The Neurohospitalist

Stress-induced hyperglycemia (SIH) has been associated with poor outcomes in stroke patients. However, the relationship between SIH and sepsis in this population remains understudied. We aimed to evaluate the association of SIH, measured using the stress hyperglycemia ratio (SHR), with the development of sepsis and mortality among critically ill stroke patients.

We retrospectively analyzed stroke patients requiring ICU admission from the MIMIC-IV database. Primary outcome was sepsis, and secondary outcomes were 30-day and 90-day all-cause mortality. Multivariable Cox and logistic regression models were used to evaluate associations.

A total of 3018 patients were included (66.8% ischemic stroke). After full adjustment for confounders, SHR was independently associated with an increased risk of sepsis (Q4 vs Q1: OR 1.46, 95% CI: 1.12-1.89, P = 0.005; continuous SHR: OR 1.31, P = 0.010). SHR also demonstrated a strong dose-response relationship with mortality; patients in Q4 had significantly higher risks of 30-day (OR 2.95, 95% CI: 2.25-3.88, P < 0.001) and 90-day mortality (OR 2.25, 95% CI: 1.80-2.82, P < 0.001). Subgroup analyses revealed significant interactions between SHR and stroke type for sepsis (P for interaction = 0.014), with a more pronounced effect observed in ischemic stroke patients. The associations between SHR and both sepsis and mortality were consistently maintained regardless of the presence of diabetes (all P < 0.050).

Elevated stress hyperglycemia ratio is independently associated with higher risks of sepsis and short-to long-term mortality among critically ill patients with stroke, with consistent associations observed irrespective of diabetes status. In contrast, no statistically significant association between SHR and sepsis was identified in the hemorrhagic stroke subgroup.

Substance use is rising among young adults with stroke. We aimed to assess the prevalence of substance use, and the use of toxicology screening in the diagnostic evaluation, for young individuals with acute ischemic stroke (AIS) at a single comprehensive stroke center.

This retrospective study was conducted at a single comprehensive stroke center in individuals ages 18 to 55 years old with AIS from 2020-24. Cases of AIS and recent substance use, or the use of cocaine, methamphetamine, marijuana, opioids, or other illicit substances within 30 days of admission, were compared to those with AIS and no substance use. Descriptive statistics and least absolute shrinkage and selection operator (LASSO) modeling were completed to evaluate predictors of toxicology screening.

Of 425 encounters screened, 307 were eligible for inclusion. Recent substance use was documented in 21.5% of encounters. Individuals with recent substance use were younger (median age 46 vs 51 years old in controls). Toxicology screens were ordered for 29.3% of all encounters, and in 27.9% of cryptogenic strokes. Models did not identify a variable that predicted the performance of toxicology screening.

Recent substance use was documented in about 1 in 5 young individuals with AIS. Further research is needed to understand the relationship between AIS and substance use, and the appropriate use of toxicology screening in stroke care.

Acute disseminated encephalomyelitis (ADEM) is a rare, rapidly progressive, immune-mediated demyelinating disorder with limited contemporary data describing its epidemiology in adults and real-world uptake of myelin oligodendrocyte glycoprotein (MOG) autoantibody testing.

We used the TriNetX global collaborative network (112 contributing healthcare organizations) to estimate ADEM prevalence and incidence rates from 2000 to 2025, both overall and stratified by age of onset, sex, race, and ethnicity. We also assessed uptake of MOG autoantibody testing among people with an ADEM diagnosis code.

We identified 4911 ADEM cases among 153,342,461 individuals from 2000 to 2025. Overall period prevalence was 3.26 (95% CI [confidence interval] 3.17-3.35) per 100,000 persons and overall incidence rate was 0.63 per 100,000 person-years (95% CI: 0.61-0.65). ADEM diagnosis codes were most frequently recorded in those ≤14 years old. Estimated were similar between sexes, lower among Black compared to White individuals, but similar across other racial groups and ethnicities. Only 11% of ADEM-coded individuals had documented MOG autoantibody testing.

In a large, real-world, electronic health record network, ADEM diagnosis codes were most frequently recorded in children, though cases were observed across the adult age range. MOG autoantibody testing was uncommon.

Data analyzing usage patterns, efficacy, tolerability, and long-term continuation of brivaracetam (BRV) when initiated in the acute, inpatient setting is lacking.

