Dysautonomia and activity in the early stroke recovery period.

Maintaining cerebral perfusion in the early stages of recovery after stroke is paramount. Autoregulatory function may be impaired during this period leaving cerebral perfusion directly reliant on intravascular volume and blood pressure (BP) with increased risk for expanding cerebral infarction during periods of low BP and hemorrhagic transformation during BP elevations. We suspected that dysautonomia is common during the acute period related to both pre-existing vascular risk factors and potentially independent of such conditions. Thus, we sought to understand the state of the science specific to dysautonomia and acute stroke. The scoping review search included multiple databases and key terms related to acute stroke and dysautonomia. The team employed a rigorous review process to identify, evaluate, and summarize relevant literature. We additionally summarized common clinical approaches used to detect dysautonomia at the bedside. The purpose of this scoping review is to understand the state of the science for the identification, treatment, and impact of dysautonomia on acute stroke patient outcomes. There is a high prevalence of dysautonomia among persons with stroke, though there is significant variability in the type of measures and definitions used to diagnose dysautonomia. While dysautonomia appears to be associated with poor functional outcome and post-stroke complications, there is a paucity of high-quality evidence, and generalizability is limited by heterogenous approaches to these studies. There is a need to establish common definitions, standard measurement tools, and a roadmap for incorporating these measures into clinical practice so that larger studies can be conducted.

Fever, Cognitive Decline, and Multifocal T2 Hyperintensities on Brain MRI: A Case Report of Cytokine Release Syndrome.

Cytokine release syndrome (CRS) is a systemic inflammatory response characterized by fever, constitutional symptoms, and multiorgan dysfunction. While most commonly associated with immunotherapy, CRS can also be incited by infections or drugs. This case details the presentation and evaluation of a 71-year-old woman with a history of primary myelofibrosis and breast cancer who presented with acute onset of altered mental status. Initial vital signs were notable for severe hypertension, tachycardia, and fever. The patient was alert and oriented only to self, with little verbal output, and spontaneously moving all extremities. The patient had a submandibular gland abscess that had been diagnosed prior to presentation via a computed tomography scan of the neck. A comprehensive analysis, including blood tests, cerebrospinal fluid (CSF) analysis, electroencephalogram (EEG), and neuroimaging, was performed. Severe leukocytosis was noted and brain MRI demonstrated scattered areas of diffusion restriction and diffuse T2 white matter hyperintensities. Serial imaging demonstrated the progression of T2 hyperintensities. Ultimately, CRS was the most likely diagnosis. In this case, the inciting event was likely an infectious etiology, suspected to be the submandibular gland abscess that was present at the time of admission. It is vital to have a high index of suspicion for CRS in patients with recent infection, drug exposure, or immune dysregulation.

Nonpharmacological Treatments for Hospitalized Patients with Stroke: A Nuanced Approach to Prescribing Early Activity.

Stroke remains a leading cause of adult disability. To date, hyperacute revascularization procedures reach 5-10% of stroke patients even in high resource health systems. There is a limited time window for brain repair after stroke, and therefore, the activities such as prescribed exercise in the earliest period will likely have long-term significant consequences. Clinicians who provide care for hospitalized stroke patients make treatment decisions specific to activity often without guidelines to direct these prescriptions. This requires a balanced understanding of the available evidence for early post-stroke exercise and physiological principles after stroke that drive the safety of prescribed exercise. Here, we provide a summary of these relevant concepts, identify gaps, and recommend an approach to prescribing safe and meaningful activity for all patients with stroke. The population of thrombectomy-eligible stroke patients can be used as the exemplar for conceptualization.

Development and Implementation of a New Model of Care for Patients With Stroke, Acute Hospital Rehabilitation Intensive SErvices: Leveraging a Multidisciplinary Rehabilitation Team.

