Faculty Bibliography

BACKGROUND:Many survivors of hemorrhagic stroke have impaired communication. We aimed to identify preadmission, admission, and post-discharge factors associated with self-reported impaired communication after hemorrhagic stroke. DESIGN/METHODS:Patients with intracerebral or subarachnoid hemorrhage (ICH or SAH) admitted at an urban academic medical center were assessed 3-months post-bleed using the communication Quality of Life in Neurological Disorders (Neuro-QoL) short form inventory. Multivariate analysis was performed to evaluate the relationship between impaired communication (Neuro-QoL scaled score < 100) and preadmission, admission, and post-discharge factors. RESULTS:Of 108 patients (68 ICH and 40 SAH), 59 (54.6%) had impaired communication 3-months post-bleed. On multivariate analysis of the full cohort, when controlling for NIHSS score on admission, impaired communication was associated with: retirement prior to admission (OR: 8.18, 95% CI 1.95-40.5, p = 0.005), hospital length-of-stay (OR: 1.11, 95% CI 1.03-1.22, p = 0.012), and cognitive impairment post-bleed (OR: 32.1, 95% CI 8.93-146, p < 0.001). There were 43 (63.2%) ICH patients with impaired communication 3-months post-bleed. On multivariate analysis, impaired communication was associated with: retirement prior to admission (OR: 9.46, 95% CI 1.76-71.8, p = 0.014), supratentorial location (OR: 8.93, 95% CI 1.22-93.6, p = 0.043), hospital length-of-stay (OR: 1.21, 95% CI 1.01-1.45, p = 0.018), and cognitive impairment post-bleed (OR: 16.3, 95% CI 3.58-102, p < 0.001). CONCLUSIONS:Impaired communication after hemorrhagic stroke is more common in patients who were retired prior to admission and who have post-bleed comorbid cognitive impairment. Increased surveillance is recommended for retired and cognitively impaired patients. Additional investigation into the relationship between communication and both retirement status and cognitive impairment is needed.

OBJECTIVE/UNASSIGNED:The authors sought to determine the relationships among cognitive impairment, psychiatric outcome, and functional status 3 months after a hemorrhagic stroke. METHODS/UNASSIGNED:Patients with nontraumatic intracerebral hemorrhage (ICH) or subarachnoid hemorrhage (SAH) were assessed by telephone 3 months after discharge by using the Quality of Life in Neurological Disorders (Neuro-QoL) cognitive function, anxiety, depression, and sleep disturbance short forms, as well as the modified Rankin Scale (mRS). The relationships between poor cognition (Neuro-QoL T score≤50), functional status, and psychiatric outcome among patients with ICH or SAH and patients with ICH only were evaluated. RESULTS/UNASSIGNED:Of 101 patients (N=62 with ICH and N=39 with SAH), 51% had poor cognition 3 months posthemorrhage, with 61% having mRS scores of 3-5, 43% having anxiety, 28% having depression, and 31% having sleep disturbance. Univariate analysis of the full cohort indicated that poor cognition was significantly associated with anxiety, depression, sleep disturbance, and mRS scores of 3-5 (p<0.05). Multivariate analysis revealed that poor cognition was significantly associated with anxiety (OR=4.38, 95% CI=1.30-14.74, p=0.017) and mRS scores of 3-5 (OR=6.15, 95% CI=1.96-19.32, p=0.002). Univariate analysis of the 62 patients with ICH indicated that poor cognition was significantly associated with anxiety, sleep disturbance, and mRS scores of 3-5 (p<0.05). Multivariate analysis revealed that poor cognition was significantly associated with anxiety (OR=10.98, 95% CI=2.32-51.99, p=0.003). CONCLUSIONS/UNASSIGNED:Poor cognition was associated with anxiety 3 months after hemorrhagic stroke. Additional research is needed to understand whether treatment for anxiety would improve cognition in this population.

BACKGROUND:Hemorrhagic stroke survivors may have cognitive impairment. We sought to identify preadmission and admission factors associated with cognitive impairment after hemorrhagic stroke. DESIGN/METHODS:Patients with nontraumatic intracerebral or subarachnoid hemorrhage (ICH or SAH) were assessed 3-months post-bleed using the Quality of Life in Neurological Disorders (Neuro-QoL) Cognitive Function short form. Univariate and multivariate analysis were used to evaluate the relationship between poor cognition (Neuro-QoL t-score ≤50) and preadmission and admission factors. RESULTS:Of 101 patients (62 ICH and 39 SAH), 51 (50 %) had poor cognition 3-months post-bleed. On univariate analysis, poor cognition was associated with (p < 0.05): age [66.0 years (52.0-77.0) vs. 54.5 years (40.8-66.3)]; private insurance (37.3 % vs. 74.0 %); BMI > 30 (13.7 % vs. 34.0 %); and admission mRS score > 0 (41.2 % vs. 14.0 %), NIHSS score [8.0 (2.0-17.0) vs. 0.5 (0.0-4.0)], and APACHE II score [16.0 (11.0-19.0) vs. 9.0 (6.0-14.3)]. On multivariate analysis, poor cognition was associated with mRS score > 0 [OR 4.97 (1.30-19.0), p = 0.019], NIHSS score [OR 1.14 (1.02-1.28), p = 0.026], private insurance [OR 0.21 (0.06-0.76), p = 0.017] and BMI > 30 [OR 0.13 (0.03-0.56), p = 0.006]. CONCLUSIONS:Cognitive impairment after hemorrhagic stroke is less common in patients with BMI > 30 and private insurance. Heightened surveillance for non-obese patients without private insurance is suggested. Additional investigation into the relationship between cognition and both BMI and insurance type is needed.

