Traumatic Brain Injury and Traumatic Spinal Cord Injury.

OBJECTIVE: This article reviews the mechanisms of primary traumatic injury to the brain and spinal cord, with an emphasis on grading severity, identifying surgical indications, anticipating complications, and managing secondary injury. LATEST DEVELOPMENTS: Serum biomarkers have emerged for clinical decision making and prognosis after traumatic injury. Cortical spreading depolarization has been identified as a potentially modifiable mechanism of secondary injury after traumatic brain injury. Innovative methods to detect covert consciousness may inform prognosis and enrich future studies of coma recovery. The time-sensitive nature of spinal decompression is being elucidated. ESSENTIAL POINTS: Proven management strategies for patients with severe neurotrauma in the intensive care unit include surgical decompression when appropriate, the optimization of perfusion, and the anticipation and treatment of complications. Despite validated models, predicting outcomes after traumatic brain injury remains challenging, requiring prognostic humility and a model of shared decision making with surrogate decision makers to establish care goals. Penetrating injuries, especially gunshot wounds, are often devastating and require public health and policy approaches that target prevention.

Super Refractory Status Epilepticus Improved After Emergency Use of Ganaxolone: Case Report.

We present a case of a 34-year-old man with epilepsy who developed super refractory status epilepticus in the setting of COVID-19 pneumonia in whom aggressive therapy with multiple parenteral, enteral, and non-pharmacologic interventions were utilized without lasting improvement in clinical examination or electroencephalogram (EEG). The patient presented with multiple recurrences of electrographic status epilepticus throughout a prolonged hospital stay. Emergency use authorization was obtained for intravenous ganaxolone, a neuroactive steroid that is a potent modulator of both synaptic and extrasynaptic GABAA receptors. Following administration of intravenous ganaxolone according to a novel dosing paradigm, the patient showed sustained clinical and electrographic improvement.

Smartphone Use in the Management of Neurological Emergencies: A Simulation-Based Study.

BACKGROUND: Smartphone use in medicine is nearly universal despite a dearth of research assessing utility in clinical performance. We sought to identify and define smartphone use during simulated neuroemergencies. METHODS: In this retrospective review of a prospective observational single-center simulation-based study, participants ranging from subinterns to attending physicians and stratified by training level (novice, intermediate, and advanced) managed a variety of neurological emergencies. The primary outcome was frequency and purpose of smartphone use. Secondary outcomes included success rate of smartphone use and performance (measured by completion of critical tasks) of participants who used smartphones versus those who did not. In subgroup analyses we compared outcomes across participants by level of training using t-tests and χ2 statistics. RESULTS: One hundred and three participants completed 245 simulation scenarios. Smartphones were used in 109 (45%) simulations. Of participants using smartphones, 102 participants looked up medication doses, 52 participants looked up management guidelines, 11 participants looked up hospital protocols, and 13 participants used smartphones for assistance with an examination scale. Participants found the correct answer 73% of the time using smartphones. There was an association between participant level and smartphone use with intermediate participants being more likely to use their smartphones than novice or advanced participants, 53% versus 29% and 26%, respectively (p < 0.05). Of the intermediate participants, those who used smartphones did not perform better during the simulation scenario than participants who did not use smartphones (smartphone users' mean score [standard deviation] = 12.3 [2.9] vs. nonsmartphone users' mean score [standard deviation] = 12.9 (2.7), p = 0.85). CONCLUSIONS: Participants commonly used smartphones in simulated neuroemergencies but use didn't confer improved clinical performance. Less experienced participants were the most likely to use smartphones and less likely to arrive at correct conclusions, and thus are the most likely to benefit from an evidence-based smartphone application for neuroemergencies.

A Modified Delphi Consensus Approach to Define Entrustable Professional Activities for Neurocritical Care Advanced Practice Providers.

