Background-Recent studies examining the effect of prior antiplatelet therapy (APT) on outcome in patients with spontaneous intracerebral hemorrhage (ICH) have shown conflicting results. The effect of platelet infusion therapy (PIT) on outcome in APT patients with ICH is unknown.

Objective Statistical models predicting outcome after intraparenchymal hemorrhage (IPH) include patients irrespective of do-not-attempt-resuscitation (DNAR) orders. We built a model to explore how the inclusion of patients with DNAR orders affects IPH prognostic models. Design Retrospective, observational cohort study from May 2001 until September 2003 Setting University-affiliated tertiary referral hospital in Seattle, Washington Patients 424 consecutive patients with spontaneous intraparenchymal hemorrhage Measurements We retrospectively abstracted information from medical records of IPH patients admitted to a single hospital. Using multivariate logistic regression of presenting clinical characteristics, but not DNAR status, we generated a prognostic score for favorable outcome (FO, defined as moderate disability or better at discharge). We compared observed probability of FO with that predicted, stratified by DNAR-status. We then generated a modified prognostic score using only non-DNAR patients. Main Results Records of 424 patients were reviewed: 44% had FO, 43% had a DNAR-order and 38% died in hospital. Observed and predicted probability of FO agreed well with all patients taken together. Observed probability of FO was significantly higher than predicted in non-DNAR patients and significantly lower in DNAR patients. Results were similar when applying a previously published and validated prognostic score. Our modified prognostic score was no longer pessimistic in non-DNAR patients, but remained overly optimistic in DNAR patients. Conclusions Although our prognostic model was well calibrated when assessing all IPH patients, predictions were significantly pessimistic in patients without, and optimistic in those with DNAR orders. Such pessimism may drive decisions to make patients DNAR in whom a FO may have been possible, thereby creating a self-fulfilling prophecy. To be most useful in clinical decision-making, IPH prognostic models should be calibrated to large IPH cohorts in whom DNAR orders were not used.

This chapter will review the spectrum of immunemediated diseases that affect the nervous system and may result in an admission to the neurological intensive care unit. Immunomodulatory strategies to treat acute exacerbations of neurological diseases caused by aberrant immune responses are discussed, but strategies for long-term immunosuppression are not presented. The recommendations for therapeutic intervention are based on a synthesis of the literature, and include recommendations by the Cochrane Collaborative, the American Academy of Neurology, and other key organizations. References from recent publications are provided for the disorders and therapies in which randomized clinical trials and large evidenced-based reviews do not exist. The chapter concludes with a brief review of the mechanisms of action, dosing, and side effects of commonly used immunosuppressive strategies in the neurocritical care unit.