A Comprehensive Perspective on Intracranial Pressure Monitoring and Individualized Management in Neurocritical Care: Results of a Survey with Global Experts.

BACKGROUND: Numerous trials have addressed intracranial pressure (ICP) management in neurocritical care. However, identifying its harmful thresholds and controlling ICP remain challenging in terms of improving outcomes. Evidence suggests that an individualized approach is necessary for establishing tolerance limits for ICP, incorporating factors such as ICP waveform (ICPW) or pulse morphology along with additional data provided by other invasive (e.g., brain oximetry) and noninvasive monitoring (NIM) methods (e.g., transcranial Doppler, optic nerve sheath diameter ultrasound, and pupillometry). This study aims to assess current ICP monitoring practices among experienced clinicians and explore whether guidelines should incorporate ancillary parameters from NIM and ICPW in future updates. METHODS: We conducted a survey among experienced professionals involved in researching and managing patients with severe injury across low-middle-income countries (LMICs) and high-income countries (HICs). We sought their insights on ICP monitoring, particularly focusing on the impact of NIM and ICPW in various clinical scenarios. RESULTS: From October to December 2023, 109 professionals from the Americas and Europe participated in the survey, evenly distributed between LMIC and HIC. When ICP ranged from 22 to 25 mm Hg, 62.3% of respondents were open to considering additional information, such as ICPW and other monitoring techniques, before adjusting therapy intensity levels. Moreover, 77% of respondents were inclined to reassess patients with ICP in the 18-22 mm Hg range, potentially escalating therapy intensity levels with the support of ICPW and NIM. Differences emerged between LMIC and HIC participants, with more LMIC respondents preferring arterial blood pressure transducer leveling at the heart and endorsing the use of NIM techniques and ICPW as ancillary information. CONCLUSIONS: Experienced clinicians tend to personalize ICP management, emphasizing the importance of considering various monitoring techniques. ICPW and noninvasive techniques, particularly in LMIC settings, warrant further exploration and could potentially enhance individualized patient care. The study suggests updating guidelines to include these additional components for a more personalized approach to ICP management.

Variation in Ischemic Stroke Payments in the USA: A Medicare Beneficiary Study.

INTRODUCTION: The growing cost of stroke care has created the need for outcome-oriented and cost-saving payment models. Identifying imbalances in the current reimbursement model is an essential step toward designing impactful value-based reimbursement strategies. This study describes the variation in reimbursement fees for ischemic stroke management across the USA. METHODS: This Medicare Fee-For-Service claims study examines USA beneficiaries who suffered an ischemic stroke from 2021Q1 to 2022Q2 identified using the Medicare-Severity Diagnosis-Related Groups (MS-DRGs). Demographic national and regional US data were extracted from the Census Bureau. The MS-DRG codes were grouped into four categories according to treatment modality and clinical complexity. Our primary outcome of interest was payments made across individual USA and US geographic regions, assessed by computing the mean incremental payment in cases of comparable complexity. Differences between states for each MS-DRG were statistically evaluated using a linear regression model of the logarithmic transformed payments. RESULTS: 227,273 ischemic stroke cases were included in our analysis. Significant variations were observed among all DRGs defined by medical complexity, treatment modality, and states (p < 0.001). Differences in mean payment per case with the same MS-DRG vary by as high as 500% among individual states. Although higher payment rates were observed in MS-DRG codes with major comorbidities or complexity (MCC), the variation was more expressive for codes without MCC. It was not possible to identify a standard mean incremental fee at a state level. At a regional level, the Northeast registered the highest fees, followed by the West, Midwest, and South, which correlate with poverty rates and median household income in the regions. CONCLUSIONS: The payment variability observed across USA suggests that the current reimbursement system needs to be aligned with stroke treatment costs. Future studies may go one step further to evaluate accurate stroke management costs to guide policymakers in introducing health policies that promote better care for stroke patients.

Latin American Consensus Statement for the Use of Contrast-Enhanced Transcranial Ultrasound as a Diagnostic Test for Detection of Right-to-Left Shunt.

BACKGROUND: The role of patent foramen ovale is a field of debate and current publications have increasing controversies about the patients' management in young undetermined stroke. Work up with echocardiography and transcranial Doppler (TCD) can aid the decision with better anatomical and functional characterization of right-to-left shunt (RLS). Medical and interventional strategy may benefit from this information. SUMMARY: a group of experts from the Latin American participants of the Neurosonology Research Group (NSRG) of World Federation of Neurology created a task force to review literature and describe the better methodology of contrast TCD (c-TCD). All signatories of the present consensus statement have published at least one study on TCD as an author or co-author in an indexed journal. Two meetings were held while the consensus statement was being drafted, during which controversial issues were discussed and voted on by the statement signatories. The statement paper was reviewed and approved by the Executive Committee of the NSRG of the World Federation of Neurology. The main objective of this consensus statement is to establish a standardization of the c-TCD technique and its interpretation, in order to improve the informative quality of the method, resulting in expanding the application of TCD in the clinical setting. These recommendations optimize the comparison of different diagnostic methods and encourage the use of c-TCD for RLS screening and complementary diagnosis in multicenter studies.

A importância do controle pressórico e alcance de metas pressóricas intensivas em pacientes diabéticos e em pacientes com acidente vascular cerebral: os estudos optimal-diabetes e optimal-stroke / The importance of blood pressure control and intensive blood pressure targets in patients with diabetes and stroke: the optimaldiabetes and optimal-stroke trials

A hipertensão arterial sistêmica representa um dos principais problemas de saúde pública no Brasil e no mundo. O controle pressórico estrito é essencial para a redução de eventos cardiovasculares maiores, pois a pressão arterial sistólica elevada é o principal fator de risco modificável para doenças cardiovasculares e mortalidade total. Ensaios clínicos randomizados prévios, como o SPRINT trial e o STEP trial, geraram evidências robustas sobre os benefícios do alcance de metas pressóricas intensivas na redução de eventos cardiovasculares maiores em pacientes hipertensos de alto risco cardiovascular não-diabéticos e sem acidente vascular cerebral (AVC) prévio. Porém, ainda há dúvidas sobre o benefício de tal estratégia nestas duas populações de pacientes. Para dar uma resposta definitiva a esta questão, os estudos OPTIMAL-DIABETES e OPTIMAL-STROKE estão sendo conduzidos com alto rigor científico no Brasil e estes já são os maiores estudos sobre o tema em nível global. Os resultados destes dois estudos, previstos para 2024/2025, são muito esperados para nos dar as evidências necessárias sobre o benefício do controle pressórico intensivo em pacientes diabéticos e pós-AVC (AU).

Hypertension represents one of the main public health problems in Brazil and in the world. Blood pressure (BP) control is essential to reduce major cardiovascular events, as high systolic BP is the main modifiable risk factor for cardiovascular diseases and any-cause deaths. Previous randomized clinical trials, such as the SPRINT trial and the STEP trial, have provided robust evidence on the benefits of intensive BP targets on the reduction of major cardiovascular events in hypertensive patients with high cardiovascular risk without diabetes and previous stroke. However, there is still uncertainty about the benefits of such strategy on this two populations of patients. To provide a definitive answer to this question, the OPTIMAL-DIABETES and OPTIMAL-STROKE trials are being conducted with high scientific rigor in Brazil and these are already the biggest studies in this area globally. The results of these two trials, expected in 2024/2025, are long awaited to provide us the necessary evidence on the benefits of intensive BP control in patients with diabetes and patients with stroke (AU).