OBJECTIVES: To define consensus entrustable professional activities (EPAs) for neurocritical care (NCC) advanced practice providers (APPs), establish validity evidence for the EPAs, and evaluate factors that inform entrustment expectations of NCC APP supervisors. DESIGN: A three-round modified Delphi consensus process followed by application of the EQual rubric and assessment of generalizability by clinicians not affiliated with academic medical centers. SETTING: Electronic surveys. SUBJECTS: NCC APPs ( n = 18) and physicians ( n = 12) in the United States with experience in education scholarship or APP program leadership. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The steering committee generated an initial list of 61 possible EPAs. The panel proposed 30 additional EPAs. A total of 47 unique nested EPAs were retained by consensus opinion. The steering committee defined six core EPAs addressing medical knowledge, procedural competencies, and communication proficiency which encompassed the nested EPAs. All core EPAs were retained and subsequently met the previously described cut score for quality and structure using the EQual rubric. Most clinicians who were not affiliated with academic medical centers rated each of the six core EPAs as very important or mandatory. Entrustment expectations did not vary by prespecified groups. CONCLUSIONS: Expert consensus was used to create EPAs for NCC APPs that reached a predefined quality standard and were important to most clinicians in different practice settings. We did not identify variables that significantly predicted entrustment expectations. These EPAs may aid in curricular design for an EPA-based assessment of new NCC APPs and may inform the development of EPAs for APPs in other critical care subspecialties.

Pragmatic Approach to In Situ Simulation to Identify Latent Safety Threats Before Moving to a Newly Built ICU.

OBJECTIVES: Transitions to new care environments may have unexpected consequences that threaten patient safety. We undertook a quality improvement project using in situ simulation to learn the new patient care environment and expose latent safety threats before transitioning patients to a newly built adult ICU. DESIGN: Descriptive review of a patient safety initiative. SETTING: A newly built 24-bed neurocritical care unit at a tertiary care academic medical center. SUBJECTS: Care providers working in neurocritical care unit. INTERVENTIONS: We implemented a pragmatic three-stage in situ simulation program to learn a new patient care environment, transitioning patients from an open bay unit to a newly built private room-based ICU. The project tested the safety and efficiency of new workflows created by new patient- and family-centric features of the unit. We used standardized patients and high-fidelity mannequins to simulate patient scenarios, with "test" patients created through all electronic databases. Relevant personnel from clinical and nonclinical services participated in simulations and/or observed scenarios. We held a debriefing after each stage and scenario to identify safety threats and other concerns. Additional feedback was obtained via a written survey sent to all participants. We prospectively surveyed for missed latent safety threats for 2 years following the simulation and fixed issues as they arose. MEASUREMENTS AND MAIN RESULTS: We identified and addressed 70 latent safety threats, including issues concerning physical environment, infection prevention, patient workflow, and informatics before the move into the new unit. We also developed an orientation manual that highlighted new physical and functional features of the ICU and best practices gleaned from the simulations. All participants agreed or strongly agreed that simulations were beneficial. Two-year follow-up revealed only two missed latent safety threats. CONCLUSIONS: In situ simulation effectively identifies latent safety threats surrounding the transition to new ICUs and should be considered before moving into new units.

Comparison of induction agents for rapid sequence intubation in refractory status epilepticus: A single-center retrospective analysis.

Endotracheal intubation, frequently required during management of refractory status epilepticus (RSE), can be facilitated by anesthetic medications; however, their effectiveness for RSE control is unknown. We performed a single-center retrospective review of patients admitted to a neurocritical care unit (NCCU) who underwent in-hospital intubation during RSE management. Patients intubated with propofol, ketamine, or benzodiazepines, termed anti-seizure induction (ASI), were compared to patients who received etomidate induction (EI). The primary endpoint was clinical or electrographic seizures within 12 h post-intubation. We estimated the association of ASI on post-intubation seizure using logistic regression. A sub-group of patients undergoing electroencephalography during intubation was identified to evaluate the immediate effect of ASI on RSE. We screened 697 patients admitted to the NCCU for RSE and identified 148 intubated in-hospital (n = 90 ASI, n = 58 EI). There was no difference in post-intubation seizure (26 % (n = 23) ASI, 29 % (n = 17) EI) in the cohort, however, there was increased RSE resolution with ASI in 24 patients with electrographic RSE during intubation (ASI: 61 % (n = 11/18) vs EI: 0 % (n = 0/6), p =.016). While anti-seizure induction did not appear to affect post-intubation seizure occurrence overall, a sub-group of patients undergoing electroencephalography during intubation had a higher incidence of seizure cessation, suggesting potential benefit in an enriched population.

