Richard Choi, DO, FNCS

Surgery for #ICH? where do we stand? where do we go from here?

www.ahajournals.org/...

Whoa, do any of you have this at your shop? 🤯

www.ahajournals.org/...

Great tool for #carotidweb!

Good thread on transfusion in neurocritical care. 2025 was a big year for liberal vs restrictive transfusion and the brain. 3 big RCTs.
In the end, the answer isn’t as clear as one would hope.

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End/ What are your thoughts on this #neurocritcare? Where will you set your threshold?

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9/ Will this data change how you practice?

My practice has been restrictive unless w/evidence of cerebral hypoperfusion, either due to symptomatic vasospasm, or cerebral hypoxia with 🧠 partial O2 tension, though the cumulative evidence suggests that more may be better

8/ The effect on unfavorable neuro outcome was lost when TRAIN was excluded, however:

7/ What did they find??

👉 🚫 effect on hospital or ICU ☠️
👉 🚫 effect on hospital or ICU length of stay
👉 ⬇️ rates of unfavorable neurologic outcome

6/ The authors identified 6️⃣ studies and 2497 patients to be included: 1239 managed liberally (goal 9-10) and 1258 managed restrictively (goal >7) for this meta-analysis

5/ The 🧠 is the organ that is most at risk for ischemia and may be particularly susceptible to anemia. At the same time, 🩸 transfusions can also carry unintended side effects.
So now what do we do? What is your current practice?
a. >7
b. >8
c. >10
d. Other

4/ Data so far from these trials has been inconclusive. TRAIN did show some potential benefit but this included #SAH, #ICH and #TBI patients, whereas dedicated TBI (HEMOTION) or SAH (SAHARA) did not show benefit

Liberal or Restrictive Transfusion Strategy in Aneurysmal Subarachnoid Hemorrhage | NEJM The effect of a liberal red-cell transfusion strategy as compared with a restrictive strategy in patients during the critical care period after an aneurysmal subarachnoid hemorrhage is unclear. We ...

3/ New data have been emerging specifically for 🧠 injured pts including:
👉 #SAHARA (www.nejm.org/doi/abs...)
👉 #HEMOTION (www.nejm.org/doi/abs...)
👉 #TRAIN (jamanetwork.com/jour...)

A Multicenter, Randomized, Controlled Clinical Trial of Transfusion Requirements in Critical Care | NEJM To determine whether a restrictive strategy of red-cell transfusion and a liberal strategy produced equivalent results in critically ill patients, we compared the rates of death from all causes at ...

2/ When we think about #RBC 🩸 transfusions in the #neurocritcare we often think of #TRICC (www.nejm.org/doi/ful...) which demonstrated that a restrictive transfusion threshold <7mg/dL was as or > effective than liberal strategy

Restrictive vs. Liberal Transfusion Strategy in Critically Ill Patients with Acute Brain Injury: A Systematic Review and Meta-analysis Neurocritical Care - The indications of red blood cell transfusions in the absence of life-threatening bleeding in neurocritical individuals are controversial. Recently, three large randomized...

1/ Happy 🦃 day #neurotwitter #neurosky #neurocritcare. Before your postprandial somnolence kicks in, wanted to talk about 🩸 transfusion parameters and break down the following article:

Important diagnosis to not miss from @StrokeAHA_ASA

www.ahajournals.org/...

What do you think #neurotwitter #neurosky #neurocritcare, does this seal the fate for surgical intervention in deep hemorrhages?

jamanetwork.com/jour...

Does your center perform #DecompressiveCraniectomy for deep #ICH #neurotwitter #neurocritcare #neurosurgery?

New evidence points to the fact that location does not matter and all patients had some benefit in this secondary analysis of #SWTICH:

www.ahajournals.org/...

In case you missed it:

Prioritization of Ethical Themes When Surrogates Object to Technology Removal After Brain Death Determination Neurocritical Care - As hospitals revise their policies for brain death/death by neurologic criteria (BD/DNC), they should provide transparent and clear plans for how to handle surrogate requests...

Interesting article on how to adapt 🏥 brain death policies in those instances when family object to removal of organ support:

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@PulmCrit
@drdangayach
@neurochristiana
@nirmalregency
@interneurona
@MicieliA_MD
@mettermd
@oneDRwoman_
@OGdukeneurosurg
@AvrahamCooperMD

@a_charidimou
@EricLawson90
@CajalButterfly
@Capt_Ammonia
@DrAtulRamesh1
@RamaniBalu1
@DSandsmarkMDPhD
@PennNeurology
@TJUHNeuroCrit
@namorrismd
@ShadiYaghi2
@MDNeurocritcare

End/ What are your thoughts on this #neurocritcare? Where do you measure ICP and MAP? Should this be standardized across the board?

@neurocritcarej
@swarnarmd
@aartisarwal
@alyssafloseldes
@caseyalbin
@JimmySuhMD
@JimSiegler
@medinariojaMD

12/ So as you can 👀 a seemingly 🤏 change in the way 1 center 📏 ICP and MAP had a pretty huge effect on 💊 for its patients! This is quite remarkable & it makes you wonder how wide of an implication it could have in terms of outcome and mortality

11/ As a result:
👉 Clonidine and metoprolol use ⬇️
👉 Norepinephrine use ⬆️

10/ As expected, they found:
✅ ICP ⬆️ when measured at ear
✅ CPP ⬇️ when measured at ear
✅ MAP did not differ between groups

9/ In this retrospective review of #TBI patients, they compared 49 patients from the 2013-16 vs. 53 in the 2018-22 time period and were well matched:

8/ In this 🇸🇪 study, a unique opportunity presented itself when the department changed where it measures ICP and MAP (after a review of the literature) as detailed in the diagram below:

7/ As you can imagine, depending on where you measure your MAP, your CPP values will be very different (image from: link.springer.com/ar...)

6/ You measure MAP at the level of:
a. Heart (right atrium)
b. Tragus
c. Outer canthus
d. Other