Chitra Venkatasubramanian, MBBS, MD, MSc, FNCS

All Publications

• Intravenous glibenclamide for cerebral oedema after large hemispheric stroke (CHARM): a phase 3, double-blind, placebo-controlled, randomised trial. The Lancet. Neurology Sheth, K. N., Albers, G. W., Saver, J. L., Campbell, B. C., Molyneaux, B. J., Hinson, H. E., Cordonnier, C., Steiner, T., Toyoda, K., Wintermark, M., Littauer, R., Collins, J., Lucas, N., Nogueira, R. G., Simard, J. M., Wald, M., Dawson, K., Kimberly, W. T., CHARM Trial investigators, Abraham, M., Acosta, I., Agostoni, E. C., Aguera Morales, E., Akaike, Y., Ale Bark, S., Alexandrov, A., Altschul, D., Arenillas Lara, J. F., Arias Rivas, S., Arnold, M., Asimos, A., Bar, M., Barlinn, K., Beccia, M., Benesch, C., Bereczki, D., Berk, J., Berkeley, J., Berrouschot, J., Bettermann, K., Bevers, M., Boesel, J., Bogdanov, E., Bonato, S., Bornstein, N., Boutwell, C., Bowling, S., Brown, H., Bruno, A., Burgin, W., Bustamante, R., Cabral Moro, C. H., Cao, W., Carandang, R., Cardona Portela, P., Castro, P., Cativo, M., Cereda, C., Cerejo, R., Chang, C., Cheng, R., Chin, M., Ching, M., Christensen, H., Chung, L., Clark, J., Clark, W., Cloud, G., Cogez, J., Comi, G., Cordato, D., Coull, B., Cronin, C., Csanyi, A., Cullis, P., Czeisler, B., Dangayach, N., Datta, M., Debouverie, M., Demchuk, A., Denier, C., Desfontaines, P., Devlin, T., Dhar, R., Diomedi, M., Dioszeghy, P., Diringer, M., Dixit, A., Dong, Q., Eichel, R., Elliott, J., Fan, D., Fernandez Sanchez, V. E., Ferro, J. M., Finocchi, C., Foreman, B., Fortea Cabo, G., Freire Goncalves, A., Fukuyama, K., Gamero Garcia, M. A., Garcia Esperon, C., Geng, D., Ghoshal, S., Gomes, J., Gordon, E., Guillon, B., Hagihara, Y., Hallevi, H., Halse, O., Han, M., Hargis, M., Harnof, S., Harsany, M., Hasegawa, Y., Hassan, A., Hayasaka, M., He, J., Hemelsoet, D., Henon, H., Herzig, R., Hill, M., Hinduja, A., Hirano, T., Horev, A., Howell, B., Hu, X., Huang, D., Hwang, Y., Ifergane, G., Isayev, Y., Ito, Y., Iversen, H., Jatuzis, D., Jeng, J., Jeon, S., Jeong, J., Ji, Q., Kahles, T., Kallmuenzer, B., Kaneko, C., Kanzawa, T., Kasner, S., Kawabata, M., Kelly, A., Kerrigan, D., Keshary, S., Khanna, A., Kidjemet-Piskac, S., Kidwell, C., Kim, M., Kimura, K., Kimura, N., Kin, S., Kirmani, J., Kitazawa, K., Kleinig, T., Koehrmann, M., Koga, M., Kollmar, R., Konno, H., Krause, M., Kuga, Y., Kullman, D., Kurka, N., Lago Martin, A., Latorre, J. G., LeDoux, D., Leal Loureiro, J., Lebedeva, A., Lee, T., Leker, R., Lemmens, R., Li, Y., Lioutas, V., Liu, C., Liu, L., Liu, W., Liu, Y., Longoni, M., Lopez, G., Lord, A., Lu, Z., Machida, A., Magoni, M., Malik, M., Marcheselli, S., Marques Pontes Neto, O., Martin, J., Martino, S., Martins Maia Carvalho, F., Masjuan Vallejo, J., Matijosaitis, V., Mayer, S., McGrade, H., Mehta, S., Melmed, K., Melnikova, E., Messe, S., Meyer, B., Miller, C., Minnerup, J., Mittal, S., Molina Cateriano, C., Moniche Alvarez, F., Moroi, J., Moulin, T., Muir, K., Murase, S., Murialdo, A., Muscat, P., Nagy, F., Nakagawa, K., Nakagawa, K., Nakano, S., Naval, N., Nencini, P., Ng, K., Niesen, W., Nomura, S., Olds, K., Olga, S., Ota, S., Ouriques Martins, S. C., Ovary, C., Panczel, G., Peretz, S., Perry, R., Petersen, N., Phan, T., Pinho E Melo, T., Poisson, S., Poljakovic, Z., Pulido, A., Radai, F., Ramiro, J. I., Ramos-Estebanez, C., Ratcliff, J., Renati, S., Richard, S., Rincon, F., Rippee, M., Rocha, M., Rodrigues, M., Rodriguez Campello, A., Roh, D., Roje Bedekovic, M., Roquer Gonzalez, J., Roriz Cruz, M., Roriz, J. M., Roshkovskaya, L., Roveri, L., Ruano, L., Rubio Borrego, F., Ruuskanen, J., Rybinnik, I., Sabet, A., Sakai, N., Sampaio Silva, G., Santo, G., Sarwal, A., Sato, K., Sato, K., Sattin, J., Schaefer, J., Schneider, H., Serena Leal, J., Shah, R., Shah, S., Sharma, K., Shepherd, S., Shi, F., Shimoe, Y., Shuaib, A., Sibon, I., Silliman, S., Skorna, M., Snider, S., Soda, H., Sprigg, N., Stetkarova, I., Strbian, D., Streib, C., Stretz, H. C., Sugimori, H., Sundararajan, S., Sung, P., Sztriha, L., Takahashi, S., Takizawa, K., Takizawa, S., Tang, S., Tassi, R., Tayal, A., Tedim Cruz, V., Telman, G., Temes, R., Terry, J., Tian, X., Timchenko, L., Timsit, S., Tirschwell, D., Tokunaga, K., Tomek, A., Toni, D., Torbey, M., Ueda, M., Uriel, E., Valverde Moyano, R., Vandermeeren, Y., Vannier, S., Vargas, A., Vecsei, L., Veltkamp, R., Venkatasubramanian, C., Viana Baptista, M., Vilionskis, A., Vohanka, S., Voznyuk, I., Wang, F., Wang, G., Wang, N., Warburton, E., Waters, M., Wen, G., Wendell, L., Werring, D., Wienecke, T., Wijeratne, T., Wilson, L., Witt, J., Wu, J., Xiong, Y., Xu, E., Xu, J., Yamano, Y., Yan, F., Yang, Y., Yi, F., Youn, T., Zachariah, G., Zafar, S., Zaidi, S., Zammit, C., Zeng, J., Zhang, G., Zhang, M., Zini, A., Zinke, J., Zurasky, J. 2024; 23 (12): 1205-1213