After ECMO Decannulation, Are Patients Thriving or Just Surviving?

The use of extracorporeal membrane oxygenation (ECMO) to support patients with cardiac arrest, cardiogenic shock, and acute respiratory distress syndrome is rising worldwide.1 While ECMO may save the lives of some of our sickest patients, the outlook of ECMO survivorship remains uncertain. Defining longer-term functional and neuropsychiatric outcomes in ECMO survivors is important for 3 reasons. First, critically ill patients are at high risk of experiencing postintensive care syndrome (PICS), defined as new physical, cognitive, or psychological impairments that present in survivors of critical illness after hospital discharge.2 PICS is associated with more severe illness and longer intensive care unit length of stay.3 Because ECMO is reserved for patients with refractory shock or hypoxia, patients treated with ECMO represent a severely ill patient population with prolonged length of stay, putting them at particularly high risk of developing PICS. Second, ECMO is associated with direct neurologic injury, including both macrohemorrhages and microhemorrhages, infarcts, and diffuse hypoxic-ischemic brain injury that likely contribute to long-term outcomes.4 Finally, ECMO is very expensive. A recent study determined that the average cost per admission for patients with COVID-19 placed on ECMO was nearly $850,000 more than those who received only mechanical ventilation.5 Understanding patient-centered outcomes will be an integral part of future cost-effectiveness analyses.

Discrepancies between Retrospective Review of "Real-Time" Electronic Health Record Documentation and Prospective Observer Documentation of In-Hospital Cardiac Arrest Quality Metrics in an Academic Cardiac Intensive Care Unit.

BACKGROUND: Every year, approximately 200,000 patients will experience in-hospital cardiac arrest (IHCA) in the United States. Survival has been shown to be greatest with the prompt initiation of CPR and early interventions, leading to the development of time-based quality measures. It is uncertain how documentation practices affect reports of compliance with time-based quality measures in IHCA. METHODS: A retrospective review of all cases of IHCA that occurred in the Cardiac Intensive Care Unit (CICU) at an academic quaternary hospital was conducted. For each case, a member of the code team (observer) documented performance measures as part of a prospective cardiac arrest quality improvement database. We compared those data to those abstracted in the retrospective review of "real-time" documentation in a Resuscitation Narrator module within electronic health records (EHRs) to investigate for discrepancies. RESULTS: We identified 52 cases of IHCA, all of which were witnessed events. In total, 47 (90%) cases were reviewed by observers as receiving epinephrine within 5 min, but only 42 (81%) were documented as such in the EHR review (p = 0.04), meaning that the interrater agreement for this metric was low (Kappa = 0.27, 95% CI 0.16-0.36). Four (27%) eligible patients were reported as having defibrillation within 2 min by observers, compared to five (33%) reported by the EHR review (p = 0.90), and with substantial agreement (Kappa = 0.73, 95% CI 0.66-0.79). There was almost perfect agreement (Kappa = 0.82, 95% CI 0.76-0.88) for the initial rhythm of cardiac arrest (25% shockable rhythm by observers vs. 29% for EHR review, p = 0.31). CONCLUSION: There was a discrepancy between prospective observers' documentation of meeting quality standards and that of the retrospective review of "real-time" EHR documentation. A further study is required to understand the cause of discrepancy and its consequences.

