, I., Lansberg, M. G., Afjei, A., Venkatasubramanian, C., Buckwalter, M. S., Hirsch, K. G. 2022

    Abstract

    BACKGROUND: Predictions of functional outcome in neurocritical care (NCC) patients impact care decisions. This study compared the predictive values (PVs) of good and poor functional outcome among health care providers with and without NCC training.METHODS: Consecutive patients who were intubated for≥72h with primary neurological illness or neurological complications were prospectively enrolled and followed for 6-month functional outcome. Medical intensive care unit (MICU) attendings, NCC attendings, residents (RES), and nurses (RN) predicted 6-month functional outcome on the modified Rankin scale (mRS). The primary objective was to compare these four groups' PVs of a good (mRS score 0-3) and a poor (mRS score 4-6) outcome prediction.RESULTS: Two hundred eighty-nine patients were enrolled. One hundred seventy-six had mRS scores predicted by a provider from each group and were included in the primary outcome analysis. At 6months, 54 (31%) patients had good outcome and 122 (69%) had poor outcome. Compared with other providers, NCC attendings expected better outcomes (p<0.001). Consequently, the PV of a poor outcome prediction by NCC attendings was higher (96%[95% confidence interval [CI] 89-99%]) than that by MICU attendings (88% [95% CI 80-93%]), RES (82% [95% CI 74-88%]), and RN (85% [95% CI 77-91%]) (p=0.047, 0.002, and 0.012, respectively). When patients who had withdrawal of life-sustaining therapy (n=67) were excluded, NCC attendings remained better at predicting poor outcome (NCC 90% [95% CI 75-97%] vs. MICU 73% [95% CI 59-84%], p=0.064). The PV of a good outcome prediction was similar among groups (MICU 65% [95% CI 52-76%], NCC 63% [95% CI 51-73%], RES 71% [95% CI 55-84%], and RN 64% [95% CI 50-76%]).CONCLUSIONS: Neurointensivists expected better outcomes than other providers and were better at predicting poor functional outcomes. The PV of a good outcome prediction was modest among all providers.

    View details for DOI 10.1007/s12028-022-01467-6

    View details for PubMedID 35314970

  • Surgical Management of Spontaneous Intracerebral Hemorrhage CURRENT TREATMENT OPTIONS IN NEUROLOGY Walia, S., Fisher, K., Dodd, R. L., Venkatasubramanian, C. 2021; 23 (8)
  • Standardized Nomenclature for Modified Rankin Scale Global Disability Outcomes: Consensus Recommendations From Stroke Therapy Academic Industry Roundtable XI. Stroke Saver, J. L., Chaisinanunkul, N., Campbell, B. C., Grotta, J. C., Hill, M. D., Khatri, P., Landen, J., Lansberg, M. G., Venkatasubramanian, C., Albers, G. W., XIth Stroke Treatment Academic Industry Roundtable 2021: STROKEAHA121034480

    Abstract

    The modified Rankin Scale (mRS), a 7-level, clinician-reported, measure of global disability, is the most widely employed outcome scale in acute stroke trials. The scale's original development preceded the advent of modern clinimetrics, but substantial subsequent work has been performed to enable the mRS to meet robust contemporary scale standards. Prior research and consensus recommendations have focused on modernizing 2 aspects of the mRS: operationalized assignment of scale scores and statistical analysis of scale distributions. Another important characteristic of the mRS still requiring elaboration and specification to contemporary clinimetric standards is the Naming of scale outcomes. Recent clinical trials have used a bewildering variety, often mutually contradictory, of rubrics to describe scale states. Understanding of the meaning of mRS outcomes by clinicians, patients, and other clinical trial stakeholders would be greatly enhanced by use of a harmonized, uniform set of labels for the distinctive mRS outcomes that would be used consistently across trials. This statement advances such recommended rubrics, developed by the Stroke Therapy Academic Industry Roundtable collaboration using an iterative, mixed-methods process. Specific guidance is provided for health state terms (eg, Symptomatic but Nondisabled for mRS score 1; requires constant care for mRS score 5) and valence terms (eg, excellent for mRS score 1; very poor for mRS score 5) to employ for 23 distinct numeric mRS outcomes, including: all individual 7 mRS levels; all 12 positive and negative dichotomized mRS ranges, positive and negative sliding dichotomies; and utility-weighted analysis of the mRS.

    View details for DOI 10.1161/STROKEAHA.121.034480

    View details for PubMedID 34320814

  • Acute Stroke Imaging Research Roadmap IV: Imaging Selection and Outcomes in Acute Stroke Clinical Trials and Practice. Stroke Campbell, B. C., Lansberg, M. G., Broderick, J. P., Derdeyn, C. P., Khatri, P., Sarraj, A., Saver, J. L., Vagal, A., Albers, G. W., STAIR XI Consortium, Adeoye, O., Ansari, S., Boltze, J., Buchan, A., Chaisinanunkul, N., Chen, C., Davis, T. P., Ermakova, T., Fisher, M., Haddad, W., Hill, M. D., Houser, G., Jadhav, A. P., Kimberly, W. T., Landen, J. W., Liebeskind, D. S., Lyden, P., Lynch, J., Mansi, C., Mocco, J., Nogueira, R. G., Savitz, S. I., Schwamm, L. H., Sheth, K. N., Solberg, Y., Venkatasubramanian, C., Warach, S., Wechsler, L. R., Zhu, B., Ziogas, N. K. 2021: STROKEAHA121035132

    Abstract

    BACKGROUND AND PURPOSE: The Stroke Treatment Academic Industry Roundtable (STAIR) sponsored an imaging session and workshop during the Stroke Treatment Academic Industry Roundtable XI via webinar on October 1 to 2, 2020, to develop consensus recommendations, particularly regarding optimal imaging at primary stroke centers.METHODS: This forum brought together stroke neurologists, neuroradiologists, neuroimaging research scientists, members of the National Institute of Neurological Disorders and Stroke, industry representatives, and members of the US Food and Drug Administration to discuss imaging priorities in the light of developments in reperfusion therapies, particularly in an extended time window, and reinvigorated interest in brain cytoprotection trials.RESULTS: The imaging session summarized and compared the imaging components of recent acute stroke trials and debated the optimal imaging strategy at primary stroke centers. The imaging workshop developed consensus recommendations for optimizing the acquisition, analysis, and interpretation of computed tomography and magnetic resonance acute stroke imaging, and also recommendations on imaging strategies for primary stroke centers.CONCLUSIONS: Recent positive acute stroke clinical trials have extended the treatment window for reperfusion therapies using imaging selection. Achieving rapid and high-quality stroke imaging is therefore critical at both primary and comprehensive stroke centers. Recommendations for enhancing stroke imaging research are provided.

    View details for DOI 10.1161/STROKEAHA.121.035132

    View details for PubMedID 34233464

  • Reversible Cerebral Vasoconstriction Syndrome in Patients with Coronavirus Disease: A Multicenter Case Series. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association Arandela, K., Samudrala, S., Abdalkader, M., Anand, P., Daneshmand, A., Dasenbrock, H., Nguyen, T., Ong, C., Takahashi, C., Shulman, J., Babi, M. A., Sivakumar, S., Shah, N., Jain, S., Anand, S., Nobleza, C. O., Shekhar, S., Venkatasubramanian, C., Salahuddin, H., Taqi, M. A., Nour, H. A., Nofar, J. B., Cervantes-Arslanian, A. M. 2021; 30 (12): 106118