Light speckle fluctuations provide a means for noninvasive measurements of cerebral blood flow index (CBFi). While conventional Diffuse Correlation Spectroscopy (DCS) quantifies these fluctuations to provide marginal brain sensitivity for CBFi in adult humans, new techniques have emerged to improve diffuse light throughput and brain sensitivity. Here we further optimize one such approach, interferometric diffusing wave spectroscopy (iDWS), with respect to the number of independent channels, camera duty cycle and full well capacity, incident laser power, noise and artifact mitigation, and data processing. We build the system on a cart and define conditions for stable operation. We show pulsatile CBFi monitoring at 4-4.5 cm source-collector separation in adults with moderate pigmentation (Fitzpatrick 4). We also report preliminary clinical measurements of patient CBFi in the Neuro Intensive Care Unit (Neuro ICU). These results push the boundaries of iDWS CBFi monitoring performance beyond previous reports.

BACKGROUND:Although it is well-known that intracerebral hemorrhage (ICH) is associated with physical and psychological morbidity, there is scant data on factors influencing social engagement after ICH. Understanding the relationship between functionality, psychological outcome and social engagement post-bleed may facilitate identification of patients at high risk for social isolation after ICH. METHODS:Patients ≥18-years-old with non-traumatic ICH from January 2015-March 2023 were identified from the Neurological Emergencies Outcomes at NYU (NEON) registry. Data on discharge functionality were collected from the medical record. 3-months post-bleed, patients/their legally-authorized representatives (LARs) were contacted to complete Neuro-QoL social engagement, anxiety, depression, and sleep inventories. Patients were stratified by ability to participate in social roles and activities (good=T-score>50, poor=T-score≤50) and satisfaction with social roles and activities (high=T-score>50 and low=T-score≤50). Univariate comparisons were performed to evaluate the relationship between post-bleed social engagement and both functionality and psychological outcome using Pearson's chi-square, Fisher's Exact test, and Mann-Whitney U tests. Multivariate logistic regression was subsequently performed using variables that were significant on univariate analysis (p<0.05). RESULTS:The social engagement inventories were completed for 55 patients with ICH; 29 (53 %) by the patient alone, 14 (25 %) by a LAR alone, and 12 (22 %) by both patient and LAR. 15 patients (27 %) had good ability to participate in social roles and activities and 10 patients (18 %) had high satisfaction with social roles and activities. Social engagement was associated with both functionality and psychological outcome on univariate analysis, but on multivariate analysis, it was only related to functionality; post-bleed ability to participate in social roles and activities was associated with discharge home, discharge GCS score, discharge mRS score, and discharge NIHSS score (p<0.05) and post-bleed satisfaction with social roles and activities was related to discharge mRS score and discharge NIHSS score (p<0.05). CONCLUSION/CONCLUSIONS:In patients with nontraumatic ICH, social engagement post-bleed was related to discharge functionality, even when controlling for depression, anxiety, and sleep disturbance.

OBJECTIVES/OBJECTIVE:The objective of this study was to determine factors associated with negative disease-related stigma after hemorrhagic stroke. MATERIALS AND METHODS/METHODS:Patients with non-traumatic hemorrhage (ICH or SAH) admitted between January 2015 and February 2021 were assessed by telephone 3-months after discharge using the Quality of Life in Neurological Disorders (Neuro-QoL) Negative Disease-Related Stigma Short Form inventory. We evaluated the relationship between disease-related stigma (T-score >50) and pre-stroke demographics, admission data, and poor functional outcome (3-month mRS score 3-5 and Barthel Index <100). RESULTS:We included 89 patients (56 ICH and 33 SAH). The median age was 63 (IQR 50-69), 43 % were female, and 67 % graduated college. Admission median GCS score was 15 (IQR 13-15) and APACHE II score was 12 (IQR 9-17). 31 % had disease-related stigma. On univariate analysis, disease-related stigma was associated with female sex, non-completion of college, GCS score, APACHE II score, and 3-month mRS score (all p < 0.05). On multivariate analysis, disease-related stigma was associated with female sex (OR = 3.72, 95 % CI = 1.23-11.25, p = 0.02) and 3-month Barthel Index <100 (OR = 3.46, 95 % CI = 1.13-10.64, p = 0.03) on one model, and female sex (OR = 3.75, 95 % CI = 1.21-11.58, p = 0.02) and 3-month mRS score 3-5 (OR = 4.23, 95 % CI = 1.21-14.75, p = 0.02) on a second model. CONCLUSION/CONCLUSIONS:Functional outcome and female sex are associated with disease-related stigma 3-months after hemorrhagic stroke. Because stigma may negatively affect recovery, there is a need to understand the relationship between these factors to mitigate stroke-related stigma.