ABSTRACT: The optimal timing and intensity of early rehabilitation remain uncertain. The literature has stated that too early high-intensity mobility within 24 hours can result in poor outcomes as compared with the 24- to 48-hour poststroke (Stroke 2012;43:2389-94. Stroke 2004;35:1005-9). However, few studies have shown that mobilizing patients a few times per day can have positive results (Stroke 2004;35:1005-9. Cerebrovasc Dis 2010;29:352-60). In addition to mobility impairments, many patients after stroke have dysphagia, aphasia, and cognitive-linguistic deficits. To date, there is limited literature on early rehabilitation in these areas. Here, we describe a program of enhanced rehabilitation in the acute care hospital. In this enhanced model of care, our team delivers up to six sessions of therapy per day focused on the patient's deficits. A patient can receive up to two sessions of each discipline daily to include physical therapy, occupational therapy, and speech language pathology. The model emphasizes team collaboration between therapy disciplines, physiatry, nursing, and neurology accomplished through a daily therapy schedule, rehabilitation huddle, and direct communication before and after therapy sessions. With this model, we aim to enhance coordination of care resulting in improved patient satisfaction and, ultimately, recovery.

Feasibility of an Enhanced Therapy Model of Care for Hospitalized Stroke Patients.

INTRODUCTION: The aim of this study was to determine the safety and feasibility of an enhanced therapy model for hospitalized stroke patients. METHODS: This was a quasi-experimental cohort study of acute stroke patients from a single hospital. In the intervention group, all hospitalized patients on the acute stroke service were seen by at least two therapy disciplines daily in addition to routine stroke care. The comparison group consisted of all patients admitted to the same stroke service 1 year before who received the standard of care. The primary endpoint was the number of completed therapy sessions. Exploratory endpoints compared the length of hospital stay, hospital readmission rates, and degree of disability measured by the 90-day modified Rankin Scale score. RESULTS: A total of 1110 records were analyzed with 553 subjects in the intervention group and 557 in the control group. The intervention group received a significantly higher number of therapy sessions. There was no significant difference in length of hospital stay. However, 30-day readmission rates were lower, and the percentage of patients who achieved a good functional outcome on the modified Rankin Scale was higher during the intervention period. CONCLUSION: Increasing exposure to intensive multidisciplinary therapy comparable with that of acute inpatient rehabilitation in the hospital setting is feasible and may reduce both readmission rates and disability.

Bringing High-Dose Neurorestorative Behavioral Training Into the Acute Stroke Unit.

ABSTRACT: Stroke remains common and is a leading cause of adult disability. While there have been enormous system changes for the diagnosis and delivery of hyperacute stroke treatments at comprehensive stroke centers, few advances have been made in those same centers for treatments focused on behavioral recovery and brain repair. Specifically, during the early hospital period, there is a paucity of approaches available for reduction of impairment beyond what is expected from spontaneous biological recovery. Thus, patients in the early stroke recovery period are not receiving the kind of training needed, at the requisite intensity and dose, to exploit a potential critical period of heightened brain plasticity that could maximize true recovery instead of just compensation. Here, we describe an ongoing pilot program to reconfigure the acute stroke unit experience to allow for a new emphasis on brain repair. More specifically, we have introduced a novel room-based video-gaming intervention; restorative neuroanimation, into the acute stroke hospital setting. This new intervention provides the opportunity for an extra hour(s) of high-intensity neurorestorative behavioral treatment that is complementary to conventional rehabilitation. To accomplish this, system redesign was required to insert this new treatment into the patient day, to properly stratify patients behaviorally and physiologically for the treatment, to optimize the digital therapeutic approach itself, and to maintain the impairment reduction after discharge.

Socialize, Eat More, and Feel Better: Communal Eating in Acute Neurological Care.

OBJECTIVE: Stroke commonly leads to feelings of isolation and loneliness, especially during the hospital period. The aim of the Communal Eating program was to support patient well-being through introducing opportunities for patients to eat lunch together. DESIGN: Patients admitted to the Brain Rescue Unit who were identified as appropriate by their attending physicians, nurses, or other clinicians were recruited to attend communal lunch. Their mood, quality of life, loneliness, communication, swallowing safety, and eating behavior were examined. RESULTS: Those who attended two or more sessions tended to have been lonelier and more psychosocially impaired at baseline. Patients who had one or fewer lunch showed no significant differences from baseline to posthospitalization on any measure. However, for those who ate two or more lunches, changes in loneliness and quality of life trended toward improvement. There was scant evidence of changes to communication or eating habits. CONCLUSION: Implementing a communal eating program in the acute hospital setting was very feasible and widely supported by patients, families, and staff. The results thus far show modest trends toward fulfilling the goal of supporting emotional well-being, while potentially supporting increased intake and, importantly, do not evidence any measurable harm.