    Abstract

    RCVS (Reversible Cerebral Vasoconstrictive Syndrome) is a condition associated with vasoactive agents that alter endothelial function. There is growing evidence that endothelial inflammation contributes to cerebrovascular disease in patients with coronavirus disease 2019 (COVID-19). In our study, we describe the clinical features, risk factors, and outcomes of RCVS in a multicenter case series of patients with COVID-19.Multicenter retrospective case series. We collected clinical characteristics, imaging, and outcomes of patients with RCVS and COVID-19 identified at each participating site.Ten patients were identified, 7 women, ages 21 - 62 years. Risk factors included use of vasoconstrictive agents in 7 and history of migraine in 2. Presenting symptoms included thunderclap headache in 5 patients with recurrent headaches in 4. Eight were hypertensive on arrival to the hospital. Symptoms of COVID-19 included fever in 2, respiratory symptoms in 8, and gastrointestinal symptoms in 1. One patient did not have systemic COVID-19 symptoms. MRI showed subarachnoid hemorrhage in 3 cases, intraparenchymal hemorrhage in 2, acute ischemic stroke in 4, FLAIR hyperintensities in 2, and no abnormalities in 1 case. Neurovascular imaging showed focal segment irregularity and narrowing concerning for vasospasm of the left MCA in 4 cases and diffuse, multifocal narrowing of the intracranial vasculature in 6 cases. Outcomes varied, with 2 deaths, 2 remaining in the ICU, and 6 surviving to discharge with modified Rankin scale (mRS) scores of 0 (n=3), 2 (n=2), and 3 (n=1).Our series suggests that patients with COVID-19 may be at risk for RCVS, particularly in the setting of additional risk factors such as exposure to vasoactive agents. There was variability in the symptoms and severity of COVID-19, clinical characteristics, abnormalities on imaging, and mRS scores. However, a larger study is needed to validate a causal relationship between RCVS and COVID-19.

    View details for DOI 10.1016/j.jstrokecerebrovasdis.2021.106118

    View details for PubMedID 34560378

  • Automated Cerebral Hemorrhage Detection Using RAPID. AJNR. American journal of neuroradiology Heit, J. J., Coelho, H., Lima, F. O., Granja, M., Aghaebrahim, A., Hanel, R., Kwok, K., Haerian, H., Cereda, C. W., Venkatasubramanian, C., Dehkharghani, S., Carbonera, L. A., Wiener, J., Copeland, K., Mont'Alverne, F. 2020

    Abstract

    BACKGROUND AND PURPOSE: Intracranial hemorrhage (ICH) is an important event that is diagnosed on head NCCT. Increased NCCT utilization in busy hospitals may limit timely identification of ICH. RAPID ICH is an automated hybrid 2D-3D convolutional neural network application designed to detect ICH that may allow for expedited ICH diagnosis. We determined the accuracy of RAPID ICH for ICH detection and ICH volumetric quantification on NCCT.MATERIALS AND METHODS: NCCT scans were evaluated for ICH by RAPID ICH. Consensus detection of ICH by 3 neuroradiology experts was used as the criterion standard for RAPID ICH comparison. ICH volume was also automatically determined by RAPID ICH in patients with intraparenchymal or intraventricular hemorrhage and compared with manually segmented ICH volumes by a single neuroradiology expert. ICH detection accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratios by RAPID ICH were determined.RESULTS: We included 308 studies. RAPID ICH correctly identified 151/158 ICH cases and 143/150 ICH-negative cases, which resulted in high sensitivity (0.956, CI: 0.911-0.978), specificity (0.953, CI: 0.907-0.977), positive predictive value (0.956, CI: 0.911-0.978), and negative predictive value (0.953, CI: 0.907-0.977) for ICH detection. The positive likelihood ratio (20.479, CI 9.928-42.245) and negative likelihood ratio (0.046, CI 0.023-0.096) for ICH detection were similarly favorable. RAPID ICH volumetric quantification for intraparenchymal and intraventricular hemorrhages strongly correlated with expert manual segmentation (correlation coefficient r=0.983); the median absolute error was 3mL.CONCLUSIONS: RAPID ICH is highly accurate in the detection of ICH and in the volumetric quantification of intraparenchymal and intraventricular hemorrhages.

    View details for DOI 10.3174/ajnr.A6926

    View details for PubMedID 33361378

  • Prognostic value of diffusion-weighted MRI for post-cardiac arrest coma. Neurology Hirsch, K. G., Fischbein, N., Mlynash, M., Kemp, S., Bammer, R., Eyngorn, I., Tong, J., Moseley, M., Venkatasubramanian, C., Caulfield, A. F., Albers, G. 2020

    Abstract

    OBJECTIVE: To validate quantitative diffusion-weighted imaging (DWI) MRI thresholds that correlate with poor outcome in comatose cardiac arrest survivors, we conducted a clinician-blinded study and prospectively obtained MRIs from comatose patients after cardiac arrest.METHODS: Consecutive comatose post-cardiac arrest adult patients were prospectively enrolled. MRIs obtained within 7 days after arrest were evaluated. The clinical team was blinded to the DWI MRI results and followed a prescribed prognostication algorithm. Apparent diffusion coefficient (ADC) values and thresholds differentiating good and poor outcome were analyzed. Poor outcome was defined as a Glasgow Outcome Scale score of ≤2 at 6 months after arrest.RESULTS: Ninety-seven patients were included, and 75 patients (77%) had MRIs. In 51 patients with MRI completed by postarrest day 7, the prespecified threshold of >10% of brain tissue with an ADC <650 *10-6 mm2/s was highly predictive for poor outcome with a sensitivity of 0.63 (95% confidence interval [CI] 0.42-0.80), a specificity of 0.96 (95% CI 0.77-0.998), and a positive predictive value (PPV) of 0.94 (95% CI 0.71-0.997). The mean whole-brain ADC was higher among patients with good outcomes. Receiver operating characteristic curve analysis showed that ADC <650 *10-6 mm2/s had an area under the curve of 0.79 (95% CI 0.65-0.93, p < 0.001). Quantitative DWI MRI data improved prognostication of both good and poor outcomes.CONCLUSIONS: This prospective, clinician-blinded study validates previous research showing that an ADC <650 *10-6 mm2/s in >10% of brain tissue in an MRI obtained by postarrest day 7 is highly specific for poor outcome in comatose patients after cardiac arrest.

    View details for DOI 10.1212/WNL.0000000000009289

    View details for PubMedID 32269116

  • Guidelines for the Acute Treatment of Cerebral Edema in Neurocritical Care Patients. Neurocritical care Cook, A. M., Morgan Jones, G. n., Hawryluk, G. W., Mailloux, P. n., McLaughlin, D. n., Papangelou, A. n., Samuel, S. n., Tokumaru, S. n., Venkatasubramanian, C. n., Zacko, C. n., Zimmermann, L. L., Hirsch, K. n., Shutter, L. n. 2020

    Abstract

    Acute treatment of cerebral edema and elevated intracranial pressure is a common issue in patients with neurological injury. Practical recommendations regarding selection and monitoring of therapies for initial management of cerebral edema for optimal efficacy and safety are generally lacking. This guideline evaluates the role of hyperosmolar agents (mannitol, HTS), corticosteroids, and selected non-pharmacologic therapies in the acute treatment of cerebral edema. Clinicians must be able to select appropriate therapies for initial cerebral edema management based on available evidence while balancing efficacy and safety.The Neurocritical Care Society recruited experts in neurocritical care, nursing, and pharmacy to create a panel in 2017. The group generated 16 clinical questions related to initial management of cerebral edema in various neurological insults using the PICO format. A research librarian executed a comprehensive literature search through July 2018. The panel screened the identified articles for inclusion related to each specific PICO question and abstracted necessary information for pertinent publications. The panel used GRADE methodology to categorize the quality of evidence as high, moderate, low, or very low based on their confidence that the findings of each publication approximate the true effect of the therapy.The panel generated recommendations regarding initial management of cerebral edema in neurocritical care patients with subarachnoid hemorrhage, traumatic brain injury, acute ischemic stroke, intracerebral hemorrhage, bacterial meningitis, and hepatic encephalopathy.The available evidence suggests hyperosmolar therapy may be helpful in reducing ICP elevations or cerebral edema in patients with SAH, TBI, AIS, ICH, and HE, although neurological outcomes do not appear to be affected. Corticosteroids appear to be helpful in reducing cerebral edema in patients with bacterial meningitis, but not ICH. Differences in therapeutic response and safety may exist between HTS and mannitol. The use of these agents in these critical clinical situations merits close monitoring for adverse effects. There is a dire need for high-quality research to better inform clinicians of the best options for individualized care of patients with cerebral edema.

