Hello, and thank you for joining us for this Year in Review, Neuroscience Research Highlights from 2021. I'm your speaker. I'm Molly McNatt. I'm a professor of clinical nursing at The Ohio State University, and I'm also assistant director of implementation science for the Helene Fold National Institute for Evidence-Based Practice in Healthcare, which is also housed at the College of Nursing at The Ohio State University. My disclosures are listed here, both professional appointments and funded disclosures, none of which are related to the work that I will be presenting today. The objective for our talk today is to appraise the latest research trials in the field of neurocritical care and identify how they may apply to clinical practice. It's important when thinking about neurocritical care research highlights to acknowledge that there's so much great work done every year, as the field of neuroscience itself very much remains uncharted territory, particularly when it comes to management of urgent and emergent neurological insults in critical care settings, and also when considering the wide range of etiologies and management approaches that we have for these patients. As such, there's so much great research work done every year by teams throughout the continuum of care to identify these potential new therapies, evaluate effectiveness of current treatments and practices, and also to identify how to best streamline current best evidence into meaningful practice recommendations for healthcare teams. So it's well beyond the scope of the talk today and these short 10 minutes to highlight all of this important work that's been done in 2021. But in attempts to make the best use of our time here today, I've identified some of the top access research articles in 2021 that addressed care of critically ill patients with neurological injuries. When we look at some of the most accessed articles throughout 2021, several fell within the categories of neurological complications of COVID-19, stroke care, coma care, and then also new guideline recommendations that have emerged. So we'll present content of the talk today under these domains. When we consider the research literature first on neurological complications of COVID-19, if you think about back in 2020, we saw a number of case reports and small single center or some series of case reports that were done that first suggested some of the neurological complications among patients hospitalized for COVID. As a result, later in 2020, several large research networks were formed to systematically begin to capture what some of these neurological signs and syndromes were among larger cohorts of hospitalized patients who had COVID-19. So it's no surprise in early 2021 then we began to see some of the early reports from these larger national and international research groups evaluating this data. And the findings tended to be pretty consistent across the various reports that we saw in 2021 from these larger groups and with what we were seeing in clinical practice. Perhaps one of the earliest large-scale reports was published in Neurology and highlighted the need for advanced neurological imaging among hospitalized COVID patients and that the presence of neurological signs and syndromes such as altered mentation and stroke significantly increased mortality among these patients. And these findings were consistent with other large-scale reports we began to see, certainly from the Global Consortium Study of NeuroCOVID, which included 28 centers across 13 countries and four continents and indicated over 80% of hospitalized COVID patients had some type of neurological sign or syndrome, with the most common being acute encephalopathy, coma and to a lesser degree stroke, which was associated with a six-fold increase in mortality. We also saw findings from several other large international groups who expanded this work with neurological complications of COVID-19 and reported the neurological signs and symptoms often persist well beyond hospital discharge. And it was some of the early indications leading to that renewed focus on long COVID that we started to see in 2021 or post-acute sequelae as SARS-CoV-2, which was later termed PASC. We also saw a number of publications in 2021 specifically looking at COVID and stroke. So again, think about early in the pandemic, early reports suggested the hypercoagulable state and potentially high rates of stroke among hospitalized patients. But at that time, again, this was back in 2020, we were lacking, again, that systematic collection and evaluation of data across larger cohorts beyond just those single-sider case series studies that we saw. So in 2021, again, it was no surprise we started to see the result of these larger-scale systematic efforts. And ultimately, several large consortiums published rates, treatments, and outcomes of patients with COVID and stroke. And from these findings, we realized that stroke really wasn't as prevalent as we had originally suspected in early 2020, with rates from these larger systematic groups in 2021 indicating that stroke ranged anywhere from 1% to 3% among hospitalized COVID patients. So some of this certainly may be attributed to better understanding and management of those hypercoagulable states in 2021 among hospitalized patients. But the studies did provide some important and more accurate estimates of the actual prevalence of stroke among COVID-19 patients and certainly impact on outcomes. Within the stroke literature specifically, exclusive of the COVID stroke literature in 2021, we saw several important papers published that continues to inform our overall management of stroke care, particularly for hospitalized and critically ill patients. Several