BACKGROUND:The utility of head computed tomography (CT) in predicting elevated intracranial pressure (ICP) is known to be limited in traumatic brain injury; however, few data exist in patients with spontaneous intracranial hemorrhage. METHODS:We conducted a retrospective review of prospectively collected data in patients with nontraumatic intracranial hemorrhage (subarachnoid hemorrhage [SAH] or intraparenchymal hemorrhage [IPH]) who underwent external ventricular drain (EVD) placement. Head CT scans performed immediately prior to EVD placement were quantitatively reviewed for features suggestive of elevated ICP, including temporal horn diameter, bicaudate index, basal cistern effacement, midline shift, and global cerebral edema. The modified Fisher score (mFS), intraventricular hemorrhage score, and IPH volume were also measured, as applicable. We calculated the accuracy, positive predictive value (PPV), and negative predictive value (NPV) of these radiographic features for the coprimary outcomes of elevated ICP (> 20 mm Hg) at the time of EVD placement and at any time during the hospital stay. Multivariable backward stepwise logistic regression analysis was performed to identify significant radiographic factors associated with elevated ICP. RESULTS:Of 608 patients with intracranial hemorrhages enrolled during the study time frame, 243 (40%) received an EVD and 165 (n = 107 SAH, n = 58 IPH) had a preplacement head CT scan available for rating. Elevated opening pressure and elevated ICP during hospitalization were recorded in 48 of 152 (29%) and 103 of 165 (62%), respectively. The presence of ≥ 1 radiographic feature had only 32% accuracy for identifying elevated opening pressure (PPV 30%, NPV 58%, area under the curve [AUC] 0.537, 95% asymptotic confidence interval [CI] 0.436-0.637, P = 0.466) and 59% accuracy for predicting elevated ICP during hospitalization (PPV 63%, NPV 40%, AUC 0.514, 95% asymptotic CI 0.391-0.638, P = 0.820). There was no significant association between the number of radiographic features and ICP elevation. Head CT scans without any features suggestive of elevated ICP occurred in 25 of 165 (15%) patients. However, 10 of 25 (40%) of these patients had elevated opening pressure, and 15 of 25 (60%) had elevated ICP during their hospital stay. In multivariable models, mFS (adjusted odds ratio [aOR] 1.36, 95% CI 1.10-1.68) and global cerebral edema (aOR 2.93, 95% CI 1.27-6.75) were significantly associated with elevated ICP; however, their accuracies were only 69% and 60%, respectively. All other individual radiographic features had accuracies between 38 and 58% for identifying intracranial hypertension. CONCLUSIONS:More than 50% of patients with spontaneous intracranial hemorrhage without radiographic features suggestive of elevated ICP actually had ICP > 20 mm Hg during EVD placement or their hospital stay. Morphological head CT findings were only 32% and 59% accurate in identifying elevated opening pressure and ICP elevation during hospitalization, respectively.

TRIAL DESIGN/METHODS:Current protocols for treatment of acute ischemic stroke with intravenous thrombolytics, such as alteplase (tPA) and tenecteplase (tNK), recommend the completion of a routine non-contrast head CT at 24 hours post treatment to evaluate for hemorrhage prior to the initiation of antiplatelet therapy for secondary stroke prevention. This guideline was instituted because it had been part of the protocol in the NINDS multicenter randomized placebo-controlled trial that showed the benefit of IV thrombolytics within 3 hours of stroke onset. Recent observational studies indicate that the repeat (stability) head CT rarely alters clinical management, in the absence of neurological worsening or evidence of clinical signs of hemorrhagic conversion, such as seizures, severe headache, or novel acute deficits. A solitary CT carries with it a non-negligible dose of radiation with additive cost to the medical system at large. METHODS:We aimed to identify, with a randomized, blinded outcome assessment trial, if a routine head CT at 24 hours, in the absence of clinical indication, negatively influences clinical outcomes. We enrolled 58 patients, and evaluated differences between groups with t-tests. We also evaluated differences between outcomes (90 day modified Rankin Scale, mRS and change in National Institutes of Health Stroke Scale, NIHSS) from pretreatment to discharge using multivariable logistic regression, including age, baseline NIHSS, and group as independent variables. RESULTS:We found no added benefit of routine CT on either outcome measure. CONCLUSION/CONCLUSIONS:It is likely safe to forgo follow up imaging after thrombolysis in the absence of clinical decompensation.

Some patients have behaviors that make interactions unpleasant, sometimes contributing to suboptimal outcomes and physician burnout. Understanding common difficult personality types can help doctors plan effective strategies for dealing with each, resulting in more effective communication, less stress, and better health outcomes.