    View details for DOI 10.1007/s12028-020-00959-7

    View details for PubMedID 32227294

  • Catecholamine-induced cerebral vasospasm and multifocal infarctions in pheochromocytoma. Endocrinology, diabetes & metabolism case reports Madhok, J. n., Kloosterboer, A. n., Venkatasubramanian, C. n., Mihm, F. G. 2020; 2020

    Abstract

    We report the case of a 76-year-old male with a remote history of papillary thyroid cancer who developed severe paroxysmal headaches in the setting of episodic hypertension. Brain imaging revealed multiple lesions, initially of inconclusive etiology, but suspicious for metastatic foci. A search for the primary malignancy revealed an adrenal tumor, and biochemical testing confirmed the diagnosis of a norepinephrine-secreting pheochromocytoma. Serial imaging demonstrated multiple cerebral infarctions of varying ages, evidence of vessel narrowing and irregularities in the anterior and posterior circulations, and hypoperfusion in watershed areas. An exhaustive work-up for other etiologies of stroke including thromboembolic causes or vasculitis was unremarkable. There was resolution of symptoms, absence of new infarctions, and improvement in vessel caliber after adequate alpha-adrenergic receptor blockade for the management of pheochromocytoma. This clinicoradiologic constellation of findings suggested that the etiology of the multiple infarctions was reversible cerebral vasoconstriction syndrome (RCVS). Pheochromocytoma remains a poorly recognized cause of RCVS. Unexplained multifocal cerebral infarctions in the setting of severe hypertension should prompt the consideration of a vasoactive tumor as the driver of cerebrovascular dysfunction. A missed or delayed diagnosis has the potential for serious neurologic morbidity for an otherwise treatable condition.The constellation of multifocal watershed cerebral infarctions of uncertain etiology in a patient with malignant hypertension should trigger the consideration of undiagnosed catecholamine secreting tumors, such as pheochromocytomas and paragangliomas. Reversible cerebral vasoconstriction syndrome is a serious but reversible cerebrovascular manifestation of pheochromocytomas that may lead to strokes (ischemic and hemorrhagic), seizures, and cerebral edema. Alpha-adrenergic receptor blockade can reverse cerebral vasoconstriction and prevent further cerebral ischemia and infarctions. Early diagnosis of catecholamine secreting tumors has the potential for reducing neurologic morbidity and mortality in patients presenting with cerebrovascular complications.

    View details for DOI 10.1530/EDM-20-0078

    View details for PubMedID 32820130

  • Surgical Performance Determines Functional Outcome Benefit in the Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation (MISTIE) Procedure NEUROSURGERY Awad, I. A., Polster, S. P., Carrion-Penagos, J., Thompson, R. E., Cao, Y., Stadnik, A., Money, P., Fam, M. D., Koskimaeki, J., Girard, R., Lane, K., McBee, N., Ziai, W., Hao, Y., Dodd, R., Carlson, A. P., Camarata, P. J., Caron, J., Harrigan, M. R., Gregson, B. A., Mendelow, A., Zuccarello, M., Hanley, D. F., Abdul-Rahim, A., Abou-Hamden, A., Abraham, M., Ahmed, A., Alba, C., Aldrich, E., Ali, H., Altschul, D., Amin-Hanjani, S., Anderson, C. S., Anderson, D., Ansari, S., Antezana, D., Ardelt, A., Arikan, F., Avadhani, R., Baguena, M., Baker, A., Barrer, S. J., Barzo, P., Becker, K. J., Bergman, T., Betz, J. F., Bistran-Hall, A. J., Bostrom, A., Braun, J., Brindley, P., Broaddus, W. C., Brown, R., Buki, A., Bulters, D., Cao, B., Carhuapoma, J., Chalela, J., Chang, T., Chicoine, M. R., Chorro, I., Chowdhry, S., Cobb, C., Corral, L., Csiba, L., Davies, J., Dawson, J., Diaz, A., Dierdeyn, C. P., Diringer, M., Dlugash, R., Ecker, R., Economas, T., Enriquez, P., Ezer, E., Fan, Y., Feng, H., Franz, D., Freeman, W., Fusco, M., Galicich, W., Gandhi, D., Gelea, M., Goldstein, J., Gonzalez, A., Grabarits, C., Greenberg, S., Gregson, B., Gress, D., Gu, E., Gupta, G., Hall, C., Harnof, S., Hernandez, F., Hoesch, R., Hoh, B. L., Houser, J., Hu, R., Huang, J., Huang, Y., Hussain, M., Insinga, S., Jadhav, A., Jaffe, J., Jahromi, B. S., Jallo, J., James, M., James, R. F., Janis, S., Jankowitz, B., Jeon, E., Jichici, D., Jonczak, K., Jonker, B., Karlen, N., Kase, C. S., Keric, N., Kerz, T., Kitagawa, R., Knopman, J., Koenig, C., Krishnamurthy, S., Kumar, A., Kureshi, I., Laidlaw, J., Lakhanpal, A., Latorre, J., LeDoux, D., Lees, K. R., Leifer, D., Leiphart, J., Lenington, S., Li, Y., Lopez, G., Lovick, D., Lumenta, C., Luo, J., Maas, M. B., MacDonald, J., MacKenzie, L., Madan, V., Majkowski, R., Major, O., Malhorta, R., Malkoff, M., Mangat, H., Maswadeh, A., Matouk, C., Mayo, S. W., McArthur, K., McCaul, S., Medow, J., Mezey, G., Mighty, J., Miller, D., Mitchell, P., Mohan, K. K., Mould, W., Muir, K., Munoz, L., Nakaji, P., Nee, A., Nekoovaght-Tak, S., Nyquist, P., O'Kane, R., Okasha, M., O'Kelly, C., Ostapkovich, N., Pandey, A., Parry-Jones, A., Patel, H., Perla, K., Pollack, A., Pouratian, N., Quinn, T., Rajajee, V., Reddy, K., Rehman, M., Reimer, R., Rincon, F., Rosenblum, M., Rybinnik, I., Sanchez, B., Sansing, L., Sarabia, R., Schneck, M., Schuerer, L., Schul, D., Schweitzer, J., Seder, D. B., Seyfried, D., Sheth, K., Spiotta, A., Stechison, M., Sugar, E. A., Szabo, K., Tamayo, G., Tanczos, K., Taussky, P., Teitelbaum, J. S., Terry, J., Testai, F., Thomas, K., Thompson, C. B., Thompson, G., Torner, J. C., Huy Tran, Tucker, K., Ullman, N., Ungar, L., Unterberg, A., Varelas, P., Vargas, N., Vatter, H., Venkatasubramanian, C., Vermillion, K., Vespa, P., Vollmer, D., Wang, W., Wang, Y., Wang, Y., Wen, J., Whitworth, L., Willis, B., Wilson, A., Wolfe, S., Wrencher, M., Wright, S. E., Xu, Y., Yanase, L., Yenokyan, G., Yi, X., Yu, Z., Zomorodi, A., MISTIE III Trial Investigators 2019; 84 (6): 1157–67
  • Efficacy and safety of minimally invasive surgery with thrombolysis in intracerebral haemorrhage evacuation (MISTIE III): a randomised, controlled, open-label, blinded endpoint phase 3 trial. Lancet (London, England) Hanley, D. F., Thompson, R. E., Rosenblum, M., Yenokyan, G., Lane, K., McBee, N., Mayo, S. W., Bistran-Hall, A. J., Gandhi, D., Mould, W. A., Ullman, N., Ali, H., Carhuapoma, J. R., Kase, C. S., Lees, K. R., Dawson, J., Wilson, A., Betz, J. F., Sugar, E. A., Hao, Y., Avadhani, R., Caron, J., Harrigan, M. R., Carlson, A. P., Bulters, D., LeDoux, D., Huang, J., Cobb, C., Gupta, G., Kitagawa, R., Chicoine, M. R., Patel, H., Dodd, R., Camarata, P. J., Wolfe, S., Stadnik, A., Money, P. L., Mitchell, P., Sarabia, R., Harnof, S., Barzo, P., Unterberg, A., Teitelbaum, J. S., Wang, W., Anderson, C. S., Mendelow, A. D., Gregson, B., Janis, S., Vespa, P., Ziai, W., Zuccarello, M., Awad, I. A., MISTIE III Investigators, Abdul-Rahim, A., Abou-Hamden, A., Abraham, M., Ahmed, A., Alba, C. A., Aldrich, E. F., Altschul, D., Amin-Hanjani, S., Anderson, D., Ansari, S., Antezana, D., Ardelt, A., Arikan, F., Baguena, M., Baker, A., Barrer, S. J., Becker, K. J., Bergman, T., Bostrom, A., Braun, J., Brindley, P., Broaddus, W. C., Brown, R., Buki, A., Cao, B., Cao, Y., Carrion-Penagos, J., Chalela, J., Chang, T., Chorro, I. M., Chowdhry, S., Corral, L., Csiba, L., Davies, J., Diaz, A. T., Dierdeyn, C. P., Diringer, M., Dlugash, R., Ecker, R., Economas, T., Enriquez, P., Ezer, E., Fan, Y., Feng, H., Franz, D., Freeman, W. D., Fusco, M., Galicich, W., Gelea, M. L., Goldstein, J., Gonzalez, A. C., Grabarits, C., Greenberg, S., Gress, D., Gu, E., Hall, C., Hernandez, F. M., Hoesch, R., Hoh, B. L., Houser, J., Hu, R., Huang, Y., Hussain, M. A., Insinga, S., Jadhav, A., Jaffe, J., Jahromi, B. S., Jallo, J., James, M., James, R. F., Jankowitz, B., Jeon, E., Jichici, D., Jonczak, K., Jonker, B., Karlen, N., Keric, N., Kerz, T., Knopman, J., Koenig, C., Krishnamurthy, S., Kumar, A., Kureshi, I., Laidlaw, J., Lakhanpal, A., Latorre, J. G., Leifer, D., Leiphart, J., Lenington, S., Li, Y., Lopez, G., Lovick, D., Lumenta, C., Luo, J., Maas, M. B., MacDonald, J., MacKenzie, L., Madan, V., Majkowski, R., Major, O., Malhorta, R., Malkoff, M., Mangat, H., Maswadeh, A., Matouk, C., McArthur, K., McCaul, S., Medow, J., Mezey, G., Mighty, J., Miller, D., Mohan, K. K., Muir, K., Munoz, L., Nakaji, P., Nee, A., Nekoovaght-Tak, S., Nyquist, P., O'Kane, R., Okasha, M., O'Kelly, C., Ostapkovich, N., Pandey, A., Parry-Jones, A., Perla, K. R., Pollack, A., Polster, S., Pouratian, N., Quinn, T., Rajajee, V., Reddy, K., Rehman, M., Reimer, R., Rincon, F., Rybinnik, I., Sanchez, B., Sansing, L., Schneck, M., Schuerer, L., Schul, D., Schweitzer, J., Seder, D. B., Seyfried, D., Sheth, K., Spiotta, A., Stechison, M., Szabo, K., Tamayo, G., Tanczos, K., Taussky, P., Terry, J., Testai, F., Thomas, K., Thompson, C. B., Thompson, G., Torner, J. C., Tran, H., Tucker, K., Ungar, L., Varelas, P., Vargas, N. M., Vatter, H., Venkatasubramanian, C., Vermillion, K., Vollmer, D., Wang, Y., Wang, Y., Wen, J., Whitworth, L. T., Willis, B., Wrencher, M., Wright, S. E., Xu, Y., Yanase, L., Yi, X., Yu, Z., Zomorodi, A. 2019