Iodine-based dual-energy CT predicts early neurological decline from cerebral edema after large hemispheric infarction.

Background & Purpose: Ischemia affecting two thirds of the MCA territory predicts development of malignant cerebral edema. However, early infarcts are hard to diagnose on conventional head CT. We hypothesize that high-energy (190keV) virtual monochromatic images (VMI) from dual-energy CT (DECT) imaging enables earlier detection of secondary injury from malignant cerebral edema (MCE). Methods: Consecutive LHI patients with NIHSS ≥ 15 and DECT within 10 hours of reperfusion from May 2020 to March 2022 were included. We excluded patients with parenchymal hematoma-type 2 transformation. Retrospective analysis of clinical and novel variables included VMI Alberta Stroke Program Early CT Score (ASPECTS), total iodine content, and VMI infarct volume. Primary outcome was early neurological decline (END). Secondary outcomes included hemorrhagic transformation, decompressive craniectomy (DC), and medical treatment of MCE. Fisher's exact test and Wilcoxon test were used for univariate analysis. Logistic regression was used to develop prediction models for categorical outcomes. Results: Eighty-four LHI patients with a median age of 67.5 [IQR 57,78] years and NIHSS 22 [IQR 18,25] were included. Twenty-nine patients had END. VMI ASPECTS, total iodine content, and VMI infarct volume were associated with END. VMI ASPECTS, VMI infarct volume, and total iodine content were predictors of END after adjusting for age, sex, initial NIHSS, and tPA administration, with a AUROC of 0.691 [0.572,0.810], 0.877 [0.800, 0.954], and 0.845 [0.750, 0.940]. By including all three predictors, the model achieved AUROC of 0.903 [0.84,0.97] and was cross validated by leave one out method with AUROC of 0.827. Conclusion: DECT with high-energy VMI and iodine quantification is superior to conventional CT ASPECTS and is a novel predictor for early neurological decline due to malignant cerebral edema after large hemispheric infarction.

Steroids Provide Temporary Improvement of Refractory Pain Following Subarachnoid Hemorrhage.

Introduction: Evidence for optimal analgesia following subarachnoid hemorrhage (SAH) is limited. Steroid therapy for pain refractory to standard regimens is common despite lack of evidence for its efficacy. We sought to determine if steroids reduced pain or utilization of other analgesics when given for refractory headache following SAH. Methods: We performed a retrospective within-subjects cohort study of SAH patients who received steroids for refractory headache. We compared daily pain scores, total daily opioid, and acetaminophen doses before, during, and after steroids. Repeated measures were analyzed with a multivariable general linear model and generalized estimating equations. Results: Included 52 patients treated with dexamethasone following SAH, of whom 11 received a second course, increasing total to 63 treatment epochs. Mean pain score on the first day of therapy was 7.92 (standard error of the mean [SEM] .37) and decreased to 6.68 (SEM .36) on the second day before quickly returning to baseline levels, 7.36 (SEM .33), following completion of treatment. Total daily analgesics mirrored this trend. Mean total opioid and acetaminophen doses on days one and two and two days after treatment were 47.83mg (SEM 6.22) and 1848mg (SEM 170.66), 34.24mg (SEM 5.12) and 1809mg (SEM 150.28), and 46.38mg (SEM 11.64) and 1833mg (SEM 174.23), respectively. Response to therapy was associated with older age, decreasing acetaminophen dosing, and longer duration of steroids. Hyperglycemia and sleep disturbance/delirium effected 28.6% and 55.6% of cases, respectively. Conclusion: Steroid therapy for refractory pain in SAH patients may have modest, transient effects in select patients.

Neurologic Complications of Critical Medical Illness.

