Poisson Modeling Predicts Acute Telestroke Patient Call Volume.

Background: Predicting the frequency of calls for telestroke and emergency teleneurology consultation is essential to prepare staffing for the immediate management of time-sensitive strokes. In this study, we evaluate Poisson distribution count data using a generalized linear model that predicts the volume of hourly telestroke calls over a 24-h period. Methods: We performed an Institutional Review Board approved retrospective cohort review of patients (January 2019-December 2022) from an institutional telestroke database at a large nonprofit multihospital system in the United States. All patients ≥18 years with a telestroke activation were included. Telestroke calls were quantified in frequency per day and analyzed by multiple time and date intervals. Poisson probability mass function (PMF) and cumulative distribution function (CDF) were used to predict call probabilities. A univariable Poisson regression model was fit to predict call volumes. Results: A total of 8,499 patients at 21 hospitals met inclusion criteria, the mean calls/day were 5.82 ± 2.54, and mean calls/day within each hour increment ranged from a minimum of 0.07 from 5 a.m. to 6 a.m. to a maximum of 0.45 from 7 p.m. to 8 p.m. The Poisson distribution was the most appropriate parametric probability model for these data, confirmed by the fit of the data to the expected distributions corresponding to the calculated means. The predicted probabilities of call frequencies by hour were calculated using the Poisson PMF and CDF; the probability of two or fewer calls/day by hour ranged from 98.9% to 99.9%. Univariable Poisson regression modeled an increase of future calls/day from 6.7 calls/day in July 2023 to 7.6 calls/day in October 2025. Conclusion: Poisson modeling closely fits telestroke call volumes, predicts the future volumes, and can be applied to any health system in which the mean call volume is known, which may inform the number of physicians needed to cover calls in real-time.

Impact of Local Tailoring on Acute Stroke Care in 21 Disparate Emergency Departments: A Prospective Stepped Wedge Type III Hybrid Effectiveness-Implementation Study.

BACKGROUND: Faster delivery of tPA (tissue-type plasminogen activator) results in better health outcomes for eligible patients with stroke. Standardization of stroke protocols in emergency departments (EDs) has been difficult, especially in nonstroke centers. We measured the effectiveness of a centrally led implementation strategy with local site tailoring to sustain adherence to an acute stroke protocol to improve door-to-needle (DTN) times across disparate EDs in a multihospital health system. METHODS: Prospective, type III hybrid effectiveness-implementation cohort study measuring performance at 21 EDs in Utah and Idaho (stroke centers [4]/nonstroke centers [17]) from January 2018 to February 2020 using a nonrandomized stepped-wedge design, monthly repeated site measures and multilevel hierarchical modeling. Each site received the implementation strategies in 1 of 6 steps providing control and intervention data. Co-primary outcomes were percentage of DTN times ≤60 minutes and median DTN time. Secondary outcomes included percentage of door-to-activation of neurological consult times ≤10 minutes and clinical effectiveness outcomes. Results were stratified between stroke and nonstroke centers. RESULTS: A total of 855 474 ED patient encounters occurred with 5325 code stroke activations (median age, 69 [IQR, 56-79] years; 51.8% female patients]. Percentage of door-to-activation times ≤10 minutes increased from 47.5% to 59.9% (adjusted odds ratio, 1.93 [95% CI, 1.40-2.67]). A total of 615 patients received tPA of ≤3 hours from symptom onset (median age, 71 [IQR, 58-80] years; 49.6% female patients). The percentage of DTN times ≤60 minutes increased from 72.5% to 86.1% (adjusted odds ratio, 3.38, [95% CI, 1.47-7.78]; stroke centers (77.4%-90.0%); nonstroke centers [59.3%-72.1%]). Median DTN time declined from 46 to 38 minutes (adjusted median difference, -9.68 [95% CI, -17.17 to -2.20]; stroke centers [41-35 minutes]; nonstroke centers [55-52 minutes]). No differences were observed in clinical effectiveness outcomes. CONCLUSIONS: A centrally led implementation strategy with local site tailoring led to faster delivery of tPA across disparate EDs in a multihospital system with no change in clinical effectiveness outcomes including rates of complication. Disparities in performance persisted between stroke and nonstroke centers.

Choosing Wisely Together: Physical and Occupational Therapy Consultation for Acute Neurology Inpatients.