    Abstract

    BACKGROUND: Acute stroke due to supratentorial intracerebral haemorrhage is associated with high morbidity and mortality. Open craniotomy haematoma evacuation has not been found to have any benefit in large randomised trials. We assessed whether minimally invasive catheter evacuation followed by thrombolysis (MISTIE), with the aim of decreasing clot size to 15 mL or less, would improve functional outcome in patients with intracerebral haemorrhage.METHODS: MISTIE III was an open-label, blinded endpoint, phase 3 trial done at 78 hospitals in the USA, Canada, Europe, Australia, and Asia. We enrolled patients aged 18 years or older with spontaneous, non-traumatic, supratentorial intracerebral haemorrhage of 30 mL or more. We used a computer-generated number sequence with a block size of four or six to centrally randomise patients to image-guided MISTIE treatment (1·0 mg alteplase every 8 h for up to nine doses) or standard medical care. Primary outcome was good functional outcome, defined as the proportion of patients who achieved a modified Rankin Scale (mRS) score of 0-3 at 365 days, adjusted for group differences in prespecified baseline covariates (stability intracerebral haemorrhage size, age, Glasgow Coma Scale, stability intraventricular haemorrhage size, and clot location). Analysis of the primary efficacy outcome was done in the modified intention-to-treat (mITT) population, which included all eligible, randomly assigned patients who were exposed to treatment. All randomly assigned patients were included in the safety analysis. This study is registered with ClinicalTrials.gov, number NCT01827046.FINDINGS: Between Dec 30, 2013, and Aug 15, 2017, 506 patients were randomly allocated: 255 (50%) to the MISTIE group and 251 (50%) to standard medical care. 499 patients (n=250 in the MISTIE group; n=249 in the standard medical care group) received treatment and were included in the mITT analysis set. The mITT primary adjusted efficacy analysis estimated that 45% of patients in the MISTIE group and 41% patients in the standard medical care group had achieved an mRS score of 0-3 at 365 days (adjusted risk difference 4% [95% CI -4 to 12]; p=0·33). Sensitivity analyses of 365-day mRS using generalised ordered logistic regression models adjusted for baseline variables showed that the estimated odds ratios comparing MISTIE with standard medical care for mRS scores higher than 5 versus 5 or less, higher than 4 versus 4 or less, higher than 3 versus 3 or less, and higher than 2 versus 2 or less were 0·60 (p=0·03), 0·84 (p=0·42), 0·87 (p=0·49), and 0·82 (p=0·44), respectively. At 7 days, two (1%) of 255 patients in the MISTIE group and ten (4%) of 251 patients in the standard medical care group had died (p=0·02) and at 30 days, 24 (9%) patients in the MISTIE group and 37 (15%) patients in the standard medical care group had died (p=0·07). The number of patients with symptomatic bleeding and brain bacterial infections was similar between the MISTIE and standard medical care groups (six [2%] of 255 patients vs three [1%] of 251 patients; p=0·33 for symptomatic bleeding; two [1%] of 255 patients vs 0 [0%] of 251 patients; p=0·16 for brain bacterial infections). At 30 days, 76 (30%) of 255 patients in the MISTIE group and 84 (33%) of 251 patients in the standard medical care group had one or more serious adverse event, and the difference in number of serious adverse events between the groups was statistically significant (p=0·012).INTERPRETATION: For moderate to large intracerebral haemorrhage, MISTIE did not improve the proportion of patients who achieved a good response 365 days after intracerebral haemorrhage. The procedure was safely adopted by our sample of surgeons.FUNDING: National Institute of Neurological Disorders and Stroke and Genentech.