Retrospective chart review of adult patients who initiated BRV in the emergency or inpatient setting at Yale New Haven Hospital over 5-year span.

Of 133 patients, BRV was used for status epilepticus (SE) in 37% (n = 49), seizures in 38% (n = 51), and rhythmic/periodic patterns (RPP) in 21% (n = 28). Eighty-six (65%) were in an ICU and 33 (25%) were in a non-ICU setting. BRV was the first anti-seizure medication (ASM) tried in 9 (7%), while 124 (93%) tried other ASMs first (mean ASMs = 2; SD = 1). Initial dosing ranged from 50-400 mg (median = 200 mg, IQR = 200-300 mg), then median maintenance dosing of 200 mg/day (IQR = 200-300 mg/day). Of patients with RPP, seizures, or SE on EEG (n = 115, 86%), 46% (n = 53) had electrographic and/or clinical improvement, including 23 (20%) with complete resolution. In patients with clinical seizures (n = 10) or SE (n = 2) not on EEG, BRV was effective in 10 patients. BRV was discontinued in 49 (36%) patients, typically for inefficacy. Of 88 survivors to discharge, 86 (98%) were discharged on ASMs, including 62% (n = 54) discharged on BRV. Follow-up data were available for 53 (60%) patients - 51 (96%) remained on ASMs, with 33 (65%) remaining on BRV (median follow-up = 30 d, IQR = 18-65 d).

BRV appears safe, well-tolerated, and efficacious for acute, inpatient management of RPP, seizures, and SE. Prospective studies validating these findings and directly comparing BRV with other ASMs are warranted.

Navigating health-related decisions after severe acute brain injury (SABI) can be challenging, especially when the patient’s preferences and the prognosis remain unclear. This uncertainty adds a layer of complexity for surrogates and medical teams striving to make treatment choices.

To address these challenges, this article presents an interview study examining decisions that were retrospectively relevant for a surrogate decision-maker.

Key moments for shared decision-making and advance care planning were identified and compared to a theoretical decision model, providing valuable insights for decision-making in the context of SABI given time-pressure, prognostic uncertainties, and the patient’s neurological impairment.

A semi-structured interview was conducted with the 31-year-old daughter of a 53-year-old woman who had experienced an aneurysmal subarachnoid hemorrhage.

The interview was thematically analyzed, and eight preference-sensitive decision moments were identified and visualized within a timeline: bleeding event, emergency treatment, intensive care unit treatment (general), severe complication, long-term life-sustaining surgical interventions, admission to rehabilitation, further severe complication, and palliation.

In conclusion, this case study supports an iterative evaluation of treatment preferences and suggests well-suited moments for reevaluation of medical treatment goals and shared decision-making within a timeline. This framework may serve to facilitate shared decision-making by identifying key preference-sensitive junctures and providing a basis for designing tools that incorporate deliberate timing.

Coccidioidal vasculitis is a serious complication of coccidioidal infection. Prior studies suggest that steroids may reduce the risk of secondary vasculitis in coccidioidal meningitis (CM), but data on optimal dosing are limited. This study compared the characteristics and outcomes of CM patients with vasculitis who received different steroid doses.

The Stanford Research Data Repository was used to identify adult patients diagnosed with coccidioidal meningitis from 1992 to 2024. Patients were divided into those who received no steroids, low or medium dose steroids, and high dose steroids. Characteristics at admission were compared by steroid use category, and their association with clinical outcomes were assessed.

A total of 65 patients with CM were identified, with mean (standard deviation) age 45 (17) and 35% female. A higher percentage of patients not treated with steroids had a better modified Rankin score (mRS) of 2 or lower on admission compared to patients who were treated with steroids (standardized mean difference [SMD] = 0.67). Compared to patients who received a low/medium dose, those who received a high dose were 32% (95% CI 0.12, 3.61; P = 0.65) less likely to experience death or vasculitis.

There is a complex relationship between the use of steroids and outcomes among patients with CM. Among steroid recipients, those who received high dose steroids may achieve better long-term outcomes. A larger study is needed to validate these findings.

End-of-life (EOL) care in acute stroke is complex. Understanding family experiences is essential to improve care quality and promote a dignified death. This study aimed to assess family members perceptions of EOL care in patients who died after stroke and to identify factors associated with perceived dignified death.