BACKGROUND: Although many hospitalized neuroscience patients have physical and occupational therapy (rehabilitation) needs, patients with none or minimal physical impairments frequently receive rehabilitation consultation, diverting from patients with greatest need. METHODS: A multidisciplinary team on the general and cerebrovascular neurology acute inpatient services mapped the rehabilitation consultation process, resulting in multiple implemented interventions including physician education on appropriate acute rehabilitation consultations, modification of multidisciplinary rounds, and discussion of patient rehabilitation needs throughout hospitalization. Nurses used the same functional impairment measurement tool used by physical and occupational therapists, the Activity Measure for Post-Acute Care Inpatient Short Forms (Basic Mobility and Activity domains). RESULTS: The rate for initial rehabilitation consults for patients with no limitations in mobility or activity during the 6-month baseline period was 12%, which was decreased to 7% and 10% during the 6-month intervention and sustain periods, respectively (P < .001). The baseline rate for patients with no limitations receiving both physical therapy and occupational therapy consultations was 62% and was decreased to 21% and 39% in the intervention and sustain periods, respectively (P < .001). Rehabilitation sessions per hospital day increased for patients with high functional impairments, from 0.52 at baseline to 0.64 in the intervention and 0.66 in the sustain periods (P = .02), which equated to 1 more rehabilitation visit per patient hospitalization. CONCLUSIONS: A multifaceted intervention led to improved utilization of acute inpatient rehabilitation consultation while increasing the frequency of rehabilitation treatment for patients with highest functional impairment.

Neuroanatomical predictors of awakening in acutely comatose patients.

OBJECTIVE: Lateral brain displacement has been associated with loss of consciousness and poor outcome in a range of acute neurologic disorders. We studied the association between lateral brain displacement and awakening from acute coma. METHODS: This prospective observational study included all new onset coma patients admitted to the Neurosciences Critical Care Unit (NCCU) over 12 consecutive months. Head computed tomography (CT) scans were analyzed independently at coma onset, after awakening, and at follow-up. Primary outcome measure was awakening, defined as the ability to follow commands before hospital discharge. Secondary outcome measures were discharge Glasgow Coma Scale (GCS), modified Rankin Scale, Glasgow Outcome Scale, and hospital and NCCU lengths of stay. RESULTS: Of the 85 patients studied, the mean age was 58 ± 16 years, 51% were female, and 78% had cerebrovascular etiology of coma. Fifty-one percent of patients had midline shift on head CT at coma onset and 43 (51%) patients awakened. In a multivariate analysis, independent predictors of awakening were younger age (odds ratio [OR] = 1.039, 95% confidence interval [CI] = 1.002-1.079, p = 0.040), higher GCS score at coma onset (OR = 1.455, 95% CI = 1.157-1.831, p = 0.001), nontraumatic coma etiology (OR = 4.464, 95% CI = 1.011-19.608, p = 0.048), lesser pineal shift on follow-up CT (OR = 1.316, 95% CI = 1.073-1.615, p = 0.009), and reduction or no increase in pineal shift on follow-up CT (OR = 11.628, 95% CI = 2.207-62.500, p = 0.004). INTERPRETATION: Reversal and/or limitation of lateral brain displacement are associated with acute awakening in comatose patients. These findings suggest objective parameters to guide prognosis and treatment in patients with acute onset of coma.

Evolution of Somatosensory Evoked Potentials after Cardiac Arrest induced hypoxic-ischemic injury.

AIM: We tested the hypothesis that early recovery of cortical SEP would be associated with milder hypoxic-ischemic injury and better outcome after resuscitation from CA. METHODS: Sixteen adult male Wistar rats were subjected to asphyxial cardiac arrest. Half underwent 7min of asphyxia (Group CA7) and half underwent 9min (Group CA9). Continuous SEPs from median nerve stimulation were recorded from these rats for 4h immediately following CA, and at 24, 48, and 72h. Clinical recovery was evaluated using the Neurologic Deficit Scale. RESULTS: All rats in group CA7 survived to 72h, while only 50% of rats in group CA9 survived to that time. Mean NDS values in the CA7 group at 24, 48, and 72h after CA were significantly higher than those of CA9. The N10 (first negative potential at 10ms) amplitude was significantly lower within 1h after CA in rats that suffered longer CA durations. SEPs were also analyzed by separating the rats into good (NDS>or=50) vs. bad (NDS<50) outcomes at 72h, again showing significant difference in N10 and peak-to-peak amplitudes between the two groups. In addition, a smaller N7 potential was consistently observed to recover earlier in all rats. CONCLUSIONS: The diminished recovery of N10 is associated with longer CA times in rats. Higher N10 and peak-to-peak amplitudes during early recovery are associated with better neurologic outcomes. N7, which may represent thalamic activity, recovers much earlier than cortical responses (N10), suggesting failure of thalamocortical conduction during early recovery.