    View details for PubMedID 30739747

  • Emergency Neurological Life Support: Fourth Edition, Updates in the Approach to Early Management of a Neurological Emergency. Neurocritical care Venkatasubramanian, C. n., Lopez, G. A., O'Phelan, K. H. 2019

    View details for DOI 10.1007/s12028-019-00810-8

    View details for PubMedID 31549348

  • Absolute risk and predictors of the growth of acute spontaneous intracerebral haemorrhage: a systematic review and meta-analysis of individual patient data LANCET NEUROLOGY Salman, R., Frantzias, J., Lee, R. J., Lyden, P. D., Battey, T. K., Ayres, A. M., Goldstein, J. N., Mayer, S. A., Steiner, T., Wang, X., Arima, H., Hasegawa, H., Oishi, M., Godoy, D. A., Masotti, L., Dowlatshahi, D., Rodriguez-Luna, D., Molina, C. A., Jang, D., Davalos, A., Castillo, J., Yao, X., Claassen, J., Volbers, B., Kazui, S., Okada, Y., Fujimoto, S., Toyoda, K., Li, Q., Khoury, J., Delgado, P., Alvarez Sabin, J., Hernandez-Guillamon, M., Prats-Sanchez, L., Cai, C., Kate, M. P., McCourt, R., Venkatasubramanian, C., Diringer, M. N., Ikeda, Y., Worthmann, H., Ziai, W. C., d'Esterre, C. D., Aviv, R. I., Raab, P., Murai, Y., Zazulia, A. R., Butcher, K. S., Seyedsaadat, S., Grotta, J. C., Marti-Fabregas, J., Montaner, J., Broderick, J., Yamamoto, H., Staykov, D., Connolly, E., Selim, M., Leira, R., Moon, B., Demchuk, A. M., Di Napoli, M., Fujii, Y., Anderson, C. S., Rosand, J. 2018; 17 (10): 885–94

    Abstract

    Intracerebral haemorrhage growth is associated with poor clinical outcome and is a therapeutic target for improving outcome. We aimed to determine the absolute risk and predictors of intracerebral haemorrhage growth, develop and validate prediction models, and evaluate the added value of CT angiography.In a systematic review of OVID MEDLINE-with additional hand-searching of relevant studies' bibliographies- from Jan 1, 1970, to Dec 31, 2015, we identified observational cohorts and randomised trials with repeat scanning protocols that included at least ten patients with acute intracerebral haemorrhage. We sought individual patient-level data from corresponding authors for patients aged 18 years or older with data available from brain imaging initially done 0·5-24 h and repeated fewer than 6 days after symptom onset, who had baseline intracerebral haemorrhage volume of less than 150 mL, and did not undergo acute treatment that might reduce intracerebral haemorrhage volume. We estimated the absolute risk and predictors of the primary outcome of intracerebral haemorrhage growth (defined as >6 mL increase in intracerebral haemorrhage volume on repeat imaging) using multivariable logistic regression models in development and validation cohorts in four subgroups of patients, using a hierarchical approach: patients not taking anticoagulant therapy at intracerebral haemorrhage onset (who constituted the largest subgroup), patients taking anticoagulant therapy at intracerebral haemorrhage onset, patients from cohorts that included at least some patients taking anticoagulant therapy at intracerebral haemorrhage onset, and patients for whom both information about anticoagulant therapy at intracerebral haemorrhage onset and spot sign on acute CT angiography were known.Of 4191 studies identified, 77 were eligible for inclusion. Overall, 36 (47%) cohorts provided data on 5435 eligible patients. 5076 of these patients were not taking anticoagulant therapy at symptom onset (median age 67 years, IQR 56-76), of whom 1009 (20%) had intracerebral haemorrhage growth. Multivariable models of patients with data on antiplatelet therapy use, data on anticoagulant therapy use, and assessment of CT angiography spot sign at symptom onset showed that time from symptom onset to baseline imaging (odds ratio 0·50, 95% CI 0·36-0·70; p<0·0001), intracerebral haemorrhage volume on baseline imaging (7·18, 4·46-11·60; p<0·0001), antiplatelet use (1·68, 1·06-2·66; p=0·026), and anticoagulant use (3·48, 1·96-6·16; p<0·0001) were independent predictors of intracerebral haemorrhage growth (C-index 0·78, 95% CI 0·75-0·82). Addition of CT angiography spot sign (odds ratio 4·46, 95% CI 2·95-6·75; p<0·0001) to the model increased the C-index by 0·05 (95% CI 0·03-0·07).In this large patient-level meta-analysis, models using four or five predictors had acceptable to good discrimination. These models could inform the location and frequency of observations on patients in clinical practice, explain treatment effects in prior randomised trials, and guide the design of future trials.UK Medical Research Council and British Heart Foundation.

    View details for PubMedID 30120039

    View details for PubMedCentralID PMC6143589

  • Phantom-based standardization of CT angiography images for spot sign detection NEURORADIOLOGY Morotti, A., Romero, J. M., Jessel, M. J., Hernandez, A. M., Vashkevich, A., Schwab, K., Burns, J. D., Shah, Q. A., Bergman, T. A., Suri, M. K., Ezzeddine, M., Kirmani, J. F., Agarwal, S., Shapshak, A., Messe, S. R., Venkatasubramanian, C., Palmieri, K., Lewandowski, C., Chang, T. R., Chang, I., Rose, D. Z., Smith, W., Hsu, C. Y., Liu, C., Lien, L., Hsiao, C., Iwama, T., Afzal, M., Cassarly, C., Greenberg, S. M., Martin, R., Qureshi, A. I., Rosand, J., Boone, J. M., Goldstein, J. N., ATACH-II Investigator, NETT Investigator 2017; 59 (9): 839–44

    Abstract

    The CT angiography (CTA) spot sign is a strong predictor of hematoma expansion in intracerebral hemorrhage (ICH). However, CTA parameters vary widely across centers and may negatively impact spot sign accuracy in predicting ICH expansion. We developed a CT iodine calibration phantom that was scanned at different institutions in a large multicenter ICH clinical trial to determine the effect of image standardization on spot sign detection and performance.A custom phantom containing known concentrations of iodine was designed and scanned using the stroke CT protocol at each institution. Custom software was developed to read the CT volume datasets and calculate the Hounsfield unit as a function of iodine concentration for each phantom scan. CTA images obtained within 8 h from symptom onset were analyzed by two trained readers comparing the calibrated vs. uncalibrated density cutoffs for spot sign identification. ICH expansion was defined as hematoma volume growth >33%.A total of 90 subjects qualified for the study, of whom 17/83 (20.5%) experienced ICH expansion. The number of spot sign positive scans was higher in the calibrated analysis (67.8 vs 38.9% p < 0.001). All spot signs identified in the non-calibrated analysis remained positive after calibration. Calibrated CTA images had higher sensitivity for ICH expansion (76 vs 52%) but inferior specificity (35 vs 63%) compared with uncalibrated images.Normalization of CTA images using phantom data is a feasible strategy to obtain consistent image quantification for spot sign analysis across different sites and may improve sensitivity for identification of ICH expansion.

    View details for PubMedID 28730267

    View details for PubMedCentralID PMC5700841

  • Emergency Neurological Life Support: Traumatic Brain Injury NEUROCRITICAL CARE Garvin, R., Venkatasubramanian, C., Lumba-Brown, A., Miller, C. M. 2015; 23: S143-S154

    Abstract

    Traumatic Brain Injury (TBI) was chosen as an Emergency Neurological Life Support topic due to its frequency, the impact of early intervention on outcomes for patients with TBI, and the need for an organized approach to the care of such patients within the emergency setting. This protocol was designed to enumerate the practice steps that should be considered within the first critical hour of neurological injury.

    View details for DOI 10.1007/s12028-015-0176-z

    View details for Web of Science ID 000367463100014

  • Emergency Neurological Life Support: Traumatic Brain Injury. Neurocritical care Garvin, R., Venkatasubramanian, C., Lumba-Brown, A., Miller, C. M. 2015; 23 Suppl 2: S143-54

    Abstract

    Traumatic Brain Injury (TBI) was chosen as an Emergency Neurological Life Support topic due to its frequency, the impact of early intervention on outcomes for patients with TBI, and the need for an organized approach to the care of such patients within the emergency setting. This protocol was designed to enumerate the practice steps that should be considered within the first critical hour of neurological injury.

