Objective: This study tested the hypothesis that patients without placement of new do-notresuscitate (DNR) orders during the first 5 days after intracerebral hemorrhage (ICH) have lower 30-day mortality than predicted by the ICH Score without an increase in severe disability at 90 days.Methods: This was a prospective, multicenter, observational cohort study at 4 academic medical centers and one community hospital. Adults (18 years or older) with nontraumatic spontaneous ICH, Glasgow Coma Scale score of 12 or less, who did not have preexisting DNR orders were included.Results: One hundred nine subjects were enrolled. Mean age was 62 years; median Glasgow Coma Scale score was 7, and mean hematoma volume was 39 cm 3 . Based on ICH Score prediction, the expected overall 30-day mortality rate was 50%. Observed mortality was substantially lower at 20.2%, absolute average difference 29.8% (95% confidence interval: 21.5%-37.7%). At 90 days, 27.1% had died, 21.5% had a modified Rankin Scale score 5 5 (severe disability). A good outcome (modified Rankin Scale score 0-3) was achieved by 29.9% and an additional 21.5% fell into the moderately severe disability range (modified Rankin Scale score 5 4).Conclusions: Avoidance of early DNR orders along with guideline concordant ICH care results in substantially lower mortality than predicted. The observed functional outcomes in this study provide clinicians and families with data to determine the appropriate goals of treatment based on patients' wishes. Neurology ® 2015;84:1739-1744 GLOSSARY CI 5 confidence interval; DNR 5 do not resuscitate; GCS 5 Glasgow Coma Scale; ICH 5 intracerebral hemorrhage; mRS 5 modified Rankin Scale.Intracerebral hemorrhage (ICH) is a common, severe form of stroke with 30-day case fatality approaching 50% in population-based series.1 Predictive models that focus on hematoma volume and level of consciousness are frequently used in the care of patients with ICH.2-4 None of these models account for the effect of early decisions to limit medical treatment, such as do-notresuscitate (DNR) orders or withdrawal of medical support, on individual patient outcomes. Recent studies demonstrate that the use of DNR orders early after ICH is heterogeneous and independently influences risk of mortality after ICH. [5][6][7][8] The published predictive models are also questioned as a self-fulfilling prophecy since clinicians tend to suggest limitations in medical support for patients with moderate to large hemorrhages. 9 This practice raises the possibility that patients who would survive with intensive medical care are dying because of early treatment limitations. Survival, however, could be at the expense of severe disability.We performed an observational ICH outcome study at 5 centers whose practice was to offer full care for patients with ICH for at least the first 5 days following symptom onset. The primary hypothesis was that 30-day mortality in these patients would be significantly less than predicted

Nicardipine offers an alternative to labetalol with similar tolerability and appears to provide a smoother blood pressure control compared to labetalol.

SUMMARYRefractory status epilepticus (RSE) is a medical emergency, with significant morbidity and mortality. The use and effectiveness of clobazam, a unique 1,5-benzodiazepine, in the management of RSE has not been reported before. Over the last 24 months, we identified 17 patients with RSE who were treated with clobazam in our hospital. Eleven of the 17 patients had prior epilepsy. Fifteen patients had focal status epilepticus. Use of clobazam was prompted by a favorable pharmacokinetic profile devoid of drug interactions. Clobazam was introduced after a median duration of 4 days and after a median of three failed antiepileptic drugs. A successful response, defined as termination of RSE within 24 h of administration, without addition or modification of concurrent AED and with successful wean of anesthetic infusions, was seen in 13 patients. Indeterminate response was seen in three patients, whereas clobazam was unsuccessful in one patient. Clobazam averted the need for anesthetic infusions in five patients. Clobazam was well tolerated, and appears to be an effective and promising option as add-on therapy in RSE. Its efficacy, particularly early in the course of SE, should be further investigated in prospective, randomized trials.

To the Editor:Morbidity and mortality associated with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are extremely visible 1 ; however, the effect of the COVID-19 pandemic on the management of other pathologies requiring complex interventions and critical care resources-the bystander effect 2 -is not well described. This is certainly true of stroke patients whose clinical outcomes are a function of early presentation, timely diagnosis, emergent intervention, and critical care management. [3][4][5] With the arrival of COVID-19 cases in the month of March in the hotspot of Michigan, we describe the bystander effect of the COVID-19 pandemic on ischemic and hemorrhagic stroke. METHODSThis is a retrospective analysis of deidentified data submitted from 11 Comprehensive Stroke Centers (CSCs) and 1 Primary Stroke Center (PSC) in Michigan and northwest Ohio. The study was approved by the University Institutional Review Board. Patient consent was not required given the retrospective nature of the study. Using Poisson regression analysis, we calculated the incidence-rate ratios (IRRs) comparing the study period of March 2020 to each of the control periods (February 2020 and March 2019). Additionally, the unpaired t-test for continuous variables and the Chi-square test for categorical variables were used as appropriate.