of the studies evaluated throughput and process-related systems of care for acute stroke. For example, we saw a really important paper that demonstrated the ongoing effectiveness of mobile stroke units, as well as important work that informs some of the early treatment decisions we make regarding endovascular therapy for stroke with or without the use of alteplase. And then also some work looking at the benefits of streamlining some of the imaging that we routinely do upon patients first presenting for stroke to help improve throughput through those first initial critical hours for stroke. And the demonstrated positive benefit of these decisions about imaging on patient hospital outcomes, certainly at discharge and for throughput of these patients, but then also the continued positive benefit of streamlining some of this early imaging and positive benefit on 90-day functional status after discharge for these stroke patients. We also saw in 2021 several papers on intracerebral hemorrhage, and more specifically on withdrawal of life-sustaining therapies across large statewide or large-scale populations, which remains a really important topic, particularly in critical care management of patients with severe neurological insults. The work that was done throughout 2021 in this topic really highlights the number of patients who present with impaired level of consciousness that can be associated with higher rates of mortality, largely due to these early decisions that are made about withholding or withdrawing life-sustaining treatments in these patients. And these estimates from some of these large statewide registries indicates that these early decisions about withdrawal of life-sustaining therapies occur in up to 20 to 40 percent of patients who present with some type of change in level of consciousness early in their hospital presentation and certainly admission, which really has important implications for the timing and the mechanisms through which we make those decisions about early withdrawal of care for these patients. In addition to stroke, there were also a number of highly-accessed publications in 2021 on coma care. Much of the work was included in…some of the work was included in the COVID-19 literature, as we referenced earlier in this talk, but many of the highly-accessed publications on coma care also outlined research and care priorities for patients with coma throughout the continuum of care, but certainly in critical care settings as well. It highlighted specific gaps that needed to be addressed in critical care management of coma in some of these seminal papers that were produced, many of which were produced by the Curing Coma Campaign, which is a collaborative interdisciplinary and international group looking to advance the science and the care of patients of coma throughout the continuum of care. And these important publications really laid the groundwork for certainly the current gaps in terms of what we know about identification and management of coma care, and then also treatment and care trajectories for these patients and the research work that really needs to be done throughout coordinated efforts going forward. In 2021, we also saw a release of some important new guidelines and scientific statements that really guide our critical care management of patients who have some type of neurological insult. So we saw a practice guideline update published on anticonvulsant prophylaxis of patients with newly diagnosed brain tumors. We also saw recommendations about perioperative neurological evaluation and management to decrease risk of acute stroke with patients undergoing different types of non-neurological surgeries. In addition, we also saw the American Heart Association and American Stroke Association issue a guideline for the prevention of stroke in patients with stroke and TIA. We also saw a release of appropriateness criteria head trauma recommendations that were put out in 2021, as well as guidelines for mobilization of the patient after neurological insults. So today was a very, very brief highlight in a short 10 minutes of neurocritical care research from 2021 that has potential to impact care delivery, both immediate as we saw in care delivery for COVID patients in the short term as we continue to identify improvements in throughput and access and early care for stroke, but then also in the long-term care of these patients as we're just beginning to evaluate impact of early withdrawal of life-sustaining treatments for patients with neurological injuries and also to streamline care and diagnosis and also treatment for coma patients. It's clear that brain science continues to be on an uncharted frontier with both expected and unexpected advances, but then also challenges in establishing what the science is and also the care then for patients who have neurological insults. It's important to note from our talk today and also with publication of scientific findings in general that the science and generation of knowledge can't just stop at the time of publication of this important work that's been done. Rather, we really have to continue to advance the care for the patients that we provide by implementing this evidence into routine practice at the bedside. This is best accomplished by use of rigorously developed guidelines, which we've seen happen today, and also use of an implementation science approach to identify what are the best methods to increase uptake or use of these research findings and get them from research into the routine care that we provide for our patients every day. Thank you so much for your time today, and we hope you have a good afternoon.

Neurocritical care

COVID-19

Stroke care

Coma care

Guideline recommendations