    View details for DOI 10.1007/s12028-015-0176-z

    View details for PubMedID 26438466

  • Serum Neuron-Specific Enolase Levels from the Same Patients Differ Between Laboratories: Assessment of a Prospective Post-cardiac Arrest Cohort. Neurocritical care Mlynash, M., Buckwalter, M. S., Okada, A., Caulfield, A. F., Venkatasubramanian, C., Eyngorn, I., Verbeek, M. M., Wijman, C. A. 2013; 19 (2): 161-166

    Abstract

    In comatose post-cardiac arrest patients, a serum neuron-specific enolase (NSE) level of >33 μg/L within 72 h was identified as a reliable marker for poor outcome in a large Dutch study (PROPAC), and this level was subsequently adopted in an American Academy of Neurology practice parameter. Later studies reported that NSE >33 μg/L is not a reliable predictor of poor prognosis. To test whether different clinical laboratories contribute to this variability, we compared NSE levels from the laboratory used in the PROPAC study (DLM-Nijmegen) with those of our hospital's laboratory (ARUP) using paired blood samples.We prospectively enrolled cardiac arrest patients who remained comatose after resuscitation. During the first 3 days, paired blood samples for serum NSE were drawn at a median of 10 min apart. After standard preparation for each lab, one sample was sent to ARUP laboratories and the other to DLM-Nijmegen.Fifty-four paired serum samples from 33 patients were included. Although the serum NSE measurements correlated well between laboratories (R = 0.91), the results from ARUP were approximately 30 % lower than those from DLM-Nijmegen. Therapeutic hypothermia did not affect this relationship. Two patients had favorable outcomes after hypothermia despite NSE levels measured by DLM-Nijmegen as >33 μg/L.Absolute serum NSE levels of comatose cardiac arrest patients differ between laboratories. Any specific absolute cut-off levels proposed to prognosticate poor outcome should not be used without detailed data on how neurologic outcomes correspond to a particular laboratory's method, and even then only in conjunction with other prognostic variables.

    View details for DOI 10.1007/s12028-013-9867-5

    View details for PubMedID 23839710

  • Christine Anne Cunegonde Wijman, MD, PhD (1965-2013). Neurocritical care Finley Caulfield, A., Venkatasubramanian, C. 2013; 19 (1): 135-136

    View details for DOI 10.1007/s12028-013-9855-9

    View details for PubMedID 23690248

  • Natural history and prognostic value of corticospinal tract Wallerian degeneration in intracerebral hemorrhage. Journal of the American Heart Association Venkatasubramanian, C., Kleinman, J. T., Fischbein, N. J., Olivot, J., Gean, A. D., Eyngorn, I., Snider, R. W., Mlynash, M., Wijman, C. A. 2013; 2 (4)

    Abstract

    The purpose of this study was to define the incidence, imaging characteristics, natural history, and prognostic implication of corticospinal tract Wallerian degeneration (CST-WD) in spontaneous intracerebral hemorrhage (ICH) using serial MR imaging.Consecutive ICH patients with supratentorial ICH prospectively underwent serial MRIs at 2, 7, 14, and 21 days. MRIs were analyzed by independent raters for the presence and topographical distribution of CST-WD on diffusion-weighted imaging (DWI). Baseline demographics, hematoma characteristics, ICH score, and admission National Institute of Health Stroke Score (NIHSS) were systematically recorded. Functional outcome at 3 months was assessed by the modified Rankin Scale (mRS) and the motor-NIHSS. Twenty-seven patients underwent 93 MRIs; 88 of these were serially obtained in the first month. In 13 patients (48%), all with deep ICH, CST-WD changes were observed after a median of 7 days (interquartile range, 7 to 8) as reduced diffusion on DWI and progressed rostrocaudally along the CST. CST-WD changes evolved into T2-hyperintense areas after a median of 11 days (interquartile range, 6 to 14) and became atrophic on MRIs obtained after 3 months. In univariate analyses, the presence of CST-WD was associated with poor functional outcome (ie, mRS 4 to 6; P=0.046) and worse motor-NIHSS (5 versus 1, P=0.001) at 3 months.Wallerian degeneration along the CST is common in spontaneous supratentorial ICH, particularly in deep ICH. It can be detected 1 week after ICH on DWI and progresses rostrocaudally along the CST over time. The presence of CST-WD is associated with poor motor and functional recovery after ICH.

    View details for DOI 10.1161/JAHA.113.000090

    View details for PubMedID 23913508

  • Magnetic resonance imaging profile of blood-brain barrier injury in patients with acute intracerebral hemorrhage. Journal of the American Heart Association Aksoy, D., Bammer, R., Mlynash, M., Venkatasubramanian, C., Eyngorn, I., Snider, R. W., Gupta, S. N., Narayana, R., Fischbein, N., Wijman, C. A. 2013; 2 (3)

    Abstract

    Spontaneous intracerebral hemorrhage (ICH) is associated with blood-brain barrier (BBB) injury, which is a poorly understood factor in ICH pathogenesis, potentially contributing to edema formation and perihematomal tissue injury. We aimed to assess and quantify BBB permeability following human spontaneous ICH using dynamic contrast-enhanced magnetic resonance imaging (DCE MRI). We also investigated whether hematoma size or location affected the amount of BBB leakage.Twenty-five prospectively enrolled patients from the Diagnostic Accuracy of MRI in Spontaneous intracerebral Hemorrhage (DASH) study were examined using DCE MRI at 1 week after symptom onset. Contrast agent dynamics in the brain tissue and general tracer kinetic modeling were used to estimate the forward leakage rate (K(trans)) in regions of interest (ROI) in and surrounding the hematoma and in contralateral mirror-image locations (control ROI). In all patients BBB permeability was significantly increased in the brain tissue immediately adjacent to the hematoma, that is, the hematoma rim, compared to the contralateral mirror ROI (P<0.0001). Large hematomas (>30 mL) had higher K(trans) values than small hematomas (P<0.005). K(trans) values of lobar hemorrhages were significantly higher than the K(trans) values of deep hemorrhages (P<0.005), independent of hematoma volume. Higher K(trans) values were associated with larger edema volumes.BBB leakage in the brain tissue immediately bordering the hematoma can be measured and quantified by DCE MRI in human ICH. BBB leakage at 1 week is greater in larger hematomas as well as in hematomas in lobar locations and is associated with larger edema volumes.

    View details for DOI 10.1161/JAHA.113.000161

    View details for PubMedID 23709564

  • Natural history and prognostic value of corticospinal tract wallerian degeneration in intracerebral hemorrhage. Journal of the American Heart Association Venkatasubramanian, C., Kleinman, J. T., Fischbein, N. J., Olivot, J., Gean, A. D., Eyngorn, I., Snider, R. W., Mlynash, M., Wijman, C. A. 2013; 2 (4): e000090

    Abstract

    The purpose of this study was to define the incidence, imaging characteristics, natural history, and prognostic implication of corticospinal tract Wallerian degeneration (CST-WD) in spontaneous intracerebral hemorrhage (ICH) using serial MR imaging.Consecutive ICH patients with supratentorial ICH prospectively underwent serial MRIs at 2, 7, 14, and 21 days. MRIs were analyzed by independent raters for the presence and topographical distribution of CST-WD on diffusion-weighted imaging (DWI). Baseline demographics, hematoma characteristics, ICH score, and admission National Institute of Health Stroke Score (NIHSS) were systematically recorded. Functional outcome at 3 months was assessed by the modified Rankin Scale (mRS) and the motor-NIHSS. Twenty-seven patients underwent 93 MRIs; 88 of these were serially obtained in the first month. In 13 patients (48%), all with deep ICH, CST-WD changes were observed after a median of 7 days (interquartile range, 7 to 8) as reduced diffusion on DWI and progressed rostrocaudally along the CST. CST-WD changes evolved into T2-hyperintense areas after a median of 11 days (interquartile range, 6 to 14) and became atrophic on MRIs obtained after 3 months. In univariate analyses, the presence of CST-WD was associated with poor functional outcome (ie, mRS 4 to 6; P=0.046) and worse motor-NIHSS (5 versus 1, P=0.001) at 3 months.Wallerian degeneration along the CST is common in spontaneous supratentorial ICH, particularly in deep ICH. It can be detected 1 week after ICH on DWI and progresses rostrocaudally along the CST over time. The presence of CST-WD is associated with poor motor and functional recovery after ICH.