A cross-sectional survey of relatives of deceased stroke patients during 1 year was conducted. Of 111 eligible cases, 68 questionnaires were returned (61.3%). Following the descriptive analysis, we compared relatives who perceived the death as dignified with those who did not. Survey responses were then integrated with clinical data regarding treatment history and place of death.

Most relatives (82.4%) considered that the patient died with dignity. Perceived dignified death was significantly associated with adequate and comprehensible prognostic information, respectful communication, respect for patient and family preferences, adequate symptom control, being accompanied at the time of death, and empathetic staff attitudes (all P < 0.05). No significant associations were observed with room type, religious variables, clerical visits, expectedness of death, continuous sedation, IV fluids, antibiotics, enteral nutrition, or location of death; symptom control ratings did not differ between sedated and non-sedated patients.

Most relatives perceived the death as dignified and they were generally satisfied with EOL care. Dignity was primarily linked to communication, respect for preferences, emotional support, and humane care rather than specific medical interventions.

Understanding trends in hospital length of stay (LOS) and costs for ischemic stroke is essential for improving care delivery and resource allocation. We evaluated national trends from 2016 to 2022, with a focus on the COVID-19 pandemic.

We performed a retrospective analysis using the National Inpatient Sample including adults (≥18 years) with a primary diagnosis of ischemic stroke (ICD-10-CM I63.x). Hospital charges were converted to estimated costs using cost-to-charge ratios and adjusted to 2022 U.S. dollars. Trends were compared between pre-COVID (2016-2019) and COVID-era (2020-2022) periods. Illness severity was stratified by the APR-DRG index, and Pearson correlation assessed the relationship between annual mean LOS and costs.

Among 953 325 ischemic stroke hospitalizations, mean LOS rose from 6.4 days in 2016 to 7.8 days in 2022. Mean hospital costs increased from $19,014 to $28,733 over the same period. COVID-era hospitalizations had significantly higher LOS (7.44 vs 6.47 days; P < 0.001) and costs ($27,006 vs $20,568; P < 0.001) compared to pre-COVID admissions. Annual mean LOS and costs were strongly correlated (r = 0.974, P < 0.001), and greater illness severity was associated with longer LOS and higher costs.

Hospital LOS and costs for ischemic stroke increased markedly from 2016 to 2022, with a sharp rise during the COVID-19 period. While LOS and costs were strongly correlated, additional factors—including illness severity, complication rates, and treatment complexity—likely contribute to rising expenditures. These findings underscore economic burden of stroke care and need for efficient inpatient care models.

Optimal timing of pharmacologic venous thromboembolism (VTE) prophylaxis after spontaneous intracerebral hemorrhage (ICH) remains uncertain due to concerns regarding hematoma expansion. Prior studies have primarily relied on arbitrary time thresholds rather than physiological markers of hemorrhage stability.

To summarize the literature on the safety and efficacy of pharmacologic VTE prophylaxis initiated after radiographic confirmation of hematoma stability in patients with spontaneous ICH.

We conducted a systematic review and meta-analysis of studies assessing heparinoids prophylaxis following repeat neuroimaging demonstrating hemorrhage stability. Three databases were searched: PubMed, Embase, Cochrane Central. The meta-analysis was registered in PROSPERO (CRD420261282903). The primary outcome was new or worsening intracranial hemorrhage, including hematoma expansion or new bleeding. Secondary outcomes included deep vein thrombosis and pulmonary embolism. Random-effects models were applied. P value was set at 0.05.

Four observational studies comprising 935 patients met inclusion criteria. Comparative meta-analysis demonstrated no significant association between pharmacologic prophylaxis after radiographic stability and intracranial bleeding risk (OR: 1.24, 95% CI: 0.80-1.94, P = 0.33), with negligible heterogeneity (I² = 0%). Sensitivity analysis restricted to parenchymal hematoma expansion showed similar results (OR 2.37, 95% CI: 0.42-13.43, P = 0.33). Thromboembolic outcomes trended in favor of pharmacological prophylaxis without reaching statistical significance (OR: 0.63, 95% CI: 0.33-1.22, P = 0.17).

Pharmacologic VTE prophylaxis initiated after radiographic confirmation of hematoma stability does not increase intracranial hemorrhage risk and may reduce thromboembolic complications. These findings support further investigation into imaging-guided, individualized strategies for pharmacologic VTE prophylaxis after ICH.