Casey Albin, MD

Great case @rkchoi.bsky.social !!!

1/ Hello #medsky #neurosky #neurocritcare #FOAMEd have another brief case that I wanted to discuss with you and see if maybe you can learn something new or reinforce old knowledge!

Heading to #AANAM? The NDEC #secretmission continues with another chance to win the glial gladiator belt.

Join @caseyalbin.bsky.social @jrgoldstein.bsky.social & @drjmartindale.bsky.social Sunday 4/6 for a digital technology tour & receive your mission instructions! #neurosky

Join the #secretmission and learn more tomorrow at 7AM for a Technology Tour in the @aanmember.bsky.social education room with @caseyalbin.bsky.social, @drjmartindale.bsky.social and @jrgoldstein.bsky.social

Do you care for pts with disorders of consciousness in any capacity (as a MD, RN, social worker, pharmacist, PT, OT, caregiver etc!!)?

👇5 min survey on what educational resources you'd like to see Neurocritical Care Society provide?

Curious about RVUs, want to know if you are billing correctly, how about diversifying your revenue stream??

We've got answers from @smuehlsch.bsky.social & Dr. Ryan Hakimi.

Save the date!

The zoom link is on SCCM connect and will be emailed if you are part of the neuroscience section

Was so fun to join you!!!

Hmm like beyond ENLS?

Curious about RVUs, want to know if you are billing correctly, how about diversifying your revenue stream??

We've got answers from @smuehlsch.bsky.social & Dr. Ryan Hakimi.

Save the date!

The zoom link is on SCCM connect and will be emailed if you are part of the neuroscience section

@ericclawsonmd.bsky.social @aartisarwal.bsky.social @drdangayach.bsky.social @hehinson.bsky.social @danharrisonmd.bsky.social @richardchoi.bsky.social

Do you care for pts with disorders of consciousness in any capacity (as a MD, RN, social worker, pharmacist, PT, OT, caregiver etc!!)?

👇5 min survey on what educational resources you'd like to see Neurocritical Care Society provide?

Bookmarked for our travel day tmw!!
Critical work to define entrustment in NeuroICU APPs!

Mark your calendars for Sunday!!

Come hang with all the brain nerds😎 in Orlando!

Help spread the word!
@aartisarwal.bsky.social @drdangayach.bsky.social
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Are we missing cases of ocular telangiectasia and ataxia (walking and coordination) syndrome? YEP. Should these folks avoid X-rays? YEP. Do you know what features these cases may present with at ~age 40. Lukas Gattermeyer-Kell and colleagues show us two key images and teach us all about it.

I think this is a reasonable take based on the evidence!

Do I really think the grade 1 SAH with a whisp of blood and low risk of DCI needs a Hgb of 9? No.

But for pt in clear vasospasm (aSAH but also TBI) or other perfusion disturbing physiology I think I will keep 9 as my threshold.

Introducing @JSCVD2's new Medical Education in Vascular Neurology section, welcoming manuscript submissions that share ideas, research, & innovation that enhance #MedEd for stroke & cerebrovascular disease.
#neurology #stroke #neurosurgery #neuroicu

www.sciencedirect.com/journal/jour...

18/
Interested in how others are interpreting these results. Again, huge congrats to the authors. and a special shout out to Dr. Ofer Sadan who led the SAHARA effort at
@emoryneurocrit.bsky.social

@ericclawsonmd.bsky.social @pulmcrit.bsky.social @aartisarwal.bsky.social @ajwpharm.bsky.social

a showtime ad for billions shows an old man talking to another man ALT: a showtime ad for billions shows an old man talking to another man

17
I think there is enough data to suggest that aiming for 9g/dL PARTICULARLY (maybe exclusively) in pts at ⬆️ risk for decreases in cerebral perfusion due to ongoing physiologic changes like vasospasm makes sense given the control population in this trial & the results of TRAIN

16/
The way I have put this together, is that I will be more aggressive (than the standard 7 or what we have allowed as 8g/dL) in transfusions for the patients at highest risk for secondary neurologic injury.

15/
It seems to me a take away is that 10g/dL is too high to offer benefit, but the lowest acceptable number I think is still up for debate, and TRAIN would suggest 9g/dL might be a more reasonable target.

Indeed, the restrictive group in SAHARA was on average > that threshold

14/
In other neurocritically ill pts including SAH (the recently published TRAIN trial), we did reduce unfavorable outcomes when we set the "liberal" threshold of <9g/dl and restrict all the way down to <7g/dl. This looked at 6 month outcome.

13/
This trial was very well done and is pragmatic and generalizable.

The threshold of 10 doesn't seem to improve neurologic outcomes.

However, I don't look at this trial and think that we conclude that maintaining a daily hgb of 8g/dl is proven ok.

12/
Between these two groups, there was no significant difference in mRS at 12 months and the risk of having a poor outcome.

11/
Note also that once the liberal group got transfused they also mostly stay well above even the liberal threshold.

So intervention was transfusion for a low threshold of 8g/dl ... but we're I think ultimately comparing outcomes for avg daily hgb of ~11g/dL to ~9.5 g/dL

10/
However, while the two group are clearly different, its important to note... the restrict group was on avg above 9 g/dl.

Said differently the controls were anemic, but did not linger 8g/dL threshold... so, the intervention, if needed, got them well away from the "danger" level

9/
The median time before enrollment was 3 days (meaning by day 3 the hgb dropped below 10). this is important as it is right before patients would enter the period of highest risk for vasospasm and DCI. And the separation of hgb levels was well differentiated between the groups

8/
The groups were well matched in terms of gender, age, WFNS scale, modified Fisher grade. Most had anterior circulation aneurysms, and most were rapidly treated endovascularly.

Radiographic vasospasm was seen in 36.6% of liberal strategy and 35% of restrictive strategy pts

a woman is smiling and saying `` they 're all so different '' while standing in front of a brick building . ALT: a woman is smiling and saying `` they 're all so different '' while standing in front of a brick building .

7/
Everything else about the management was determined per the treating team.

And remember, there is variability between institutions about BP goals, how frequently IA is performed, how DCI is screened for, and how meds like milrinone and intrathecal nicardipine are used.

6/
And given this and other studies on the importance of anemia avoidance, surveyed neurointensivists, neurosurgeons, and intensivists felt that a threshold of 8g/dL was a more acceptable lower limit than waiting until 7g/dL to transfuse.

So 8 it is.

The Effect of Packed Red Blood Cell Transfusion on Cerebral Oxygenation and Metabolism After Subarachnoid Hemorrhage - PubMed PRBC transfusion resulted in PbtO2 improvement without a clear effect on cerebral metabolism prior to SAH.

5/
wait wait wait.... in other critical care situations we use a threshold of 7g/dL for transfusion... why wasn't this the threshold?

Because prior studies have suggested anemia adversely affects cerebral oxygenation and metabolism after aSAH.
pubmed.ncbi.nlm.nih.gov/26195087/