PERSPECTIVES: Origins of the Neuro ICU and the FOUR Score with Dr. Eelco Wijdicks

In this episode of the NCS Podcast Hot Topics series, host Rich Choi, DO, is joined by Ofer Sadan, MD, PhD, neurointensivist at Emory University and associate editor of Neurocritical Care, to discuss the recent study, "Association of Rotational Thromboelastometry Parameters With Hematoma Expansion After Spontaneous Intracerebral Hemorrhage," published in Neurocritical Care. Their discussion begins with the evolution of coagulation testing and the differences between thromboelastography (TEG) and ROTEM before turning to the study's findings. Among 70 patients, researchers identified an association between clot lysis measurements and hematoma expansion, raising questions about whether subtle changes in coagulation could help predict which patients are most at risk. Choi and Sadan also consider the study's limitations, the challenges of translating these findings into clinical practice and how future research could help identify patients who may benefit from more targeted interventions.

In this Masterclass episode of the Neurocritical Care Society Podcast, hosts Stephan Mayer, MD, FCCM, FNCS, and Jon Rosenberg, MD, sit down with Marek Czosnyka, PhD, Professor of Brain Physics at the University of Cambridge, to discuss his career in brain monitoring and the work that has shaped modern neurocritical care. Professor Czosnyka shares how his early background in biomedical engineering led to research in intracranial pressure monitoring, the development of the pressure reactivity index (PRx) and eventually the concept of optimal cerebral perfusion pressure (CPPopt). They also discuss cerebral autoregulation, transcranial Doppler and noninvasive ICP monitoring, near-infrared spectroscopy and how these tools can help clinicians better understand what is happening in the brain at the bedside. Professor Czosnyka shares where he sees the field heading next, including the use of artificial intelligence to interpret monitoring data and the potential for closed-loop systems to help guide treatment. The views expressed on the NCS Podcast are solely those of the hosts and guests and do not necessarily reflect the opinions or official positions of the Neurocritical Care Society

In this episode of the NCS Podcast Hot Topics series, host Eric Lawson, MD, speaks with Stephan Mayer, MD, about the FASTEST clinical trial and the decades-long effort to determine whether ultra-early hemostatic therapy can improve outcomes for patients with spontaneous intracerebral hemorrhage (ICH). Dr. Mayer shares how the idea of using recombinant factor VIIa in ICH first emerged and how earlier trials helped shape the questions researchers are asking today. The conversation explores what FASTEST revealed about the relationship between treatment timing, hematoma expansion and functional outcomes — and why identifying the patients most likely to benefit remains so important. Dr. Mayer also discusses the role of the CTA spot sign, the risks that must be weighed with factor VIIa and how lessons from FASTEST are informing the next phase of research. Drs. Lawson and Mayer also discuss where hemostatic therapy could fit within the Code ICH approach and how advances in imaging and radiomics may help clinicians recognize ongoing bleeding sooner and better target treatment. The views expressed on the NCS Podcast are solely those of the host and guest and do not necessarily reflect the opinions or official positions of the Neurocritical Care Socie

In this episode of the NCS Podcast Hot Topic series, host Eric Lawson, MD, is joined by Mona Kumar, MD, of the University of Pennsylvania, Lori Kennedy, PhD, RN, ACNP-BC, of UC Davis Health, and Meghan Vallejo, PharmD, BCCCP, of Temple University Hospital: three members of the multidisciplinary panel behind the newly published "Treatment of Antithrombotic Associated Intracranial Hemorrhage in Adults: A Focused Guideline Update from the Neurocritical Care Society and Society of Critical Care Medicine." The conversation opens with how this focused update differs from the society's 2016 guideline, including a narrower set of clinical questions and a considerably more rigorous review process built around systematic reviews, formal risk of bias tools and a diverse voting panel that included a patient representative. From there, Drs. Kumar, Kennedy and Vallejo talk through several of the panel's toughest calls, weighing where the evidence was strong enough to guide practice and where long standing bedside habits are still running ahead of the data. The conversation then turns to where these recommendations fit into broader ICH care pathways, what still needs to be studied, and where the panel sees a role, and a limit, for AI in future guideline development.

In this episode of the NCS Podcast Hot Topics series, host Rich Choi, DO, welcomes back Andrew Webb, PharmD, to unpack "Effect of Desmopressin on Attaining Therapeutic Hypernatremia with Hypertonic Saline Continuous Infusion in Intracranial Hemorrhage," recently published in Neurocritical Care. Desmopressin has become a familiar tool for blunting antiplatelet-associated bleeding in intracranial hemorrhage, but its vasopressin-receptor activity raises a concern. Does it work against efforts to raise sodium with hypertonic saline? Dr. Webb traces desmopressin's path from a 1970s antidiuretic drug for diabetes insipidus to a hemostatic agent borrowed from the hemophilia literature, then walks through its pharmacokinetics, typical hemostatic dosing and the relatively modest side-effect profile clinicians should watch for. The conversation turns to a single-center retrospective study that paired a protocolized, TEG-guided desmopressin dose with a nurse-driven hypertonic saline sliding-scale infusion targeting a sodium goal of 150–155 mEq/L. Drs. Choi and Webb walk through how the study was designed and what it found, touching on sodium goal attainment, TEG changes, 3% saline volumes and thromboembolic risk. They also dig into the study's limitations, including its more conservative desmopressin dosing relative to practice at other centers, and agree a randomized trial is still needed to settle desmopressin's role in ICH management more broadly. For clinicians giving desmopressin alongside hypertonic saline, Dr. Webb offers a practical piece of advice worth tuning in for. The views expressed on the NCS Podcast are solely those of the hosts and guests and do not necessarily reflect the opinions or official positions of the Neurocritical Care Society.