OBJECTIVE: This article reviews the neurologic complications encountered in patients admitted to non-neurologic intensive care units, outlines various scenarios in which a neurologic consultation can add to the diagnosis or management of a critically ill patient, and provides advice on the best diagnostic approach in the evaluation of these patients. LATEST DEVELOPMENTS: Increasing recognition of neurologic complications and their adverse impact on long-term outcomes has led to increased neurology involvement in non-neurologic intensive care units. The COVID-19 pandemic has highlighted the importance of having a structured clinical approach to neurologic complications of critical illness as well as the critical care management of patients with chronic neurologic disabilities. ESSENTIAL POINTS: Critical illness is often accompanied by neurologic complications. Neurologists need to be aware of the unique needs of critically ill patients, especially the nuances of the neurologic examination, challenges in diagnostic testing, and neuropharmacologic aspects of commonly used medications.

Evaluating salvage electroconvulsive therapy for the treatment of prolonged super refractory status epilepticus: A case series.

BACKGROUND AND OBJECTIVES: Clinicians have treated super refractory status epilepticus (SRSE) with electroconvulsive therapy (ECT); however, data supporting the practice are scant and lack rigorous evaluation of continuous electroencephalogram (cEEG) changes related to therapy. This study aims to describe a series of patients with SRSE treated at our institution with ECT and characterize cEEG changes using a blinded review process. METHODS: We performed a single-center retrospective study of consecutive patients admitted for SRSE and treated with ECT from January 2014 to December 2022. Our primary outcome was the resolution of SRSE. Secondary outcomes included changes in ictal-interictal EEG patterns, anesthetic burden, treatment-associated adverse events, and changes in clinical examination. cEEG was reviewed pre- and post-ECT by blinded epileptologists. RESULTS: Ten patients underwent treatment with ECT across 11 admissions (8 female, median age 57 years). At the time of ECT initiation, nine patients had ongoing SRSE while two had highly ictal patterns and persistent encephalopathy following anesthetic wean, consistent with late-stage SRSE. Super-refractory status epilepticus resolution occurred with a median time to cessation of 4 days (interquartile range [IQR]: 3-9 days) following ECT initiation. Background continuity improved in five patients and periodic discharge frequency decreased in six. There was a decrease in anesthetic use following the completion of ECT and an improvement in neurological exams. There were no associated adverse events. DISCUSSION: In our cohort, ECT was associated with improvement of ictal-interictal patterns on EEG, and resolution of SRSE, and was not associated with serious adverse events. Further controlled studies are needed.

Scoping Review of Racial, Ethnic, and Sex Disparities in the Diagnosis and Management of Hemorrhagic Stroke.

BACKGROUND AND OBJECTIVES: In the United States, Black, Hispanic, and Asian Americans experience excessively high incidence rates of hemorrhagic stroke compared with White Americans. Women experience higher rates of subarachnoid hemorrhage than men. Previous reviews detailing racial, ethnic, and sex disparities in stroke have focused on ischemic stroke. We performed a scoping review of disparities in the diagnosis and management of hemorrhagic stroke in the United States to identify areas of disparities, research gaps, and evidence to inform efforts aimed at health equity. METHODS: We included studies published after 2010 that assessed racial and ethnic or sex disparities in the diagnosis or management of patients aged 18 years or older in the United States with a primary diagnosis of spontaneous intracerebral hemorrhage or aneurysmal subarachnoid hemorrhage. We did not include studies assessing disparities in incidence, risks, or mortality and functional outcomes of hemorrhagic stroke. RESULTS: After reviewing 6,161 abstracts and 441 full texts, 59 studies met our inclusion criteria. Four themes emerged. First, few data address disparities in acute hemorrhagic stroke. Second, racial and ethnic disparities in blood pressure control after intracerebral hemorrhage exist and likely contribute to disparities in recurrence rates. Third, racial and ethnic differences in end-of-life care exist, but further work is required to understand whether these differences represent true disparities in care. Fourth, very few studies specifically address sex disparities in hemorrhagic stroke care. DISCUSSION: Further efforts are necessary to delineate and correct racial, ethnic, and sex disparities in the diagnosis and management of hemorrhagic stroke.

