Neurocritical Care最新文献

Background: The receptor tyrosine kinase AR4-type receptor in erythropoietin-producing hepatocellular carcinoma (EphA4) has been linked to disruption of the blood-brain barrier (BBB) and hemorrhagic transformation after acute ischemic stroke. Here, we explored whether EphA4 may be involved in parenchymal hematoma (PH) after ischemic stroke.

Methods: Data were analyzed from patients who were admitted to West China Hospital of Sichuan University within 48 h of stroke onset between January 2017 and December 2019. EphA4 levels in serum were measured within 24 h after admission, and baseline computed tomography perfusion was performed immediately upon admission. Potential relationships of EphA4 levels or ipsilateral flow extraction product (FED) with occurrence of PH were explored using logistic regression.

Results: Of the 578 patients (337 men) analyzed, who were a median age of 69 years old, 56 (9.69%) developed PH. Serum EphA4 levels were higher in patients with PH than in those without PH (44.96 vs. 37.86 ng/mL, P = 0.036). After adjustment for confounders, higher serum EphA4 levels (≥ 32.21 ng/mL) were significantly associated with PH (odds ratio [OR] 3.84, 95% confidence interval [CI] 1.66-8.90, P = 0.002). Among the 230 patients in whom brain perfusion was analyzed using computed tomography perfusion, ipsilateral FED was significantly associated with PH after adjusting for confounders (OR 2.43, 95% CI 1.63-3.63, P < 0.001). The two parameters of EphA4 level and ipsilateral FED interacted in their association with PH (P_interaction = 0.037): higher EphA4 level was associated with PH in those with higher ipsilateral FED (OR 1.04, 95% CI 1.01-1.07, P = 0.006), not in those with lower FED.

Conclusions: Elevated EphA4 levels in serum are associated with higher risk of PH after ischemic stroke, especially among patients showing greater permeability of the BBB as reflected in higher ipsilateral FED on computed tomography perfusion.

Background: Early postoperative cerebral infarction (ePCI) following spontaneous intracerebral hemorrhage (ICH) is a severe complication. This study aimed to develop and validate a cisterns and cortical sulci effacement (CCSE) score for predicting ePCI and to compare its predictive performance with that of established clinical scoring systems.

Methods: Data on spontaneous ICH from two centers were retrospectively analyzed. The visibility of 10 cisterns and the left/right cortical sulci was assessed on preoperative computed tomography scans (scored as 0 = visible, 1 = not visible), and the total sum constituted the CCSE score. Interrater and intrarater reliability were assessed using Cohen's κ coefficient. Logistic regression and subgroup analyses were conducted to explore the association between CCSE and ePCI. Predictive performance was evaluated using receiver operating characteristic curves, and restricted cubic splines were used to assess potential nonlinearity.

Results: From a cohort of 3,968 consecutive patients with spontaneous ICH from May 2015 to September 2022, 637 individuals (mean age 57.3 years [SD 12.5]; 71.3% male) were included in the final analysis, with 71 (11.1%) developing ePCI. The CCSE score showed excellent intrarater (κ = 0.93) and interrater (κ = 0.86) reliability and was strongly associated with ePCI risk (odds ratio 2.14 per point, 95% confidence interval [CI] 1.80-2.53, p < 0.001). Subgroup analyses confirmed the robustness of the association. The CCSE score outperformed traditional scores, including the Glasgow Coma Scale, Original Intracerebral Hemorrhage Scale, and Modified Intracerebral Hemorrhage A score (area under the curve = 0.91; 95% CI 0.86-0.95). Additionally, a nonlinear relationship was identified (p for nonlinearity = 0.002), with a CCSE score threshold ≥ 4.02 for risk discrimination.

Conclusions: The CCSE score may be a reliable and practical tool for predicting ePCI in patients with supratentorial ICH.

Background: Patient differences from optimal mean arterial pressure (MAP_OPT) derived by a cerebral oximetry index (COx_a) are associated with outcome, but the validity of COx_a-derived MAP_OPT remains in question due to the lack of agreement with pressure reactivity index (PRx)-derived MAP_OPT. The study aimed to elucidate the relationship between PRx and COx_a to justify the use of COx_a and COx_a-derived MAP_OPT in patients with aneurysmal subarachnoid hemorrhage (aSAH).

Methods: This was a retrospective single-center study of six patients with aSAH with simultaneous near-infrared spectroscopy, intracranial pressure, and MAP monitoring. Repeated-measures Pearson correlation and Bland-Altman plot analysis were performed to compare PRx and COx_a and to compare PRx-derived MAP_OPT and COx_a-derived MAP_OPT. Coinciding changes in PRx and COx_a were compared, and the ability of COx_a to detect PRx-based autoregulation impairment was assessed over different time windows.

Results: Repeated-measures Pearson correlation analysis showed no correlation between PRx and COx_a (r = 0.06, p < 0.01). The correlation between PRx- and COx_a-derived MAP_OPT over 388 h was r = 0.50 (p < 0.01). The bias and upper and lower limits of agreement were - 1.60, + 20.24, and - 23.43 mm Hg, respectively. The shift in the overall distribution of moving correlation to higher values as the time-window length increased was more pronounced for COx_a than PRx (COx_a: 0.09-0.41, PRx: 0.00-0.15). When using a typical PRx threshold of 0.3, COx_a was found to be ineffective in identifying impaired autoregulation across all time windows (area under the receiver operating characteristic curve: 0.494-0.527).

Conclusions: The threshold applied to PRx should not be applied to COx_a. It is suggested to consider higher thresholds for COx_a than PRx in deriving the range for MAP_OPT calculations for continuous cerebral autoregulation assessment in aSAH. Further research is needed to optimize the MAP_OPT derived from PRx and COx_a based on specific monitoring targets.