Providers' Perceptions of Neurology Care Delivered Through Telemedicine Technology.

Background: The COVID-19 pandemic and subsequent acceleration of telemedicine usage allowed many neurologists to trial telemedicine for neurological care. The purpose of this study is to explore neurology providers' experiences with delivering telemedicine care during the COVID-19 pandemic. Methods: Semistructured video interviews were conducted with 27 neurology providers who practice at a single, urban academic center. Interviews were transcribed and analyzed for content and themes. Results: Five major themes were identified: virtual examination subspecialty differences, tips and tricks for the virtual examination, improved infrastructure needs, future technologies that could support the virtual examination, and preferences for the postpandemic telemedicine protocol. Subspecialists who described their visits as more focused on behavioral examination and obtaining patient history reported fewer limitations with delivering neurological care through telemedicine platforms. Conclusions: The implementation of a telemedicine system should reflect the needs of each neurology subspecialty. Funding is needed to improve logistical infrastructure for health providers' telemedicine visits, such as technical and administrative assistance, as well as creation and testing of technologies to support physical examination in the virtual environment.

Telemedicine Services for the Delivery of Specialty Home-Based Neurological Care.

Introduction: The COVID-19 pandemic accelerated the adoption of telemedicine services for the delivery of outpatient neurological care. We sought to understand perceptions and the acceptance of this technology by neurology specialists during the proliferation of telemedicine services into their outpatient practices. Methods: We adapted the Telehealth Usability Questionnaire for neurological care via telemedicine. Our 29-item questionnaire evaluated the telemedicine system in three domains: quality of the telemedicine platform, ability to conduct a sufficient neurological examination, and overall system confidence. The survey was distributed to 88 clinical neurology faculty in the Johns Hopkins Health System. Responses were collapsed into "Favorable," "Neutral," and "Unfavorable." Within each domain, responses to individual questions were analyzed by neurology subspecialty using descriptive statistics. Results: We received completed surveys from 46 of the 88 (52%) neurology faculty. Of those, most reported favorable comfort with the current platform (98%), ease of use (73%), and quality (80%). However, responses indicated only average ability to troubleshoot telemedicine platform issues when they occurred (55%) and to complete an entire neurological examination (52%). Subspecialty comparisons revealed differences in diagnostic confidence; 30% of neuromuscular faculty indicated that they could make accurate neurological diagnoses through a tele-examination as opposed to ≥84% for other specialties. Conclusions: The use of telemedicine services for the delivery of outpatient neurological care is feasible and acceptable to most neurologists, although diagnostic confidence compared with in-person visits may be reduced and differs by subspecialty. Improvements in technological infrastructure and care models are needed to advance telemedicine neurological care delivery. Our data also suggest that a larger multicenter investigation of telemedicine use post-pandemic would be useful.

Biological Sex Differences in Risk Factors and Outcomes Among Hospitalized Adults With Stroke in Lusaka, Zambia.

OBJECTIVE: We investigated sex differences in clinical characteristics and outcomes among hospitalized adults with stroke in Zambia. METHODS: We retrospectively collected information for 324 consecutively hospitalized adults with stroke on the neurology service at the University Teaching Hospital in Lusaka, Zambia, between October 2018 and March 2019. Stroke characteristics were then compared by biological sex. RESULTS: Female participants constituted 62% (n = 200) of the cohort, were older (61 ± 19 vs 57 ± 16 years, p = 0.06), had fewer hemorrhagic stroke than male participants (22% vs 37%, p = 0.001), and had higher rates of hypertension (84% vs 74%, p = 0.04), diabetes (19% vs 13%, p = 0.04), heart disease (38% vs 27%, p = 0.04), and history of stroke (26% vs 14%, p = 0.01). Male participants had higher rates of alcohol (33% vs 4%, p < 0.001) and tobacco (19% vs 2%, p < 0.001) use. Female participants were less likely to have neuroimaging completed during their hospitalization (82% vs 94%, p = 0.002) and had higher 90 days postdischarge mortality (28% vs 10%, p = 0.002) independent of age and stroke subtype (OR 2.48, 95% CI 1.1-5.58, p = 0.03). DISCUSSION: Female participants in this Zambian stroke cohort had a higher prevalence of vascular risk factors but were less likely to have neuroimaging completed. Postdischarge mortality was markedly higher among female participants even after adjusting for age and stroke subtype. Our data highlight the need for future studies of social and socioeconomic factors that may influence stroke-related outcomes.