    View details for DOI 10.1161/JAHA.113.000090

    View details for PubMedID 23913508

  • Magnetic resonance imaging profile of blood-brain barrier injury in patients with acute intracerebral hemorrhage. Journal of the American Heart Association Aksoy, D., Bammer, R., Mlynash, M., Venkatasubramanian, C., Eyngorn, I., Snider, R. W., Gupta, S. N., Narayana, R., Fischbein, N., Wijman, C. A. 2013; 2 (3): e000161

    Abstract

    Spontaneous intracerebral hemorrhage (ICH) is associated with blood-brain barrier (BBB) injury, which is a poorly understood factor in ICH pathogenesis, potentially contributing to edema formation and perihematomal tissue injury. We aimed to assess and quantify BBB permeability following human spontaneous ICH using dynamic contrast-enhanced magnetic resonance imaging (DCE MRI). We also investigated whether hematoma size or location affected the amount of BBB leakage.Twenty-five prospectively enrolled patients from the Diagnostic Accuracy of MRI in Spontaneous intracerebral Hemorrhage (DASH) study were examined using DCE MRI at 1 week after symptom onset. Contrast agent dynamics in the brain tissue and general tracer kinetic modeling were used to estimate the forward leakage rate (K(trans)) in regions of interest (ROI) in and surrounding the hematoma and in contralateral mirror-image locations (control ROI). In all patients BBB permeability was significantly increased in the brain tissue immediately adjacent to the hematoma, that is, the hematoma rim, compared to the contralateral mirror ROI (P<0.0001). Large hematomas (>30 mL) had higher K(trans) values than small hematomas (P<0.005). K(trans) values of lobar hemorrhages were significantly higher than the K(trans) values of deep hemorrhages (P<0.005), independent of hematoma volume. Higher K(trans) values were associated with larger edema volumes.BBB leakage in the brain tissue immediately bordering the hematoma can be measured and quantified by DCE MRI in human ICH. BBB leakage at 1 week is greater in larger hematomas as well as in hematomas in lobar locations and is associated with larger edema volumes.

    View details for DOI 10.1161/JAHA.113.000161

    View details for PubMedID 23709564

  • Intracranial hypotension producing reversible coma: a systematic review, including three new cases A review JOURNAL OF NEUROSURGERY Loya, J. J., Mindea, S. A., Yu, H., Venkatasubramanian, C., Chang, S. D., Burns, T. C. 2012; 117 (3): 615-628

    Abstract

    Intracranial hypotension is a disorder of CSF hypovolemia due to iatrogenic or spontaneous spinal CSF leakage. Rarely, positional headaches may progress to coma, with frequent misdiagnosis. The authors review reported cases of verified intracranial hypotension-associated coma, including 3 previously unpublished cases, totaling 29. Most patients presented with headache prior to neurological deterioration, with positional symptoms elicited in almost half. Eight patients had recently undergone a spinal procedure such as lumbar drainage. Diagnostic workup almost always began with a head CT scan. Subdural collections were present in 86%; however, intracranial hypotension was frequently unrecognized as the underlying cause. Twelve patients underwent one or more procedures to evacuate the collections, sometimes with transiently improved mental status. However, no patient experienced lasting neurological improvement after subdural fluid evacuation alone, and some deteriorated further. Intracranial hypotension was diagnosed in most patients via MRI studies, which were often obtained due to failure to improve after subdural hematoma (SDH) evacuation. Once the diagnosis of intracranial hypotension was made, placement of epidural blood patches was curative in 85% of patients. Twenty-seven patients (93%) experienced favorable outcomes after diagnosis and treatment; 1 patient died, and 1 patient had a morbid outcome secondary to duret hemorrhages. The literature review revealed that numerous additional patients with clinical histories consistent with intracranial hypotension but no radiological confirmation developed SDH following a spinal procedure. Several such patients experienced poor outcomes, and there were multiple deaths. To facilitate recognition of this treatable but potentially life-threatening condition, the authors propose criteria that should prompt intracranial hypotension workup in the comatose patient and present a stepwise management algorithm to guide the appropriate diagnosis and treatment of these patients.

    View details for DOI 10.3171/2012.4.JNS112030

    View details for Web of Science ID 000307627100031

    View details for PubMedID 22725982

  • A comparison of cooling techniques to treat cardiac arrest patients with hypothermia. Stroke research and treatment Finley Caulfield, A., Rachabattula, S., Eyngorn, I., Hamilton, S. A., Kalimuthu, R., Hsia, A. W., Lansberg, M. G., Venkatasubramanian, C., BAUMANN, J. J., Buckwalter, M. S., Kumar, M. A., Castle, J. S., Wijman, C. A. 2011; 2011: 690506-?

    Abstract

    Introduction. We sought to compare the performance of endovascular cooling to conventional surface cooling after cardiac arrest. Methods. Patients in coma following cardiopulmonary resuscitation were cooled with an endovascular cooling catheter or with ice bags and cold-water-circulating cooling blankets to a target temperature of 32.0-34.0°C for 24 hours. Performance of cooling techniques was compared by (1) number of hourly recordings in target temperature range, (2) time elapsed from the written order to initiate cooling and target temperature, and (3) adverse events during the first week. Results. Median time in target temperature range was 19 hours (interquartile range (IQR), 16-20) in the endovascular group versus. 10 hours (IQR, 7-15) in the surface group (P = .001). Median time to target temperature was 4 (IQR, 2.8-6.2) and 4.5 (IQR, 3-6.5) hours, respectively (P = .67). Adverse events were similar. Conclusion. Endovascular cooling maintains target temperatures better than conventional surface cooling.

    View details for DOI 10.4061/2011/690506

    View details for PubMedID 21822470

  • Natural History of Perihematomal Edema After Intracerebral Hemorrhage Measured by Serial Magnetic Resonance Imaging STROKE Venkatasubramanian, C., Mlynash, M., Finley-Caulfield, A., Eyngorn, I., Kalimuthu, R., Snider, R. W., Wijman, C. A. 2011; 42 (1): 73-80

    Abstract

    knowledge on the natural history and clinical impact of perihematomal edema (PHE) associated with intracerebral hemorrhage is limited. We aimed to define the time course, predictors, and clinical significance of PHE measured by serial magnetic resonance imaging.patients with primary supratentorial intracerebral hemorrhage ≥ 5 cm(3) underwent serial MRIs at prespecified intervals during the first month. Hematoma (H(v)) and PHE (E(v)) volumes were measured on fluid-attenuated inversion recovery images. Relative PHE was defined as E(v)/H(v). Neurologic assessments were performed at admission and with each MRI. Barthel Index, modified Rankin scale, and extended Glasgow Outcome scale scores were assigned at 3 months.twenty-seven patients with 88 MRIs were prospectively included. Median H(v) and E(v) on the first MRI were 39 and 46 cm(3), respectively. Median peak absolute E(v) was 88 cm(3). Larger hematomas produced a larger absolute E(v) (r(2)=0.6) and a smaller relative PHE (r(2)=0.7). Edema volume growth was fastest in the first 2 days but continued until 12 ± 3 days. In multivariate analysis, a higher admission hematocrit was associated with a greater delay in peak PHE (P=0.06). Higher admission partial thromboplastin time was associated with higher peak rPHE (P=0.02). Edema volume growth was correlated with a decline in neurologic status at 48 hours (81 vs 43 cm(3), P=0.03) but not with 3-month functional outcome.PHE volume measured by MRI increases most rapidly in the first 2 days after symptom onset and peaks toward the end of the second week. The timing and magnitude of PHE volume are associated with hematologic factors. Its clinical significance deserves further study.