Intensive Blood Pressure Control After Mechanical Thrombectomy for Acute Ischemic Stroke.

Optimal blood pressure targets following successful mechanical thrombectomy remain uncertain. While some observational studies suggest that the relationship between blood pressure and outcomes follows a U-shaped curve, others suggest a linear relationship where lower is better. The recent BP-TARGET study (Blood Pressure Target in Acute Stroke to Reduce Hemorrhage After Endovascular Therapy) did not find a benefit to intensive blood pressure lowering regarding the risk of symptomatic intracranial hemorrhage, but it was not sufficiently powered to detect differences in functional outcomes. On its heels arrived the ENCHANTED2 (Enhanced Control of Hypertension and Thrombectomy Stroke Study)/mechanical thrombectomy trial, the first trial of intensive blood pressure lowering in patients with hypertension following successful mechanical thrombectomy powered to detect a difference in functional outcomes. The trial randomized patients to either a systolic blood pressure less than 120 or 140 to 180 mm Hg. The trial was terminated early due to safety concerns in the more intensive blood pressure-lowering group. In this emerging therapy critique, we explore concerns regarding the generalizability of ENCHANTED2/mechanical thrombectomy, including the high prevalence of intracranial atherosclerosis in the studied population. We survey mechanisms for poor outcomes in patients who receive overly aggressive blood pressure reduction following successful thrombectomy, such as poststroke autoregulatory compromise and persistent microcirculatory hypoperfusion. Finally, we advocate for a more moderate approach, pending further research.

Adjunctive virtual reality pain relief after traumatic injury: a proof-of-concept within-person randomized trial.

ABSTRACT: In this study, we hypothesized that immersive virtual reality (VR) environments may reduce pain in patients with acute traumatic injuries, including traumatic brain injuries. We performed a randomized within-subject study in patients hospitalized with acute traumatic injuries, including traumatic brain injury with moderate pain (numeric pain score ≥3 of 10). We compared 3 conditions: (1) an immersive VR environment (VR Blu), (2) a content control with the identical environment delivered through nonimmersive tablet computer (Tablet Blu), and (3) a second control composed of donning VR headgear without content to control for placebo effects and sensory deprivation (VR Blank). We enrolled 60 patients, and 48 patients completed all 3 conditions. Objective and subjective data were analyzed using linear mixed-effects models. Controlling for demographics, baseline pain, and injury severity, we found differences by conditions in relieving pain (F 2,75.43 = 3.32, P = 0.042). VR Blu pain reduction was greater than Tablet Blu (-0.92 vs -0.16, P = 0.043), but VR Blu pain reduction was similar to VR Blank (-0.92 vs -1.24, P = 0.241). VR Blu was perceived as most effective by patients for pain reduction (F 2,66.84 = 16.28, P < 0.001), and changes in measures of parasympathetic activity including heart rate variability (F 2,55.511 = 7.87, P < 0.001) and pupillary maximum constriction velocity (F 2,61.41 = 3.50, 1-tailed P = 0.038) echoed these effects. There were no effects on opioid usage. These findings outlined a potential clinical benefit for mollifying pain related to traumatic injuries.

Feasibility of accelerated code team activation with code button triggered smartphone notification.

INTRODUCTION: Studies support rapid interventions to improve outcomes in patients with in-hospital cardiac arrest. We sought to decrease the time to code team activation and improve dissemination of patient-specific data to facilitate targeted treatments. METHODS: We mapped code blue buttons behind each bed to patients through the electronic medical record. Pushing the button sent patient-specific data (admitting diagnosis, presence of difficult airway, and recent laboratory values) through a secure messaging system to the responding teams' smartphones. The code button also activated a hospital-wide alert through the operator. We piloted the system on seven medicine inpatient units from November 2019 through May 2022. We compared the time from code blue button press to smartphone message receipt vs traditional operator-sent overhead page. RESULTS: The code button was the primary mode of code team activation for 12/35 (34.3%) cardiac arrest events. The code team received smartphone notifications a median of 78 s (IQR = 47-127 s) before overhead page. The median time to adrenaline administration for codes activated with the code button was not significantly different (240 s (IQR 142-300 s for code button) vs 148 s (IQR = 34-367 s) for overhead page, p = 0.89). Survival to discharge was 3/12 (25.0%) for codes activated with the code button vs 4/23 (17.4%) when activated by calling the operator (p = 0.67). CONCLUSION: Implementation of a smartphone-based code button notification system reduced time to code team activation by 78 s. Larger cohorts are necessary to assess effects on patient outcomes.