Stroke Outcome Related to Initial Volume Status and Diuretic Use.

Background We hypothesized that stroke outcome is related to multiple baseline hydration-related factors including volume contracted state (VCS) and diuretic use. Methods and Results We analyzed a prospective cohort of subjects with ischemic stroke <24 hours of onset enrolled in acute treatment trials within VISTA (Virtual International Stroke Trials Archive). A VCS was defined based on blood urea nitrogen-to-creatinine ratio. The primary end point was modified Rankin Scale score at 90 days. Primary analysis used generalized ordinal logistic regression over the mRS range, adjusted for Totaled Health Risks in Vascular Events score, onset-to-enrollment time, and thrombolytic use. Of 5971 eligible patients with stroke, 42% were taking diuretics at the time of hospitalization, and 44% were in a VCS. Patients in a VCS were older, had more vascular risk factors, were more likely taking diuretics, and had more severe strokes. Diuretic use was associated with both reduced chance of achieving a good functional outcome (odds ratio [OR], 0.57 [95% CI, 0.52-0.63]) and increased mortality at 90 days (OR, 2.30 [95% CI, 2.04-2.61]). VCS was associated with greater mortality 90 days after stroke (OR, 1.53 [95% CI, 1.33-1.76]). There was no evidence of effect modification among the 3 exposures of VCS, diuretic use, or hypokalemia in relation to outcome. Conclusions A VCS at the time of hospitalization was associated with more severe stroke and odds of death but not associated with worse functional outcome when accounting for relevant characteristics. Diuretic use and low serum potassium at the time of stroke onset were associated with worse outcome and may be worthy of further investigation.

Arterial Spin Labeling Imaging Characteristics of Anti-leucine-rich Glioma-Inactivated 1 Encephalitis: A Qualitative and Quantitative Analysis.

Background and Significance: Autoimmune encephalitis (AE) is a rare group of diseases that can present with stroke-like symptoms. Anti-leucine-rich glioma inactivated 1 (LGI1) encephalitis is an AE subtype that is infrequently associated with neoplasms and highly responsive to prompt immunotherapy treatment. Therefore, accurate diagnosis of LGI1 AE is essential in timely patient management. Neuroimaging plays a critical role in evaluating stroke and stroke mimics such as AE. Arterial Spin Labeling (ASL) is an MRI perfusion modality that measures cerebral blood flow (CBF) and is increasingly used in everyday clinical practice for stroke and stroke mimic assessment as a non-contrast sequence. Our goal in this preliminary study is to demonstrate the added value of ASL in detecting LGI1 AE for prompt diagnosis and treatment. Methods: In this retrospective single center study, we identified six patients with seropositive LGI1 AE who underwent baseline MRI with single delay 3D pseudocontinuous ASL (pCASL), including five males and one female between ages 28 and 76 years, with mean age of 55 years. Two neuroradiologists qualitatively interpreted the ASL images by visual inspection of CBF using a two-point scale (increased, decreased) when compared to both the ipsilateral and contralateral unaffected temporal and non-temporal cortex. The primary measures on baseline ASL evaluation were a) presence of ASL signal abnormality, b) if present, signal characterization based on the two-point scale, c) territorial vascular distribution, d) localization, and e) laterality. Quantitative assessment was also performed on postprocessed pCASL cerebral blood flow (CBF) maps. The obtained CBF values were then compared between the affected temporal cortex and each of the unaffected ipsilateral parietal, contralateral temporal, and contralateral parietal cortices. Results: On consensus qualitative assessment, all six patients demonstrated ASL hyperperfusion and corresponding FLAIR hyperintensity in the hippocampus and/or amygdala in a non-territorial distribution (6/6, 100%). The ASL hyperperfusion was found in the right hippocampus or amygdala in 5/6 (83%) of cases. Four of the six patients underwent initial follow-up imaging where all four showed resolution of the initial ASL hyperperfusion. In the same study on structural imaging, all four patients were also diagnosed with mesial temporal sclerosis (MTS). Quantitative assessment was separately performed and demonstrated markedly increased CBF values in the affected temporal cortex (mean, 111.2 ml/min/100 g) compared to the unaffected ipsilateral parietal cortex (mean, 49 ml/min/100 g), contralateral temporal cortex (mean, 58.2 ml/min/100 g), and contralateral parietal cortex (mean, 52.2 ml/min/100 g). Discussion: In this preliminary study of six patients, we demonstrate an ASL hyperperfusion pattern, with a possible predilection for the right mesial temporal lobe on both qualitative and quantitative assessments in patients with seropositive LGI1. Larger scale studies are necessary to further characterize the strength of these associations.

