From international guidelines to real-world practice consensus on investigations and management of status epilepticus in adults: A modified Delphi approach.

OBJECTIVE: To establish a consensus which is practical and ready-to-use on investigations (ISE) and for management of status epilepticus (MSE) in adults using a modified Delphi approach. PATIENTS AND METHODS: A 4-round modified Delphi approach was used. First and second rounds were conducted using Google® survey with structured statements and 6-point Likert scale response. Threshold agreement was set to ≥80%. Third round was a face-to-face meeting aimed to facilitate the development of approach algorithms for ISE and MSE. Fourth round was a final review asking participants to rate the algorithms post completion. RESULTS: The panel consisted of 8 board-certified epileptologists along with 6 neurologists from main regional hospitals across Thailand. Thirty-seven statements for ISE and 68 statements for MSE were used for the Round I survey, 17/37 (45.9%) and 49/68 (72.1%) reached threshold agreement (≥80%). The average absolute-agreement intraclass correlation coefficients for ISE and MSE were 0.82 (95% CI 0.71, 0.89) and 0.81 (95% CI 0.73, 0.87), respectively; indicating good extent of consensus among participants. Upon Round II, further 10/18 (55.6%) for ISE and 10/19 (52.6%) for MSE reached agreement. In Round III, face-to-face point-by-point discussion was performed to generate approach algorithms. All (100%) provided positive responses with the algorithms post completion in Round IV. CONCLUSION: A practical and ready-to-use consensus using modified Delphi approach on ISE and MSE was developed in a Thai regional hospital context. In real practice, this approach is more suitable and feasible for a localized setting when compared with totally adopting international guidelines.

Prognostic Parameters for Symptomatic Intracranial Hemorrhage after Intravenous Thrombolysis in Acute Ischemic Stroke in an Asian Population.

BACKGROUND: Symptomatic intracranial hemorrhage (sICH) is a major complication after intravenous thrombolysis leading to severe disability and death. The incidence was higher in Asian than in western countries. Prognostic factors across ethnicities are presumably different. Studies in Asian populations are limited. METHOD: Clinical data from January 2008 to September 2016 in one provincial and four regional hospitals in the northern part of Thailand were retrospectively reviewed. Patients were those with acute ischemic stroke, to whom recombinant tissue plasminogen activator (rt-PA) had been prescribed. They were classified into 3 groups; no intracranial hemorrhage (no ICH), asymptomatic intracranial hemorrhage (asICH) and symptomatic intracranial hemorrhage (sICH), based on clinical and brain imaging (computed tomography or CT). Prognostic parameters were investigated using a multi-level, multivariable ordinal logistic model. RESULTS: After exclusion of ineligible patients, the remaining 1,172 patients were classified into no ICH (n=923, 78.8%), asICH (n=154, 13.1%) and sICH (n=95, 8.1%). Independent prognostic parameters for intracranial hemorrhage were the National Institutes of Health Stroke Scale (NIHSS) >20 (OR, 3.51; 95% CI, 2.18-5.65; p<0.001), NIHSS >10 (OR, 2.02; 95% CI, 1.42-2.87; p<0.001), use of nicardipine during rt-PA (OR, 1.61; 95% CI, 1.09-2.40; p=0.018), systolic blood pressure (SBP) prior to thrombolysis ≥ 140 mmHg (OR, 1.47; 95% CI, 1.06-2.04; p=0.021), and platelet count <250,000 cell/mm3 (OR, 1.45; 95% CI, 1.04-2.01; p=0.029). CONCLUSION: Patients with these parameters should be closely monitored. Information should be provided to the patients and their relatives.