Using the ICH score during acute telestroke consults to triage transfer to tertiary centers.

OBJECTIVE: Constrained resources at tertiary centers indicate a need for re-exploration of the practice of routinely transferring all community hospital patients with complex conditions such as hemorrhagic stroke (ICH). We addressed the clinical question of whether information available during acute care telestroke consults could identify ICH patients not requiring specialty services or neurosurgical intervention who could safely remain at the local center for care. DESIGN: Retrospective cohort analysis abstracting clinical factors to identify ICH patients associated with need for tertiary care or neurosurgical intervention. SETTING: The Duke Telestroke Network (DTN) in Central NC and Southern Virginia. PATIENTS: All DTN transferred ICH patients January 1, 2017 to December 31, 2018. INTERVENTIONS: We defined neurosurgical intervention as craniotomy, digital subtraction angiography, or external ventricular drain placement. MEASUREMENTS AND RESULTS: We identified 116 transferred ICH patients. Sixty-two were female, the median Glasgow coma score (GCS) was 13, and the median ICU and hospital length of stay were 2 and 7 days respectively. Thirty of the patients were offered and 27 ultimately received neurosurgical intervention. Using inclusion/exclusion criteria from two ICH surgical trials would have increased the intervention group to 35 patients (30%). Components of the ICH score differentiated surgical from non-surgical patients; patients with an ICH score of <2 and GCS ≥13 received no interventions. Nearly 50% of patients could receive medical management locally. CONCLUSIONS: Coupling the ICH score and GCS can provide triage guidance identifying patients for retention at the referring center. This retained population is distinct from patients eligible for current or novel surgical interventions. This approach provides a framework for assessment of transfers across specialty areas and furthers the value of telehealth networks.

Autoimmune Encephalitis: NMDA Receptor Encephalitis as an Example of Translational Neuroscience.

Autoimmune encephalitis (AE) is a group of disorders causing synaptic receptor dysfunction with a broad range of neurological symptoms that has been historically difficult to differentiate clinically. Today, AE represents an excellent example of the rapid determination of the cause of a disease and the ability to identify potential treatments using relatively simple basic science techniques of investigation. Of the number of autoimmune encephalitides identified thus far, one of the best examples of the impact of basic science studies on disease management is NMDA receptor mediated autoimmune encephalitis (NMDAr-AE). In this review, we will provide an overview of the epidemiology of NMDAr-AE, clinical features and treatments, and the basic science tools and techniques that were used to identify the cause, correlate symptoms to underlying pathophysiology, and to understand the mechanism of disease pathology.