Predictors of in-hospital and 90-day post-discharge stroke mortality in Lusaka, Zambia.

BACKGROUND: Factors associated with stroke mortality are understudied in sub-Saharan Africa but have implications for designing interventions that improve stroke outcomes. We investigated predictors of in-hospital and 90-day post-discharge stroke mortality in Lusaka, Zambia. METHODS: Data from consecutive adults admitted with stroke at University Teaching Hospital in Lusaka, Zambia between October 2018 and March 2019 were retrospectively reviewed for clinical in-hospital outcomes. Vital status at 90-days post-discharge was determined through phone calls. Factors associated with stroke mortality were included in multivariable logistic regression models utilizing multiple imputation analysis to determine independent predictors of in-hospital and 90-days post-discharge mortality. RESULTS: In-hospital mortality was 24%, and 90-day post-discharge mortality was 22% among those who survived hospitalization. Hemorrhagic and unknown strokes, ICU care, seizures, and aspiration pneumonia were significantly associated with in-hospital mortality. Among these, hemorrhagic stroke (OR 2.88, 95% CI 1.27-6.53, p = 0.01) and seizures (OR 29.5, 95% CI 2.14-406, p = 0.01) remained independent predictors of in-hospital mortality in multivariable analyses. Ninety-day post-discharge mortality was significantly associated with older age, previous stroke, atrial fibrillation, and aspiration pneumonia, but only older age (OR 1.04, 95% CI 1.01-1.06, p = 0.007) and aspiration pneumonia (OR 3.93, 95% CI 1.30-11.88, p = 0.02) remained independently associated with 90-day mortality in multivariable analyses. CONCLUSION: This Zambian stroke cohort had high in-hospital and 90-day post-discharge mortality that were associated with several in-hospital complications. Our data indicate the need for improvement in both acute stroke care and post-stroke systems of care to improve stroke outcomes in Zambia.

Added Value of Arterial Spin Labeling in Detecting Posterior Reversible Encephalopathy Syndrome as a Stroke Mimic on Baseline Neuroimaging: A Single Center Experience.

Differentiating stroke from stroke mimics is a diagnostic challenge in every day practice. Posterior Reversible Encephalopathy Syndrome (PRES) is an important stroke mimic with nonspecific symptomatology, making prompt and accurate diagnosis challenging. Baseline neuroimaging plays a pivotal role in detection and differentiation of stroke from many common mimics and is thus critical in guiding appropriate management. In particular, MR perfusion (MRP) imaging modalities provide added value through detection and quantification of multiple physiological parameters. Arterial Spin Labeling (ASL) is a non-contrast, noninvasive MRP technique increasingly used in clinical practice; however, there is limited description of ASL in PRES in the existing literature. In this single center retrospective pilot study, we investigate the added value of ASL in detecting PRES in the largest series to date. We hope this study can serve as the basis for larger scale investigations exploring the utility of ASL in detecting stroke mimics such as PRES for accurate and efficient management of such patients.

The Impact of Mean Arterial Pressure and Volume Contraction in With Acute Ischemic Stroke.

