Advances in Stroke

The science of neurocritical care and emergency medicine has advanced in several areas over the last year, particularly in the management of acute hypertension during neurological emergencies. Intracerebral HemorrhageEarly ascription of do-not-resuscitate status to patients with intracerebral hemorrhage (ICH) has been previously shown to correlate with in-hospital mortality raising concerns over a self-fulfilling prophecy in clinical care. This has been replicated by a large observational study in Seattle, whereby the presence of a do-not-resuscitate order altered the multivariate predictive model of outcomes.1 In exploration of potential treatments for ICH, use of do-not-resuscitate should be investigated prospectively because this simple change in practice (ie, not de-escalating care for the first several days in all patients with ICH) could positively affect outcomes. In regard to blood pressure management, a multimodality monitoring study this year using invasive brain tissue oxygen and cerebral microdialysis in 18 patients with ICH showed less brain tissue hypoxia and lower lactate/pyruvate ratios in patients with higher cerebral perfusion pressures.2 Current ICH guidelines recommend blood pressure modification based on absolute blood pressure value and intracranial pressure alone3; customizing this recommendation based on real-time feedback from measures of brain physiology makes sense but …