  Abstract

  BACKGROUND: No treatment is available to prevent brain oedema, which can occur after a large hemispheric infarction. Glibenclamide has previously been shown to improve functional outcome and reduce neurological or oedema-related death in patients younger than 70 years who were at risk of brain oedema after an acute ischaemic stroke. We aimed to assess whether intravenous glibenclamide could improve functional outcome at 90 days in patients with large hemispheric infarction.METHODS: CHARM was a phase 3, double-blind, placebo-controlled, randomised trial conducted across 143 acute stroke centres in 21 countries. We included patients aged 18-85 years with a large stroke, defined either by an Alberta Stroke Program Early CT Score (ASPECTS) of 1-5 or by an ischaemic core lesion volume of 80-300 mL on CT perfusion or MRI diffusion-weighted imaging. Patients were randomly assigned in a 1:1 ratio to either intravenous glibenclamide (8·6 mg over 72 h) or placebo. The study drug was started within 10 h of stroke onset. The primary efficacy outcome was the shift in the distribution of scores on the modified Rankin Scale at day 90, as a measure of functional outcome. The primary efficacy outcome was analysed in a modified intention-to-treat population, which included all randomly assigned patients aged 18-70 years. The safety population comprised all randomly assigned patients who received a dose. This trial is registered with ClinicalTrials.gov (NCT02864953). The trial was stopped early by the sponsor for strategic and operational reasons (slow enrolment because of COVID-19), before any unblinding or knowledge of the trial results.FINDINGS: Between Aug 29, 2018, and May 23, 2023, 535 patients were enrolled and randomly assigned, of whom 518 received a dose (safety population) and 431 were aged 18-70 years and comprised the modified intention-to-treat population (217 were assigned glibenclamide and 214 placebo). The mean age of patients was 58·7 (SD 9·0) years in the placebo group and 58·0 (9·5) years in the glibenclamide group; the median US National Institutes of Health Stroke Scale (NIHSS) score was 19 (IQR 16-23) in the placebo group and 19 (IQR 16-22) in the glibenclamide group; and the mean time from stroke onset to study drug start was 8·9 h (SD 2·1) in the placebo group and 9·2 h (2·1) in the glibenclamide group. Intravenous glibenclamide was not associated with a favourable shift in the modified Rankin scale at 90 days (common odds ratio [OR] 1·17 [95% CI 0·80-1·71], p=0·42). 90-day mortality was 29% (61 of 214) in the placebo group and 32% (70 of 217) in the glibenclamide group (hazard ratio 1·20 [0·85-1·70]; p=0·30). Serious adverse events in the prespecified safety population were consistent with the known safety profile of glibenclamide and included hypoglycaemia in 15 (6%) of 259 patients in the glibenclamide group and in four (2%) of 259 patients in the placebo group, leading to dose interruption or reduction in seven (3%) patients in the glibenclamide group and in one (<1%) in the placebo group.INTERPRETATION: Intravenous glibenclamide did not improve functional outcome in patients aged 18-70 years after large hemispheric infarction, although the trial was underpowered to make definitive conclusions because it was stopped early. Future prospective evaluation could be warranted to identify a possible benefit of intravenous glibenclamide in specific subgroups.FUNDING: Biogen.

  View details for DOI 10.1016/S1474-4422(24)00425-3

  View details for PubMedID 39577921

• 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)

  View details for DOI 10.1007/s11940-021-00678-0

  View details for Web of Science ID 000679832900001

• 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

• 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

• 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

• 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

  View details for DOI 10.1093/neuros/nyz077

  View details for Web of Science ID 000471247000027

• 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

• Myocarditis following scorpion sting The Antiseptic S. Dandapani, Subbiah, Chitra V. 1998: 303-304
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