Background and Purpose: Hydration at the time of stroke may impact functional outcomes. We sought to investigate the relationship between blood pressure, hydration status, and stroke severity in patients with acute ischemic stroke (AIS). Methods: We evaluated hydration status, determined by blood urea nitrogen (BUN)/creatinine ratio, in consecutive patients with AIS from a single comprehensive stroke center. Baseline mean arterial pressure (MAP) was analyzed using a linear spline with a knot at 90 mmHg. Baseline stroke severity was defined based on admission NIH Stroke Scale scores (NIHSSS) and MRI diffusion-weighted imaging. Results: Among 108 eligible subjects, 55 (51%) presented in a volume contracted state. In adjusted models, in the total sample, for every 10 mmHg higher MAP up to 90 mmHg, NIHSSS was 2.8 points lower (p = 0.053), without further statistically significant association between MAP above 90 and NIHSSS. This relationship was entirely driven by the individuals in a volume contracted state: MAP was not associated with NIHSSS in individuals who were euvolemic. For individuals in a volume contracted state, each 10 mmHg higher MAP, up to 90 mmHg, was associated with 6.9 points lower NIHSSS (95% CI -11.1, -2.6). MAP values above 90 mmHg were not related to NIHSSS in either dehydrated or euvolemic patients. Conclusions: Lower MAP contributes to more severe stroke in patients who are volume contracted, but not those who are euvolemic, suggesting that hydration status and blood pressure may jointly contribute to the outcome. Hydration status should be considered when setting blood pressure goals for patients with AIS.

Risk factors and outcomes of HIV-associated stroke in Zambia.

OBJECTIVE: To compare risk factors and clinical outcomes between people with HIV (PWH) and HIV-uninfected (HIV-) adults with stroke hospitalized in Zambia. METHODS: We retrospectively reviewed charts of all adults admitted to the University Teaching Hospital in Lusaka, Zambia with a clinical diagnosis of stroke between October 2018 and March 2019. Standardized data collection instruments were used to collect demographic, clinical, laboratory and imaging results. Comparison between individuals with and without HIV infection was made using t tests for continuous parametric variables, Wilcoxon rank-sum tests for continuous nonparametric variables, and chi-square analyses for categorical variables. RESULTS: Two hundred and seventy-two adults with stroke were admitted of whom 58 (21%) were PWH. Compared with HIV- participants, PWH were younger [(48 ±â€Š14) years versus 62 ±â€Š18) years, P < 0.001]. PWH were less likely to have hypertension (65 versus 83%, P = 0.003) and more likely to have no traditional cerebrovascular risk factors (34 versus 15%, P = 0.01). Deep vein thrombosis (DVT) (4 versus 1%, P = 0.04) was more common during hospitalization amongst PWH but there was no difference in in-hospital mortality (21 versus 23%, P = 0.65). Among PWH with stroke, factors associated with in-hospital mortality were Glasgow Coma Scale (GCS) on admission (7 versus 10, P = 0.046), hypertension (92 versus 59%, P = 0.04) and fever (58 versus 13%, P = 0.003). CONCLUSION: This Zambian cohort of PWH and stroke is notable for being significantly younger with fewer traditional stroke risk factors but higher rates of DVT than their HIV-uninfected counterparts. GCS on admission, hypertension and fever were associated with in-hospital mortality.

Transcranial Doppler in Acute COVID-19 Infection: Unexpected Associations.

BACKGROUND AND PURPOSE: Stroke may complicate coronavirus disease 2019 (COVID-19) infection based on clinical hypercoagulability. We investigated whether transcranial Doppler ultrasound has utility for identifying microemboli and clinically relevant cerebral blood flow velocities (CBFVs) in COVID-19. METHODS: We performed transcranial Doppler for a consecutive series of patients with confirmed or suspected COVID-19 infection admitted to 2 intensive care units at a large academic center including evaluation for microembolic signals. Variables specific to hypercoagulability and blood flow including transthoracic echocardiography were analyzed as a part of routine care. RESULTS: Twenty-six patients were included in this analysis, 16 with confirmed COVID-19 infection. Of those, 2 had acute ischemic stroke secondary to large vessel occlusion. Ten non-COVID stroke patients were included for comparison. Two COVID-negative patients had severe acute respiratory distress syndrome and stroke due to large vessel occlusion. In patients with COVID-19, relatively low CBFVs were observed diffusely at median hospital day 4 (interquartile range, 3-9) despite low hematocrit (29.5% [25.7%-31.6%]); CBFVs in comparable COVID-negative stroke patients were significantly higher compared with COVID-positive stroke patients. Microembolic signals were not detected in any patient. Median left ventricular ejection fraction was 60% (interquartile range, 60%-65%). CBFVs were correlated with arterial oxygen content, and C-reactive protein (Spearman ρ=0.28 [P=0.04]; 0.58 [P<0.001], respectively) but not with left ventricular ejection fraction (ρ=-0.18; P=0.42). CONCLUSIONS: In this cohort of critically ill patients with COVID-19 infection, we observed lower than expected CBFVs in setting of low arterial oxygen content and low hematocrit but not associated with suppression of cardiac output.