Predicting neurological outcome following cardiac arrest.

Because a large number of patients will suffer cardiac arrest each year, physicians must place attention on improving care for patients in the post-resuscitative setting. Part of this effort requires setting realistic goals based on patients' potential for recovery. Recovery from cardiac arrest often depends on the extent of anoxic brain injury, and for this reason primary teams consult neurologists to offer insight into potential for awakening from post-arrest coma. In doing so, neurologists inform a decision with legal, social and ethical implications. Though inapplicable without preparation at the time of cardiac arrest, the four principles of medical ethics have a direct impact on decision making during the post-resuscitative period. A review of the literature reveals that physical examination, electrophysiology, radiology, and biochemical markers can prove useful in estimating a patient's chances for neurological recovery from cardiac arrest. These factors most reliably predict poor outcome, but do so with high specificity. However, the role of the neurology consultant must change to include guidance on strategies of neuroprotection. Aggressive efforts directed towards neuroprotection may change predictions for outcomes after cardiac arrest in the future.

B-type natriuretic peptide as a marker for heart failure in patients with acute stroke.

OBJECTIVE: To determine whether serum N-terminal pro-B-type natriuretic peptide (N-BNP), a biomarker of myocardial wall stress, is specific to acute heart failure (HF) in patients hospitalized with stroke. DESIGN: Case-control study. SETTING: Tertiary hospital, Neurosciences Critical Care Unit and Stroke Unit. PATIENTS: Consecutive patients with acute ischemic or hemorrhagic stroke who were evaluated for HF. INTERVENTION: None. MEASUREMENTS AND RESULTS: Cases and controls were classified, respectively, as patients with or without HF, defined according to modified Framingham criteria. Seventy-two patients were evaluated, 39 with ischemic stroke, 22 with aneurysmal subarachnoid hemorrhage (SAH), and 11 with intracerebral hemorrhage (ICH). Thirty-four patients (47%) met criteria for HF, and 47 patients (65%) had systolic or diastolic left ventricular (LV) dysfunction on echocardiogram. Serum N-BNP was measured a median of 48 h following the onset of stroke and was increased (> 900 pg/ml) in 56 patients (78%), with higher levels in non-survivors (11898 +/- 12741 vs 4073 +/-5691; p = 0.001). In a multiple regression model, N-BNP elevation was not independently associated with HF (OR 5.4, 95% CI 0.8-36.0, p = 0.084). At a cut-off of 900 pg/ml, the sensitivity of N-BNP for HF was 94%, specificity 37%, positive predictive value (PPV) 57%, and negative predictive value (NPV) 88%. For systolic or diastolic LV dysfunction, the sensitivity of N-BNP was 89%, specificity 44%, PPV 75%, and NPV 69%. CONCLUSIONS: These results demonstrate that N-BNP elevation is not specific to HF or LV dysfunction in patients with acute ischemic stroke, SAH, and ICH.

Urgent intervention to reduce functional deficits after postoperative stroke.

BACKGROUND: A 67-year-old right-handed man with a history of atrial fibrillation developed sudden aphasia after urological surgery. Initial diffusion-weighted and perfusion-weighted MRI demonstrated an area of hypoperfusion in Broca's area, with minimal infarction. INVESTIGATIONS: Neurological examination, language testing and brain MRI scans with diffusion-weighted and perfusion-weighted imaging. DIAGNOSIS: Acute cardioembolic stroke with minimal infarction in Broca's area and a surrounding region of potentially salvageable, hypoperfused cortex. MANAGEMENT: Saline-induced hypertension resulting in rapid restoration of cortical perfusion and a resolution of the initial speech and language deficits. The utility of perfusion-weighted imaging in selecting appropriate candidates for urgent treatment of stroke when thrombolysis is contraindicated is discussed.