Acute Headache Management for Patients with Subarachnoid Hemorrhage: An International Survey of Health Care Providers.

BACKGROUND: Severe headaches are common after subarachnoid hemorrhage. Guidelines recommend treatment with acetaminophen and opioids, but patient data show that headaches often persist despite multimodal treatment approaches. Considering an overall slim body of data for a common complaint affecting patients with SAH during their intensive care stay, we set out to assess practice patterns in headache management among clinicians who treat patients with SAH. METHODS: We conducted an international cross-sectional study through a 37-question Web-based survey distributed to members of five professional societies relevant to intensive and neurocritical care from November 2021 to January 2022. Responses were characterized through descriptive analyses. Fisher's exact test was used to test associations. RESULTS: Of 516 respondents, 329 of 497 (66%) were from North America and 121 of 497 (24%) from Europe. Of 435 respondents, 379 (87%) reported headache as a major management concern for patients with SAH. Intensive care teams were primarily responsible for analgesia during hospitalization (249 of 435, 57%), whereas responsibility shifted to neurosurgery at discharge (233 of 501, 47%). Most used medications were acetaminophen (90%), opioids (66%), corticosteroids (28%), and antiseizure medications (28%). Opioids or medication combinations including opioids were most frequently perceived as most effective by 169 of 433 respondents (39%, predominantly intensivists), followed by corticosteroids or combinations with corticosteroids (96 of 433, 22%, predominantly neurologists). Of medications prescribed at discharge, acetaminophen was most common (303 of 381, 80%), followed by opioids (175 of 381, 46%) and antiseizure medications (173 of 381, 45%). Opioids during hospitalization were significantly more prescribed by intensivists, by providers managing higher numbers of patients with SAH, and in Europe. At discharge, opioids were more frequently prescribed in North America. Of 435 respondents, 299 (69%) indicated no change in prescription practice of opioids with the opioid crisis. Additional differences in prescription patterns between continents and providers and while inpatient versus at discharge were found. CONCLUSIONS: Post-SAH headache in the intensive care setting is a major clinical concern. Analgesia heavily relies on opioids both in use and in perception of efficacy, with no reported change in prescription patterns for opioids for most providers despite the significant drawbacks of opioids. Responsibility for analgesia shifts between hospitalization and discharge. International and provider-related differences are evident. Novel treatment strategies and alignment of prescription between providers are urgently needed.

Pain Control and Anxiolysis After Subarachnoid Hemorrhage Using Immersive Virtual Reality: A Case Report.

Debilitating headache persists after acute aneurysmal subarachnoid hemorrhage (SAH). Despite high prevalence, little is known regarding optimal treatment strategies for SAH-related headache. Nonpharmacologic adjunctive therapies are emerging as tools to help treat pain and limit opioid exposure in the hospital. Virtual reality (VR) is an immersive audiovisual experience that has been shown to reduce pain perception in other patient populations. The role of VR in acute brain injury is unknown. Here we report a patient with SAH who suffered from persistent headache during her hospitalization despite escalation of analgesic pharmacotherapy. A trial of VR was used as an adjunct to medication over four days. The patient reported subjective improvement in pain and anxiety. VR may provide additional analgesia and anxiolysis over pharmacologic measures alone and warrants further study in patients with acute brain injury.