    View details for DOI 10.1161/STROKEAHA.110.590646

    View details for PubMedID 21164136

  • MRI Profile of the Perihematomal Region in Acute Intracerebral Hemorrhage STROKE Olivot, J., Mlynash, M., Kleinman, J. T., Straka, M., Venkatasubramanian, C., Bammer, R., Moseley, M. E., Albers, G. W., Wijman, C. A. 2010; 41 (11): 2681-2683

    Abstract

    The pathophysiology of the presumed perihematomal edema immediately surrounding an acute intracerebral hemorrhage is poorly understood, and its composition may influence clinical outcome. Method-Twenty-three patients from the Diagnostic Accuracy of MRI in Spontaneous intracerebral Hemorrhage (DASH) study were prospectively enrolled and studied with MRI. Perfusion-weighted imaging, diffusion-weighted imaging, and fluid-attenuated inversion recovery sequences were coregistered. TMax (the time when the residue function reaches its maximum) and apparent diffusion coefficient values in the presumed perihematomal edema regions of interest were compared with contralateral mirror and remote ipsilateral hemispheric regions of interest.Compared with mirror and ipsilateral hemispheric regions of interest, TMax (the time when the residue function reaches its maximum) and apparent diffusion coefficient were consistently increased in the presumed perihematomal edema. Two thirds of the patients also exhibited patchy regions of restricted diffusion in the presumed perihematomal edema.The MRI profile of the presumed perihematomal edema in acute intracerebral hemorrhage exhibits delayed perfusion and increased diffusivity mixed with areas of reduced diffusion.

    View details for DOI 10.1161/STROKEAHA.110.590638

    View details for PubMedID 20947849

  • MIGRAINE-LIKE HEADACHE WITH VISUAL DEFICIT AND PERFUSION ABNORMALITY ON MRI NEUROLOGY Kapinos, G., Fischbein, N. J., Zaharchuk, G., Venkatasubramanian, C. 2010; 74 (21): 1743-1745

    View details for Web of Science ID 000278018400014

    View details for PubMedID 20498443

    View details for PubMedCentralID PMC2882211

  • Outcome prediction in mechanically ventilated neurologic patients by junior neurointensivists NEUROLOGY Caulfield, A. F., GABLER, L., Lansberg, M. G., Eyngorn, I., Mlynash, M., Buckwalter, M. S., Venkatasubramanian, C., Wijman, C. A. 2010; 74 (14): 1096-1101

    Abstract

    Physician prediction of outcome in critically ill neurologic patients impacts treatment decisions and goals of care. In this observational study, we prospectively compared predictions by neurointensivists to patient outcomes at 6 months.Consecutive neurologic patients requiring mechanical ventilation for 72 hours or more were enrolled. The attending neurointensivist was asked to predict 6-month 1) functional outcome (modified Rankin scale [mRS]), 2) quality of life (QOL), and 3) whether supportive care should be withdrawn. Six-month functional outcome was determined by telephone interviews and dichotomized to good (mRS 0-3) and poor outcome (mRS 4-6).Of 187 eligible patients, 144 were enrolled. Neurointensivists correctly predicted 6-month functional outcome in 80% (95% confidence interval [CI], 72%-86%) of patients. Accuracy for a predicted good outcome was 63% (95% CI, 50%-74%) and for poor outcome 94% (95% CI, 85%-98%). Excluding patients who had life support withdrawn, accuracy for good outcome was 73% (95% CI, 60%-84%) and for poor outcome 87% (95% CI, 74%-94%). Accuracy for exact agreement between neurointensivists' mRS predictions and actual 6-month mRS was only 43% (95% CI, 35%-52%). Predicted accuracy for QOL was 58% (95% CI, 39%-74%) for good/excellent and 67% (95% CI, 46%-83%) for poor/fair. Of 27 patients for whom withdrawal of care was recommended, 1 patient survived in a vegetative state.Prediction of long-term functional outcomes in critically ill neurologic patients is challenging. Our neurointensivists were more accurate in predicting poor outcome than good outcome in patients requiring mechanical ventilation >or=72 hours.

    View details for Web of Science ID 000276354400005

    View details for PubMedID 20368630

  • Utility of Early MRI in the Diagnosis and Management of Acute Spontaneous Intracerebral Hemorrhage CEREBROVASCULAR DISEASES Wijman, C. A., Venkatasubramanian, C., Bruins, S., Fischbein, N., Schwartz, N. 2010; 30 (5): 456-463

    Abstract

    The optimal diagnostic evaluation for spontaneous intracerebral hemorrhage (ICH) remains controversial. In this retrospective study, we assessed the utility of early magnetic resonance imaging (MRI) in ICH diagnosis and management.Eighty-nine (72%) of 123 patients with spontaneous ICH underwent a brain CT and MRI within 30 days of ICH onset. Seventy patients with a mean age of 62 ± 15 years were included. A stroke neurologist and a general neurologist, each blinded to the final diagnosis, independently reviewed the admission data and the initial head CT and then assigned a presumed ICH cause under 1 of 9 categories. ICH cause was potentially modified after subsequent MRI review. The final 'gold standard' ICH etiology was determined after review of the complete medical record by an independent investigator. Change in diagnostic category and confidence and the potential impact on patient management were systematically recorded.Mean time to MRI was 3 ± 5 days. Final ICH diagnosis was hypertension or cerebral amyloid angiopathy (CAA) in 50% of patients. After MRI review the stroke neurologist changed diagnostic category in 14%, diagnostic confidence in an additional 23% and management in 20%, and the general neurologist did so in 19, 21 and 21% of patients, respectively. MRI yield was highest in ICH secondary to ischemic stroke, CAA, vascular malformations and neoplasms, and did not differ by age, history of hypertension, hematoma location or the presence of intraventricular hemorrhage.The results of this study suggest potential additive clinical benefit of early MRI in patients with spontaneous ICH.

    View details for DOI 10.1159/000316892

    View details for Web of Science ID 000282752200004

    View details for PubMedID 20733299

    View details for PubMedCentralID PMC2992640

  • Favorable Outcome From A Locked-In State Despite Extensive Pontine Infarction By MRI NEUROCRITICAL CARE Samaniego, E. A., Lansberg, M. G., DeGeorgia, M., Venkatasubramanian, C., Wijman, C. A. 2009; 11 (3): 369-371

    Abstract

    Outcome prediction of patients who are in a locked-in state is challenging. Extensive pontine infarction on diffusion weighted imaging MRI (DWI) has been proposed as a poor prognosticator. We report on three patients with a locked-in state with unexpected favorable recoveries despite DWI evidence of widespread pontine ischemia.Report of three cases.Three young patients (32-, 30-, and 16-years-old) presented with a locked-in state caused by pontine infarction. The first patient did not receive any acute stroke therapies, the second patient underwent endovascular therapy 20 h after symptom onset resulting in partial recanalization of the basilar artery, and the third patient progressed to a locked-in state despite having received intravenous tissue plasminogen activator. The DWI of all three patients demonstrated acute and widespread pontine infarction involving more than two-thirds of the pons. Two patients regained full independence in their activities of daily living. The third patient remained wheelchair bound, but lives with her family, eats independently, uses a typewriter and wrote a book.Patients who are in a locked-in state may have substantial functional recovery despite DWI evidence of extensive pontine infarction.

    View details for DOI 10.1007/s12028-009-9268-y

    View details for Web of Science ID 000271943800011

    View details for PubMedID 19707888

  • Transient Isolated Vertigo Secondary to an Acute Stroke of the Cerebellar Nodulus Arch Neurol Schwartz N, V. A. 2007
  • Natural history and clinical significance of perihematomal edema after spontaneous intracerebral hemorrhage (abstract) Stroke Venkatasubramanian C, M. K. 2007
  • The effect of blood pressure on hematoma and perihematomal area in acute intracerebral hemorrhage. Neurosurgery clinics of North America Wijman, C. A., Venkatasubramanian, C. 2006; 17: 11-24

    View details for PubMedID 17967690

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