Acute Viral Illnesses and Ischemic Stroke: Pathophysiological Considerations in the Era of the COVID-19 Pandemic.

The severe acute respiratory syndrome coronavirus 2 or coronavirus disease 2019 (COVID-19) pandemic has raised concerns about the correlation with this viral illness and increased risk of stroke. Although it is too early in the pandemic to know the strength of the association between COVID-19 and stroke, it is an opportune time to review the relationship between acute viral illnesses and stroke. Here, we summarize pathophysiological principles and available literature to guide understanding of how viruses may contribute to ischemic stroke. After a review of inflammatory mechanisms, we summarize relevant pathophysiological principles of vasculopathy, hypercoagulability, and hemodynamic instability. We will end by discussing mechanisms by which several well-known viruses may cause stroke in an effort to inform our understanding of the relationship between COVID-19 and stroke.

Physiological Responses to In-Bed Cycle Ergometry Treatment in Intensive Care Unit Patients with External Ventricular Drainage.

PURPOSE: Evidence suggests that early physical activity can be accomplished safely in the neurocritical care unit (NCCU); however, many NCCU patients are often maintained in a state of inactivity due to impaired consciousness, sensorimotor deficits, and concerns for intracranial pressure elevation or cerebral hypoperfusion in the setting of autoregulatory failure. Structured in-bed mobility interventions have been proposed to prevent sequelae of complete immobility in such patients, yet the feasibility and safety of these interventions is unknown. We studied neurological and hemodynamic changes before and after cycle ergometry (CE) in a subset of NCCU patients with external ventricular drains (EVDs). METHODS: Patients admitted to the NCCU who had an EVD placed for cerebrospinal fluid drainage and intracranial pressure (ICP) monitoring underwent supine CE therapy with passive and active cycling settings. Neurologic status, ICP and hemodynamic parameters were monitored before and after each CE session. RESULTS: Twenty-seven patients successfully underwent in-bed CE in the NCCU. No clinically significant changes were recorded in neurologic or in physiological parameters before or after CE. There were no device dislodgements or other adverse effects requiring cessation of a CE session. CONCLUSION: These data suggest that supine CE in a heterogeneous cohort of neurocritical care patients with EVDs is safe and tolerable. Larger prospective studies are needed to determine the efficacy and optimal dose and timing of supine CE in neurocritical care patients.

Exploring community engaged research experiences and preferences: a multi-level qualitative investigation.

BACKGROUND: Community engagement may make research more relevant, translatable, and sustainable, hence improving the possibility of reducing health disparities. The purpose of this study was to explore strategies for community engagement adopted by research teams and identify areas for enhancing engagement in future community engaged research. METHODS: The Community Engagement Program of the Johns Hopkins Institute for Clinical and Translational Research hosted a forum to engage researchers and community partners in group discussion to reflect on their diverse past and current experiences in planning, implementing, and evaluating community engagement in health research. A total of 50 researchers, research staff, and community partners participated in five concurrent semi-structured group interviews and a whole group wrap-up session. Group interviews were audiotaped, transcribed verbatim, and analyzed using content analysis. RESULTS: Four themes with eight subthemes were identified. Main themes included: Community engagement is an ongoing and iterative process; Community partner roles must be well-defined and clearly communicated; Mutual trust and transparency are central to community engagement; and Measuring community outcomes is an evolving area. Relevant subthemes were: engaging community partners in various stages of research; mission-driven vs. "checking the box"; breadth and depth of engagement; roles of community partner; recruitment and selection of community partners; building trust; clear communication for transparency; and conflict in community engaged research. CONCLUSION: The findings highlight the benefits and challenges of community engaged research. Enhanced capacity building for community engagement, including training and communication tools for both community and researcher partners, are needed.